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. 2025 Jul 19;26(1):103.
doi: 10.1186/s12910-025-01228-y.

Advancing equity in healthcare systems: understanding implicit bias and infant mortality

Sophia M Gran-Ruaz  1 , Shruti Mistry  1 , M Myriah MacIntyre  1 , Dana Strauss  1 , Sonya C Faber  1   2 , Monnica T Williams  3   4
Affiliations

Advancing equity in healthcare systems: understanding implicit bias and infant mortality

Sophia M Gran-Ruaz et al. BMC Med Ethics. .

Abstract

Using data from the Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) and Project Implicit, this study examined whether anti-Black implicit racial biases predict infant mortality for Black Americans. We examined state-level mean Black-White Implicit Association Test (BW-IAT) Bias Scores and controlled for explicit bias scores and White infant mortality rates for over 1.7 million American participants across ten different ethnoracial groups between 2018-2020. Hierarchical linear regressions determined state-level anti-Black implicit bias significantly predicted state-level Black infant mortality rates, above and beyond explicit bias and White infant mortality, in 2018 (b = .32, t(34) = 2.09, p < .05), 2019 (b = .30, t(34) = 2.09, p < .05), and 2020 (b = .32, t(34) = 2.18, p < .05). State-level anti-Black implicit bias also explained a significant proportion of variance in state-level infant mortality rates, in 2018 (R2 = 0.30, F(3, 35) = 4.89, p < 0.01), 2019 (R2 = .33, F(3, 36) = 5.95, p < .01), and 2020 (R2 = .39, F(3, 35) = 7.58, p < .001). Also, among healthcare professionals, there are similar levels of implicit biases compared to the general American population. Findings suggest that implicit racial bias is a risk factor for Black infant mortality. These findings also point to the ethical challenge implicit biases pose to equitable decision-making and patient-provider relationships in healthcare. By integrating these insights into interdisciplinary discussions, this study provides supporting data for systemic reforms and anti-bias training to create a healthcare system grounded in fairness and equity.

Keywords: Anti-Black racism; Black Americans; Explicit bias; Implicit bias; Infant mortality.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: Participants from Project Implicit received informed consent prior to participation, and the study was approved by the University of Virginia IRB (PI: Dr. Bethany Teachman). This study complied with the Declaration of Helsinki. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Mean BW-IAT Bias Scores by ethnoracial group for the general population and those working in a healthcare profession. Caption. Bias Scores range on a continuum of –2 to + 2. Positive scores indicate a relative positive bias for White people, while negative scores indicate a relative positive bias for Black people. Bars represent standard error
Fig. 2
Fig. 2
Implicit Bias Score by state and healthcare profession status for 2020. A. Implicit Bias within Healthcare Professionals. B. General Population Implicit Bias. Note: Bias Score exist on a continuum of -2 to + 2. Darker hue indicates more pro-White bias
See this image and copyright information in PMC

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