Frequently Asked Questions - Birth Equity

The California Birth Equity Collaborative is a California Maternal Quality Care Collaborative (CMQCC) quality improvement initiative to improve birth care, experiences and outcomes for Black mothers and birthing people in California. Our team is comprised of partnerships among CMQCC, participating hospitals and their local communities and state/national and local experts.

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.

CMQCC is leading this work in partnership with our pilot hospitals, CMQCC is a multi-stakeholder group based at Stanford University that focuses on improving hospital-based maternity care in California. CMQCC has previously managed data-driven projects that incorporated best practices, learning collaboratives, and brought together existing and new partnerships in order to sustain and advance maternal health. Through our ongoing efforts and partnerships, CMQCC has helped California to produce one of the lowest overall maternal mortality rates in the country.

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

The California Birth Equity Collaborative is approaching this work with an evolving practice of cultural humility as we partner with hospitals and their local communities, to advance a culture of birth equity and respectful and dignified birth care.

The California Birth Equity Collaborative has adopted the Women’s Health Organization definition of respectful maternity care – which refers to care organized for and provided to all women in a manner that maintains their dignity, privacy and confidentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labor and childbirth, regardless of their race, ethnicity, nationality, gender, religion, sexuality, age, disability, HIV status, immigration status, housing status, income or insurance status and type.

Together with our partners, the California Birth Equity Collaborative prioritizes the voices, knowledge, and lived experiences of Black mothers and birthing people to develop and implement tools that advance respectful and dignified care, trusting relationships, responsive listening, and shared decision-making between Black birthing people, hospitals and the community.

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.

Maternal mortality or pregnancy-related deaths is defined as deaths during any pregnancy or within 42 days after a pregnancy ends. The pregnancy-related death ratio is an estimate of the number of pregnancy-related deaths for every 100,000 live births. The pregnancy-related death ratio in California is 7.3/100,000 live births. The pregnancy-related death ratio in the U.S. is 20.7/100,000 live births based on 2018 data.

The pregnancy-related deaths organized by race in the U.S. is described below, based on 2015 data:

  • 47.2 deaths per 100,000 live births for Black women
  • 38.8 deaths per 100,000 live births for American Indian/Native Alaskan women
  • 18.1 deaths per 100,000 live births for White women
  • 12.1 deaths per 100,000 live births for Hispanic women
  • 11.6 deaths per 100,000 live births for Asian/Pacific Islander women

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.

The California Birth Equity team is comprised of partnerships among:

  • Participating hospitals
  • State/national and local experts

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.

We envision this project will have three key steps:

  1. Mobilizing partners to work together in collaboration with community members to care and advocate for Black mothers and birthing people
  2. Utilizing hospital-level data to inform the quality improvement initiative
  3. Implementing multi-partner, large-scale pilot interventions (see below) that integrate hospital clinical providers and the community with public health, community health, and perinatal services

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.

Five hospitals are participating in the pilot. These hospitals were chosen based on the following criteria:

  1. At least 150 births per year by Black women
  2. A commitment by the hospital’s leadership to addressing birth equity
  3. Engagement with CMQCC in prior quality improvement efforts
  4. Data indicating an opportunity for improvement in their maternal outcomes for Black mothers and birthing people
  5. Representation of three diverse geographic areas within the state

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.

We will feel that the pilot has been successful if we — meaning CMQCC’s California Birth Equity Collaborative, pilot hospitals and their local communities working together — are able to do the following:

  • Show improvement in a newly developed and validated patient-reported experience metric of respect and dignity
  • Create and sustain respectful and culturally responsive relationships among Black mothers and birthing people, hospitals and their local communities.
  • Hospital staff at each of the pilot hospitals complete equity education
  • Build pilot hospital capacity to view and interpret their Birth Equity dashboard; co-identify strategies to advance birth equity; and incorporate regular data metric presentations and techniques to achieve key birth equity goals
  • Observe and characterize change in birth culture and staff knowledge, attitudes, and skills in advancing a culture of birth equity

If we are successful with our Collaborative goals, we expect to reduce the variation in maternal outcome measurements for Black mothers and birthing people compared with all other races in the long term.

  • 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.

For information about the pilot, please contact us at

To learn more about CMQCC and stay up to date with our latest news, please create an account on our website to subscribe to our newsletter and webinar announcements.