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, by, and with Black mothers and birthing people in California. Our team is comprised of partnerships among:

  • Black/Black women-led community-based organizations (CBOs)
  • Participating hospitals
  • State/national and local advisory groups

It is funded by the California Health Care Foundation.

The goal of the Collaborative is to improve care, experiences, and outcomes for, by, and with 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. We will also acknowledge the prior work of Black women-led CBOs and seek to amplify their knowledge, leadership and contributions through sharing of best practices and partnering with them throughout the initiative.

Over the course of the two-year pilot initiative, the Collaborative will work together with three hospitals and community stakeholders with the goal of developing and testing:

  • a patient-reported experience metric (PREM)
  • online interactive interprofessional educational modules
  • best practices for sustainable community-hospital partnerships in order to align community and hospital expectations around the birth experience

The two-year 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 hospitals, CBOs, and state/national and local advisors. 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.

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, the difference in outcomes for Black mothers compared with all other racial groups has persisted.

Further analysis revealed that clinical safety bundles and social support interventions done in isolation, without an integrated approach, did not produce the desired outcomes. Thus, CMQCC’s Birth Equity Collaborative presents an opportunity to develop QI tools to promptly evaluate and transform birth care, experiences, and outcomes through the integration of clinical and sociocultural interventions and community-hospital partnerships

  • Data shows that even in the absence of risk factors such as 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 the quality of care and 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 Black women-led CBOs and our hospital partners.

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:

  • Black/Black women-led community-based organizations (CBOs)
  • Participating hospitals
  • State/national and local advisory groups

Black women clinicians, social scientists, and public health scholars with institutional affiliation outside of our key community areas will serve as mentors to support the overall pilot goals, activities, and measures of success in our state/national advisory group.

CMQCC will facilitate partnerships between participating hospitals and local advisory groups including patient representatives, community members and hospital staff whose role is to address the specific pilot goals, activities and measures at each of the three pilot hospitals.

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:

  • Mobilizing partners to work together in collaboration with community members to care and advocate for Black mothers and birthing people
  • Utilizing hospital-level data to inform the quality improvement initiative
  • 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

Over a two-year period, the Collaborative will partner with community stakeholders and hospitals in the co-development and co-testing of the following:

  1. Community-informed theoretical model to develop a participatory patient-reported experience metric (PREM)
  2. Series of online interactive and interprofessional educational modules:
    • to raise awareness and knowledge of the historical origins and present day examples of racism, mistreatment, discrimination, and disrespect experienced in the daily lives of Black mothers and birthing people across society and in our health systems
    • to increase hospital providers’ confidence in describing and reducing the impact of different types of discrimination and injustices on Black birthing people’s care, autonomy, and dignity
    • to provide effective patient-centered communication techniques to transform counseling and shared decision-making for Black mothers and birthing people
  3. Best practices for developing effective and sustainable community-hospital partnerships that are comprised of local CBOs, community members and Black birthing people

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

Three hospitals are participating in the pilot. Once finalized, we will share the names and locations. 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

Black women-led CBOs and CMQCC can collaborate in two ways:

  1. Development and testing of quality improvement tools and approaches in hospitals in four key areas: evaluation and assessments, education and training, social media and communications, and community informed consensus building
  2. Development of effective and sustainable community-hospital partnerships through local advisory groups for each of the pilot hospitals.

For information about CBO partnerships and the potential for grant funding from the California Health Care Foundation to advance the Collaborative’s goals and activities within the hospitals or local advisory groups, please contact Karen A. Scott, MD, MPH, Director:

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 three pilot hospitals to develop and test approaches and materials. 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, communities, hospitals, and advisors 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 partnerships among Black mothers and birthing people, CBOs, the Collaborative, hospitals, and advisors
  • Have the e-learning course completed by hospital staff at each of the pilot hospitals
  • 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. 

It will only be possible to achieve the aims if we, the Collaborative and our partners, successfully:

  • Develop and utilize a shared language and understanding about what birth equity means, and appreciate the medical and social context of birth care, experiences, and outcomes in the U.S. and California
  • Acknowledge and amplify the resilience and community-informed knowledge of Black childbirth expectations, needs, experiences, and outcomes
  • Establish strategies to create and assess sustainable and respectful community-hospital partnerships
  • Identify opportunities in orientation and ongoing education for clinicians and staff in advancing a culture of birth equity in hospital births
  • Develop community-informed meanings and measurements of respectful and dignified culture and care during hospital births
  • 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 via the state and local community advisory groups and through activities such as town hall meetings