Advancing Birth Equity Through Quality Improvement Education: The SPEAK UP Champion Course

Abstract

Background:

Black, non-Hispanic, and Indigenous perinatal patients in the United States experience disproportionately high rates of maternal mortality and morbidity compared with other racial and ethnic groups. While multiple social and institutional factors contribute to these inequities, structural racism, including implicit bias, remains key drivers shaping patient–health care professional interactions and the quality and equity of care.

Objective:

To evaluate, using a health equity lens, changes in perinatal health professionals’ knowledge, attitudes, awareness, and self-reported preparedness and actions to mitigate racism before and after participation in the Institute for Perinatal Quality Improvement’s SPEAK UP Champion course on implicit and explicit racial bias.

Methods:

We analyzed 1,303 pre-course surveys, 772 post-course surveys, and 48 follow-up implementation surveys collected from 28 SPEAK UP Champion courses delivered between 2021 and 2023. Surveys assessed knowledge, attitudes, awareness, and self-reported planned or implemented bias-mitigation strategies. Univariate analyses summarized outcomes, and chi-square tests examined racial differences in self-reported implicit bias.

Results:

Post-course surveys showed improvements in understanding race as a social construct, increased recognition of racism as a driver of perinatal disparities, and heightened awareness of disrespect toward Black and Indigenous patients. Participants reported greater preparedness to identify biased behaviors and develop equity-focused quality improvement (QI) goals, including self-reported planned or early implementation of bias-mitigation strategies. Implementation survey findings reflected respondent-reported practice changes among a small, self-selected subset of participants.

Conclusion:

These findings suggest that (1) the SPEAK UP Champion course was associated with increased racial bias awareness and enhanced participants’ reported capacity to develop bias-mitigation QI action plans; and (2) integrating equity-focused education on implicit and explicit racial bias with QI methods may represent a promising, systems-level approach to advancing equity across the perinatal continuum that warrants broader implementation and further evaluation using rigorous outcome measures.

Keywords

implicit and explicit racial bias equity-centered racial bias mitigation health equity birth equity perinatal quality improvement perinatal health care workforce education

Background

Maternal mortality and severe maternal morbidity (SMM) remain critical indicators of health system performance and equity in the United States, reflecting how clinical structures and processes along with policy factors shape outcomes for birthing people. In 2023, the U.S. pregnancy-related mortality ratio declined to 18.6 per 100,000 live births, down from 22.3 in 2022.¹ Black women experienced a pregnancy-related ratio 3.5 times higher than White women (50.3 vs. 14.5 per 100,000), with lower ratios among Hispanic and Asian women (12.4 and 10.7).¹ National SMM rates were 79.7 per 10,000 delivery hospitalizations in 2019, with upward trends continuing.²

Disparities in perinatal outcomes are not explained by individual risk factors but are rooted in systemic racism, reinforced by structural inequities, discriminatory policies, and implicit and explicit biased practices in health systems.^3–5 Addressing these inequities requires a clear conceptual grounding in health equity, which situates bias in health care practices and quality improvement (QI) within the broader social and structural conditions driving differential perinatal risks and outcomes. Health equity refers to a condition in which all individuals have a fair and just opportunity to achieve optimal health, without being limited by social position or other socially constructed disadvantages.^6,7 The Quintuple Aim formally embeds equity as a core quality domain of health care improvement.⁸ Birth equity extends this principle to pregnancy and childbirth by emphasizing the right of every birthing person to safe, respectful, and high-quality care, supported by systems that address structural racism and social inequities across the perinatal continuum.⁹

Bias in health care and the role of education

Research confirms that health professionals, regardless of intent or personal values, hold implicit and explicit racial/ethnic biases.¹⁰ Implicit bias operates through unconscious attitudes that influence perceptions and behaviors,^11–14 whereas explicit bias involves conscious beliefs.¹⁵ These biases shape treatment decisions and patient–caretaker interactions^10,14,16 and are associated with discriminatory care patterns and adverse outcomes, particularly when implicit bias is activated under stressful conditions.^17,18 Reducing bias among health care professionals is therefore essential to improving perinatal outcomes.¹⁹

Implicit bias education has been widely adopted within health care policy and professional education, supported by professional organizations (e.g., American College of Obstetricians and Gynecologists and the Alliance for Innovation on Maternal Health)^20–23 and state mandates (e.g., California).^20,24,25 However, educational approaches vary widely in content, duration, and theoretical grounding; in one systematic review, only 41% of studies applied an explicit framework.²⁶ Moreover, evidence of sustained impact remains limited.¹⁵ Without integration of actionable strategies and system-level supports, many programs risk becoming perfunctory and insufficient to produce meaningful equity gains.

In contrast, the Institute for Perinatal Quality Improvement’s (PQI’s) (www.perinatalQI.org) SPEAK UP Program incorporates bias education with equity-focused QI methods to support translation from awareness to action. The SPEAK UP acronym represents seven practical strategies for interrupting bias and promoting respectful, equitable care: Set Limits, Practice and Prepare, Express Your Concerns, Apologize, Keep Improving, Uncover and Learn, and Persuade Others to SPEAK UP. While widely disseminated, the effectiveness of the program’s foundational SPEAK UP Champion course had not been formally evaluated prior to this study.

Purpose

This evaluation examined: (1) how learners’ knowledge, attitudes, awareness, and self-reported behaviors to mitigate racism in perinatal care changed following participation in the SPEAK UP Champion courses and (2) learners’ overall satisfaction with the education.

Methods

Education, action, and analytic equity framework

Guided by scholarship emphasizing framework-based intervention design and evaluation,¹³ the SPEAK UP Champion course was grounded in PQI’s Education, Action, and Analytic Equity Framework (Fig. 1A), which applies established Knowledge–Attitudes–Practices/Skills (KAP/S) evaluation principles to bias education and QI methods.²⁷ The KAP/S framework has been used in prior syntheses of health care professional education.²⁸ In addition, pedagogical elements were informed by work emphasizing reflective, psychologically safe, and practice-oriented learning for addressing bias.¹⁸ The PQI Framework guided course design and evaluation across five domains (Fig. 1B): knowledge (understanding racial disparities and race as a social construct); awareness (recognition of implicit and explicit bias informed by self-assessment and structured reflection)¹⁶; attitudes (beliefs, empathy, and openness to equity-oriented change); behaviors (actions and plans to apply bias-mitigation strategies like respectful communication and perspective-taking)¹⁴; and equity (engagement in equity-focused QI activities). The framework extends traditional KAP/S models by incorporating awareness, acknowledging that implicit bias can influence clinical judgment even among clinicians who consciously endorse fairness and equal treatment.^29,30

FIG. 1.

Education, action, and analytic equity framework guiding the SPEAK UP Champion Course. (A) Conceptual framework depicting progression from knowledge acquisition to equity-focused outcomes. (B) Operationalization of framework domains to course components and evaluation measures used in this study.

Figure 1 depicts both the conceptual progression from knowledge acquisition to equity-oriented outcomes (Fig. 1A) and the operationalization of the PQI Framework domains to course components and evaluation measures used in this study (Fig. 1B).

Intervention: SPEAK UP Champion implicit and explicit racial bias course

PQI applies QI and implementation science principles to reduce preventable perinatal morbidity and mortality and address racial and ethnic disparities in perinatal health outcomes. Launched in 2019, the SPEAK UP Program was, at the time of this evaluation, the only nationally available curriculum specifically designed to address both implicit and explicit bias among perinatal health professionals while integrating QI methods. The program aims to prepare SPEAK UP Champions—perinatal clinicians and public health professionals—to identify, address, and dismantle structural and interpersonal contributors to perinatal inequities within their organizations and communities. The action-oriented curriculum integrates didactic instruction, case-based discussion, interactive exercises, and structured reflection, guided by the SPEAK UP acronym practices (Table 1, Panel F). Course content includes historical and epidemiological context on racial disparities, video-based learning, clinical scenarios, and role-play exercises designed to support skill building in real-world settings. A distinguishing feature is the inclusion of QI methodology, through which participants develop SMARTIE (Specific, Measurable, Achievable, Relevant, Time-bound, Inclusive, and Equitable) goals³¹ and individualized, equity-focused QI action plans to facilitate translation of course content into workplace practice. This overarching approach explicitly applies an equity lens to improvement initiatives, enabling health professionals to systematically identify inequities, design targeted interventions, and monitor outcomes across clinical and organizational domains.³²

Table 1.

Knowledge, Awareness, Attitudes, and Self-Reported Behaviors Related to Racism in Maternity Care

Sample size	(N = 1,303)	(N = 772)	(N = 48)
Sample size	Pre-course	Post-course	Implementation
Panel A. Knowledge
Item
Pregnant people should receive care/support for healthy births	1,281 (98.3)	770 (99.9)	48 (100.0)
Respectful/supportive care is essential to perinatal quality	1,258 (96.6)	771 (99.9)	48 (100.0)
Maternal mortality disparities are largely due to racism	1,123 (86.2)	734 (95.0)	47 (97.9)
Panel B. Awareness
Item
Racism in health care leads to poor outcomes	1,223 (93.9)	730 (94.6)	47 (97.9)
Missing	57 (4.4)	19 (2.5)	0 (0.0)
I have implicit biases based on skin color	375 (28.8)	418 (54.1)	29 (60.4)
Missing	57 (4.4)	19 (2.5)	0 (0.0)
Panel C. Attitudes toward racism
Item
Race is not biology/genetics	746 (57.3)	651 (84.3)	42 (87.5)
Missing	57 (4.4)	68 (8.8)	0 (0.0)
Racial categories created for economic/political gain	917 (70.4)	703 (91.1)	43 (89.6)
Missing	57 (4.4)	23 (3.0)	0 (0.0)
Recognition of disrespect toward Black/Indigenous in pregnancy	735 (56.4)	757 (98.1)^a	N/A
Missing	57 (4.4)	12 (1.6)	—
Panel D. Pre-course practices to mitigate racism (pre-course survey only; N = 1,303)
\| Practice \| Pre-course
n (%) \|
\|---\|---:\|
\| Anti-racism initiatives excluding diversity and inclusion work^b \| 697 (53.5) \|
\| Racism-focused perinatal initiatives rated as effective:
\|-Implemented QI to address inequities^c \| 671 (51.5) \|
\|-Track maternal mortality by race/ethnicity \| 622 (47.7) \|
\|-Track maternal morbidity by race/ethnicity \| 406 (31.2) \|
\|-Perinatal health equity committee \| 206 (15.8) \|
\|-Staff implicit bias self-assessment \| 93 (7.1) \|
\|-Organizational racial equity assessment \| 120 (9.2) \|
Panel E. Self-reported behavioral change (implementation survey only; N = 48)
Item			n (%)
Better recognize disrespect toward Black/Indigenous people			46 (95.8)
Making improvements in work setting			48 (95.9)
Accomplish SPEAK UP course goals			38 (79.2)
Fully/partially implemented action plan			39 (81.2)
Use QI methods to support action plan			35 (72.9)
Panel F. Self-reported SPEAK UP behaviors to mitigate racism (implementation survey only; N = 48)
Item			n (%)
“Set limits” to ensure respectful treatment of Black women at work/in social setting			46 (95.8)/48 (100.0)
“Practice and prepare” to speak up when needed			46 (95.8)
“Express concerns” when witnessing disrespectful care at work/in social setting			45 (93.7)/44 (91.7)
“Apologize” for hurtful or racist words or actions			42 (91.3)
“Keep improving” knowledge around racial bias and anti-racism			48 (100.0)
“Uncover and learn” about my own racial biases			48 (100.0)
“Persuade” others to SPEAK UP			46 (95.9)

Values are n (%) agreeing or strongly agreeing unless otherwise specified. Em dashes (—) indicate not assessed; N/A indicates the item was not included in that survey phase. Panel B: Percentages reflect respondents who agreed or strongly agreed. Baseline uncertainty or disagreement was calculated as the complement of agreement (i.e., 100% minus “agree/strongly agree”) across pre-course items related to race, bias, and racism, yielding an estimated range of approximately 30–71%. Panel A–C: Reported ranges reflect the minimum (8.8%) and maximum (41.7%) absolute percentage-point change between pre- and post-course agreement levels across items assessing knowledge, awareness, and attitudes related to race, bias, and racism. Implementation survey responses were not linked to pre-/post-course data.

For all panels: agree or strongly agree, n (%).

Post-course item assessed self-reported preparedness.

94 responses missing (7.4%).

110 responses missing (7.7%).

PQI conducted multiple SPEAK UP Champion conferences annually as stand-alone professional development offerings or components of broader perinatal equity initiatives with state health departments, perinatal quality collaboratives, and hospital systems across multiple states. Collaborating partners included the Massachusetts Department of Public Health and the Perinatal Neonatal Quality Improvement Network of Massachusetts, the Illinois Perinatal Quality Collaborative, the Oklahoma Department of Health, the Georgia Perinatal Quality Collaborative and Georgia Department of Health, and hospital systems in Georgia.

Design

This study used a pre–post evaluation design. Surveys assessed perinatal health professionals’ self-reported knowledge, awareness, attitudes, and self-reported behaviors following participation in one of 28 SPEAK UP Champion courses delivered at the state or national level between 2021 and 2023. Pre- and post-course surveys were administered immediately before and after the education, with pre-course surveys establishing baseline knowledge, attitudes, awareness, and prior equity-related activities; post-course surveys capturing immediate changes in these domains and participants’ self-reported preparedness and intended or early application of bias-mitigation strategies; and a national implementation survey assessing self-reported implementation of course strategies and QI actions. The implementation survey was administered between September and December 2023 to participants who completed the SPEAK UP Champion course between 2019 and 2023, representing a follow-up period ranging from approximately 9 months to 4 years post-course, depending on course timing. Implementation survey responses were not linked to individual pre-course data.

Inclusion and exclusion criteria

Surveys from perinatal health professionals were eligible for inclusion if participants attended a state-specific or national SPEAK UP Champion course between January 2021 and December 2023 and completed at least one course-related survey. Duplicate registrations were removed, retaining only the most complete dataset per participant. In addition, surveys with substantial missing demographic information or incomplete responses to core outcome questions were excluded from the relevant analyses.

Analytic approach

Univariate analyses were used to assess trainees’ knowledge, awareness, attitudes, and self-reported practices before and after the education, as well as overall satisfaction with the course. Bivariate analyses, including chi-square tests, examined associations between trainees’ race and responses to the item: “I have implicit biases based on the color of someone’s skin” across all three surveys. The evaluation protocol was reviewed and approved by the Pearl Institutional Review Board (IRB ID: 2023-0218) in July 2023. All analyses were conducted using Stata version 17.³³

Results

Descriptive characteristics

Between 2021 and 2023, 28 SPEAK UP Champion courses (21 state-level, 7 national) were delivered, yielding 1,303 pre-course, 772 post-course, and 48 implementation surveys (Table 2). Post-course survey completion was lower than pre-course completion, reflecting 40.8% attrition across study phases. The implementation survey response rate was 3.7–3.9%, reflecting a small subset of course completers (Table 3). Across surveys, respondents were nurses (55.3–72.9%), physicians (6.7–8.3%), midwives (5.4–8%), and doulas or community health workers (<5%). By race/ethnicity, respondents identified as Non-Hispanic White (63.6–75.9%), Non-Hispanic Black (11.9–20.8%), or Hispanic (2.1–7%) (Table 3).

Table 2.

SPEAK UP Champion Courses and Survey Responses by State and Year

State or national course	2021			2022			2023
State or national course	No. courses	Pre-n	Post-n	No. courses	Pre-n	Post-n	No. courses	Pre-n	Post-n
CT	—	—	—	—	—	—	2	98	41
GA	1	68	8	1	38	138	1	29	19
IL	1	48	42	2	75	55	—	—	—
MA	5	282	160	3	182	79	1	101	41
NJ	2	75	21	—	—	—	—	—	—
PA	—	—	—	—	—	—	1	55	45
TN	1	19	8	—	—	—	—	—	—
National	3	139	55	3	52	24	1	42	36
Total	13	631	294	9	347	296	6	325	182

Values are reported as n, the number of survey respondents. Pre-course surveys (Pre-n) and post-course surveys (Post-n) were administered immediately prior to and following course completion, respectively. Dashes (–) indicate years in which no SPEAK UP Champion course was conducted for that state or course type. National courses were open to participants from multiple states.

Table 3.

Respondent Characteristics Across SPEAK UP Evaluation Surveys

Characteristic	Pre-course/post-course/implementation
Sample size	N = 1,303/772/48
Professional role
Registered nurse	720 (55.3)/527 (68.3)/35 (72.9)
Midwife	70 (5.4)/62 (8.0)/3 (6.3)
Physician	90 (6.9)/52 (6.7)/4 (8.3)
Doula/community health worker	71 (5.4)/26 (3.4)/0 (0.0)
Other	352 (27.0)/105 (13.6)/6 (12.5)
Race/ethnicity
Non-Hispanic Black	239 (18.3)/92 (11.9)/10 (20.8)
Non-Hispanic White	829 (63.6)/586 (75.9)/35 (72.9)
Hispanic	91 (7.0)/40 (5.2)/1 (2.1)
Other	73 (5.6)/38 (4.9)/1 (2.1)
Prefer not to answer	19 (1.5)/14 (1.8)/1 (2.1)
Missing	52 (4.0)/2 (0.3)/0 (0.0)
Year of course^a
2019	—/—/3 (6.3)
2020	—/—/6 (12.5)
2021	631 (48.4)/294 (28.1)/16 (33.3)
2022	347 (26.6)/296 (38.3)/14 (29.2)
2023	325 (24.9)/182 (23.6)/9 (18.8)
Course location
Connecticut (CT)	98 (7.5)/41 (5.3)/3 (6.3)
Georgia (GA)	135 (10.4)/165 (21.3)/8 (16.7)
Illinois (IL)	123 (9.4)/97 (12.6)/7 (14.6)
Massachusetts (MA)	565 (43.4)/280 (36.3)/11 (22.9)
New Jersey (NJ)	75 (5.8)/21 (2.7)/2 (4.2)
Pennsylvania (PA)	55 (4.2)/45 (5.8)/5 (10.4)
Tennessee (TN)	19 (1.5)/8 (1.0)/—
National multi-state course	233 (17.9)/115 (14.9)/—
Other states^b	—/—/12 (25.0)
Prior implicit bias course ≤3 years	701 (53.8)/—/—

Values are n (%) of respondents who answered agree or strongly agree. Columns list pre-course/post-course/implementation survey responses. Em dashes (—) indicate not applicable or not assessed.

Agree or strongly agree, n (%).

Implementation survey administered September–December 2023 to participants in 2019–2023 (∼9 months to 4 years post-course) (total N = 48: Year 2019—n = 3; 2020—n = 6; 2021—n = 16; 2022—n = 14; 2023—n = 9). Implementation survey responses not linked to pre-/post-course data.

Other states include AK, CA, IA, NE, NY, NC, TX, and WA.

Overview of findings

Four findings emerged: (1) improvements in knowledge, attitudes, and awareness; (2) a high baseline prevalence of misinformation; (3) behavioral preparedness and self-reported practice change; and (4) associations between learners’ race and self-reported implicit bias.

Improved knowledge, attitudes, awareness, and baseline misinformation

More than half of participants reported prior exposure to an implicit bias course within the past 3 years (53.8%, n = 701; Table 3). Despite this, baseline responses showed substantial misinformation, with 30–71.2% of participants expressing uncertainty or disagreement with statements related to race, bias, and racism prior to the course (Table 1, Panel B, see note). Knowledge of racism’s role in maternal mortality increased by 8.8%, from 86.2% (n = 1,123) pre-course to 95.0% (n = 734) post-course (Table 1, Panel A). Agreement that race is not biological increased by 27.0%, from 57.3% (n = 746) to 84.3% (n = 651), and endorsement that racial categories were created for economic or political gain rose by 20.7%, from 70.4% (n = 917) to 91.1% (n = 703) (Table 1, Panel C). Recognition of disrespect toward Black and Indigenous people during pregnancy increased from 56.4% (n = 735) to 98.1% (n = 757).

Self-reported behavioral change

Before the course, just over half of respondents (53.5%, n = 697) reported involvement in initiatives explicitly targeting racism, most often implementing QI strategies to reduce perinatal inequities (51.5%, n = 671) and tracking maternal mortality (47.7%, n = 622) and morbidity (31.2%, n = 406) by race/ethnicity (Table 1, Panel D). Fewer reported creating equity committees (15.8%, n = 206), conducting organizational assessments (9.2%, n = 120), or requiring staff to complete implicit bias self-assessments (7.1%, n = 93). Post-course, participants described equitable steps across six themes, including data use, education, engagement, interrupting bias, anti-racism planning, and QI initiatives. Across the SPEAK UP acronym, reported equity-focused actions were nearly universal: Set Limits, Keep Improving, and Uncover and Learn (100%, n = 48 each); Practice/Prepare (95.8%, n = 46); Persuade Others (95.9%, n = 46); Express Concerns (93.7%, n = 45); and Apologize (93.3%, n = 42) (Table 1, Panel F).

Follow-up implementation survey findings (Table 1, Panel E) provide contextual information on participants’ self-reported implementation of bias-mitigation strategies after course completion. Implementation survey respondents (N = 48) reported high levels of perceived adoption of course strategies. Most reported increased recognition of disrespect toward Black and Indigenous people (95.8%, n = 46), changes in personal or social settings (89.1%, n = 41), implementation of their SPEAK UP action plan (81.2%, n = 39), and application of QI methods (70.8%, n = 35). Because this group represents a small, self-selected subset of participants, these findings reflect the experiences of implementation survey respondents and should not be generalized to all course participants.

Learners’ race and self-reported implicit biases

Across pre- and post-course surveys, agreement with the statement “I have implicit biases based on the color of someone’s skin” increased after the course. Overall agreement rose from 28.8% pre-course (n = 375) to 54.1% post-course (n = 418), representing a 25.3% increase. Differences by race were statistically significant (p < 0.001). Prior to the course, 24.3% (n = 58) of Black respondents reported agreement, compared with 33.1% (n = 274) of White respondents. Post-course, agreement increased to 57.1% (n = 335) among White respondents and 47.8% (n = 4) among Black respondents (Table 4).

Table 4.

Associations Between Race and Self-Awareness of Implicit Racial Bias

Question: “I have implicit biases based on the color of someone’s skin.” All chi-square tests for race differences p < 0.001
Race/ethnicity	Strongly disagree	Disagree	Neutral	Agree	Strongly agree	Agree + strongly agree (%)
Panel A. Pre- and post-course surveys (N = 1,303 pre; N = 772 post)
A1. Pre-course survey
Non-Hispanic White (n = 829)	180 (21.7)	152 (18.3)	223 (26.9)	169 (20.4)	105 (12.7)	33.1
Non-Hispanic Black (n = 239)	73 (30.5)	51 (21.3)	57 (23.9)	37 (15.5)	21 (8.8)	24.3
Other/no answer (n = 235)	61 (26.0)	31 (13.2)	100 (42.6)	29 (12.3)	14 (6.0)	18.3
Total	314 (24.1)	234 (18.0)	380 (29.2)	235 (18.0)	140 (10.7)	28.8
A2. Post-course survey
Non-Hispanic White (n = 586)	33 (5.6)	50 (8.5)	168 (28.7)	149 (25.4)	186 (31.7)	57.1
Non-Hispanic Black (n = 92)	12 (13.0)	14 (15.2)	22 (23.9)	22 (23.9)	22 (23.9)	47.8
Other/no answer (n = 94)	5 (5.3)	5 (5.3)	45 (47.9)	18 (19.2)	21 (22.3)	41.5
Total	50 (6.5)	69 (8.9)	235 (30.4)	189 (24.5)	229 (29.7)	54.1
Panel B. Implementation survey (N = 48)
Administered ∼9 months to 4 years post-course; not linked to individual pre-/post-course survey data
Non-Hispanic White (n = 35)	2 (5.7)	3 (8.6)	6 (17.1)	10 (28.6)	14 (40.4)	69.0
Non-Hispanic Black (n = 10)	1 (10.0)	1 (10.0)	4 (40.0)	1 (10.0)	3 (30.0)	40.0
Other/no answer (n = 3)	0	1 (33.3)	1 (33.3)	0	1 (33.3)	33.3
Total	3 (6.3)	5 (10.4)	11 (22.9)	11 (22.9)	18 (37.5)	60.4

Values are reported as row percentages. Missing responses for the pre-course survey (n = 57; 4%) and post-course survey (n = 19; 2%) are recoded as “neutral.”

In the implementation survey cohort, 60% (n = 9) of respondents reported agreement. By race, 69% (n = 24) of White respondents and 40% (n = 4) of Black respondents reported agreement, although sample sizes—particularly among Black respondents—were small (Table 4).

Discussion

SPEAK UP: advancing equity through QI

Guided by a health equity analytic lens, this evaluation examines SPEAK UP as an upstream workforce intervention across the perinatal continuum. The findings highlight how equity-centered professional education can advance justice, strengthen accountability, and support a more respectful and equitable future for pregnant people and their communities. Findings suggest that participation in the SPEAK UP Champion Course was associated with improvements in participants’ knowledge, attitudes, and awareness related to racial bias, as well as increased self-reported preparedness to apply bias-mitigation strategies in practice. By pairing education with QI action planning, the course addressed prevalent misinformation, supported reflection and planning for equity-oriented practice, and highlighted differences in how learners of different racial backgrounds self-reported implicit bias awareness.

Knowledge, attitudes, awareness, and misinformation

Many learners entered the course with fundamental misconceptions, despite 53.8% (n = 701) having completed implicit bias education within 3 years of taking this course. This aligns with evidence that many health professionals frequently hold implicit and explicit biases,^15,34 with three in four nurses reporting witnessing racism in practice.³⁵ Educational materials continue to obscure the fact that race is a social construct,³⁶ and professional declarations, like the American Medical Association’s 2020 statement,³⁷ remain recent and not universally adopted. The persistence of disinformation reflects structural racism that normalizes “whiteness” and perpetuates false biological explanations for health disparities.³⁸

Although post-course surveys demonstrated absolute improvements ranging from 8.8% to 41.7% across key knowledge, awareness, and attitude items (Table 1, Panel A–C), residual uncertainty remained (e.g., “race is not biological”), indicating the need for repeated, reinforced learning and action-oriented opportunities.

Learners’ race and self-reported implicit biases

The course stressed that implicit bias affects all individuals and is deeply embedded in society, including within one’s own racial or ethnic group. Health care professionals bring diverse cultural, ethnic, and national identities, shaping varied experiences with racism and bias. Health professionals who grew up or were educated abroad may lack familiarity with the sociocultural context of U.S. racism, and colorism—bias based on skin tone—may further shape self-perceptions of bias.³⁹ Yet, direct comparisons of self-reported denial of bias across racial groups remain limited. Future research should examine how cultural background, lived experiences, and conceptual knowledge of racism shape providers’ acknowledgment of implicit bias.

Behavioral preparedness and self-reported practice change

Bias education that focuses solely on knowledge acquisition is insufficient, as translation into equity-oriented practice requires intentional structures that support application and practice change.¹³ Kruse et al. found that only 23% (9 of 39) of reviewed studies included a “commitment to action/change” strategy, and even then, details were vague.²⁸ The SPEAK UP course addressed this gap by integrating SMARTIE goal setting and QI implementation planning, explicitly prompting participants to identify and report concrete equity-focused changes they implemented or intended to implement in their clinical or organizational practice. This approach aligns with a core QI principle that equity is inseparable from quality and with growing consensus in the health care literature that equity must be intentionally integrated into QI efforts to avoid hollow gains.^8,40 Over 90% of implementation survey respondents self-reported tangible changes—reducing bias, fostering inclusivity, and advocating for systemic reforms—within a small, self-selected sample. Although self-reported and not independently verified, these findings suggest substantial behavioral preparedness and early adoption of equity-oriented practices ∼9 months to 4 years after course participation. However, because implementation respondents could not be consistently linked to individual pre-course data, implementation findings are not interpreted as longitudinal outcomes.

Limitations

Although this study is one of the first multiple states evaluations of an implicit and explicit racial bias course program for perinatal health professionals, there are some limitations that should be noted. Findings rely on self-reported data, which are subject to social desirability bias and may overestimate preparedness or reported practice change. Survey participation declined by 40.8% from pre- to post-course; this decline may be attributed to time constraints, incomplete participation, or reduced post-course engagement. However, respondent composition by professional role remained stable across surveys (Table 3).

The implementation survey had a low response rate, limiting representativeness and generalizability. Because pre-/post-course surveys were not linked at the individual level, inferential pre–post analyses were not conducted, limiting conclusions about causal change over time. The absence of a control or comparison group restricts causal inference, and the evaluation could not determine whether self-reported changes were sustained or translated into measurable perinatal outcomes. Information on participants’ prior bias-related education was limited, constraining interpretation of baseline differences. Future studies should incorporate longitudinal designs, comparison groups, and objective outcome measures to assess durability and real-world impact.

Implications

Although downstream perinatal outcomes were not assessed, this evaluation underscores the importance of operationalizing equity through QI goal setting and structured action planning, consistent with QI science in which structure, process, and capacity precede outcome change. The predominance of nurses may reflect a combination of workforce composition, scheduling and format accessibility, perceived curriculum–role alignment, recruitment pathways, and institutional or professional factors influencing participation in continuing education initiatives across perinatal disciplines. Future efforts should more intentionally engage physicians, midwives, doulas, and community health workers through discipline-specific outreach and professional partnerships to support multidisciplinary equity-focused practice. Building clinician and system readiness to address inequity is a necessary intermediate step toward achieving sustained improvements in perinatal outcomes.⁸ The SPEAK UP framework offers a replicable model with potential to inform policy, accreditation, and broader system-level equity efforts.²⁸

Conclusion

Implicit and explicit racial biases in perinatal care compromise both health care quality and equity. Findings suggest that the SPEAK UP Champion course supports readiness for equity-oriented implementation, as reflected in measurable gains in knowledge, attitudes, awareness, and self-reported adoption of bias-mitigation practices and QI strategies, while underscoring the need for future studies to assess durability and objectively measured outcomes. By embedding equity-focused QI methods within bias education, the SPEAK UP Program equips perinatal professionals to recognize inequities, identify opportunities for improvement, and develop structured approaches to advance equitable care. Collectively, these findings contribute to a reimagined vision of perinatal care in which equity is operationalized through workforce education, systems-level change, and sustained commitment to respectful care, affirming the program’s value as a scalable approach to advancing birth equity.

Authors’ Contributions

R.B.: Conceptualization, project administration, funding acquisition, investigation, writing—original draft preparation, and writing—review and editing. D.B.: Conceptualization, methodology, funding acquisition, investigation, supervision, writing—original draft preparation, and writing—review and editing.

Footnotes

Acknowledgments

The authors wish to acknowledge the contributions of Dr. Andreea Creanga and Dr. Noelene Jeffers, who served as research consultants on the analysis of these data. Their expertise and critical feedback substantially strengthened the quality and rigor of this research.

Author Disclosure Statement

Debra Bingham is the owner and founder of the Institute for Perinatal Quality Improvement, LLC, which owns the SPEAK UP program and materials. Renee Byfield is the Director of the SPEAK UP Program. In these roles, they are paid for providing this education and consultations.

Funding Information

The Georgia Health Initiative (formerly the Healthcare Georgia Foundation) and Massachusetts Department of Health provided some funding that supported this research.

Abbreviations Used

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