Frequently Asked Questions - Birth Equity

The goal of the Collaborative is to improve care, experiences, and outcomes for Black mothers and birthing people during hospital births. We will facilitate shifts in birth culture and care in the hospital setting by prioritizing the voices and lived experiences of Black people who have given birth in California.

Over the course of the pilot initiative, the Collaborative is working together with five hospitals and community stakeholders with the goal of developing and testing a patient-reported experience metric (PREM), identifying online interactive interprofessional educational resources, and demonstrating best practices for interventions for addressing hospital culture leading to supporting birth equity. The goal of the Collaborative is the development of a Birth Equity Quality Improvement Toolkit, or “how-to guide,” reflecting learnings and tested interventions appropriate for widespread dissemination.

A core value of the Collaborative is cultural humility. Cultural humility is one of the principles that informs the ways in which people build trusting and intentional relationships with each other. Cultural humility governs our language, behavior and interactions with our partners within the Collaborative. Two Black women physicians and public health scholars, Dr. Melanie Tervalon, MD, MPH, and Dr. Jann Murray-Garcia, MD, MPH, first defined cultural humility, which requires a commitment to three core tenets:

1. critical self-reflection and lifelong learning
2. recognizing and mitigating inherent power imbalances
3. developing mutually beneficial non-hierarchical clinical and advocacy partnerships with community members, amplifying the expertise of the resides in the community
4. creating institutional alignment and accountability

Since 1999, the reported maternal mortality data in California show a persistent 3-4x gap between Black mothers and mothers from all other racial groups. Also, maternal mortality rates nearly doubled in California between 1999 and 2006. CMQCC was founded in 2006 at Stanford University School of Medicine together with the State of California. Since CMQCC’s inception, California’s maternal mortality rate has declined by 55 percent while the national maternal mortality rate continued to rise. The expectation was that widespread adoption of CMQCC’s clinical safety bundles would reduce the gap in the number of maternal deaths among Black women. However, despite the reduction in overall black maternal deaths, the difference in outcomes for Black mothers compared with all other racial groups has persisted.

• Data shows that even in the absence of risk factors such as maternal age over 35 years, lack of health insurance, inadequate or no prenatal care, and less than high school education, the U.S. system of health care is not protecting Black mothers and birthing people from experiencing higher numbers of deaths or life-threatening complications during pregnancy and childbirth.
• Increasing evidence points to racism within and across multiple levels, and not race, as a key cause of these birth disparities.
• Data also show variations in outcomes across hospitals in California, highlighting opportunities for advancing equity in quality improvement.

The success that California has achieved in the significant reduction in maternal mortality rates is a direct reflection of the outcomes that are possible when collaboration exists around a patient safety concern. The existing data and literature evidence has provided the impetus to formalize an action plan to address this racial equity issue. With our California Birth Equity Collaborative pilot, CMQCC aims to transform birth care for Black mothers and birthing people together with our hospital partners and their local communities.

We know from our data that many outcomes vary significantly across hospitals in California. We know from our past work that it is possible to address this variation. We fully recognize that the origins and effects of mistreatment and disrespect impact Black mothers and birthing communities far before, during, and after pregnancy and childbirth. As a start, our intent is to focus this work on a discrete, manageable setting (the hospital) where we believe we can make a significant impact in birth care and outcomes.

Hospitals are a critical, nearly universal site of maternity care; more than 98% of births occur there nationally. Hospital providers need to provide holistic, culturally congruent care that is both evidence-based and personalized to the needs of individuals and communities within the context of their lived experiences. Hospitals are an important setting in which it is possible to significantly impact birth care and outcomes. Additionally, CMQCC has the expertise, existing data tools and relationships focused on improving clinical care in the hospital setting. However, we anticipate that most if not all of our approaches will also be applicable to the outpatient setting in the future.

Over many years, CMQCC, in partnership with CA Department of Public Health (CDPH), methodically identified the key drivers of maternal mortality (or pregnancy-related deaths) and morbidity (severe complications) through CDPH’s maternal mortality reviews. CMQCC then developed toolkits, or “how-to guides” to address these drivers, and worked with hundreds of hospitals in the state to implement them. All of the maternal quality improvement toolkits are available at no cost here.

The Collaborative will partner with our pilot hospitals and their local communities in the following:

1. Development and testing of a patient-reported experience metric (PREM)
2. Identification of online interactive and interprofessional educational resources.
3. Demonstrating best practices for interventions for addressing hospital culture leading to supporting birth equity.

The Collaborative will conclude with the development of a Birth Equity Quality Improvement Toolkit reflecting learnings from the pilot.

Yes. Our intention is to create a toolkit with evidence-based quality improvement resources for hospitals that can be scaled up for implementation across the state. We will be working with the pilot hospitals to develop and test methodologies and resources. If we identify approaches that are impactful, our intent is to spread them widely to all hospitals in California.

• Hosting webinars to share our learnings
• Sharing progress and stories on CMQCC’s website
• Sharing experiences, lessons learned, high-level information on best practices, and the stories of community members and clinicians through hospital specific activities.