A Strategy To Improve Outcomes

The mission of CMQCC’s Community Birth Partnership Initiative (CBPI) is to improve health outcomes during pregnancy and birth by increasing the quality and whole-person safety of hospital transfer processes, when a transfer is needed for a community birth. The Initiative also seeks to enhance integration between perinatal care systems that have traditionally worked in isolation from each other in California. 

The Initiative is built upon critical concepts and strategies in the newly published update to CMQCC’s Toolkit to Support Vaginal Birth and Reduce Primary Cesareans and is grounded in health equity, shared decision making, and respectful care. Although birth at home or in community birth centers is generally safe for low-risk women, studies show that newborns face a higher risk of death compared to hospital births, especially if complications occur and access to hospital care is delayed, highlighting the critical need for timely, respectful, and well-coordinated transfer procedures.

CBPI is supported by funding from Skyline Foundation.

 

Background: Two Unprecedented Crises

It is common knowledge now that the United States carries the distinction of having the worst maternal mortality rate of all economically advanced countries. Additionally, a 2021 report released by the California Department of Public Health, using an enhanced surveillance methodology, showed that Black birthing and pregnant people have a pregnancy-related mortality risk that is four to six times greater than white people in California.

On top of this, California is dealing with a significant dilemma in maternity care access. In 2014, the American College of Obstetricians and Gynecologists (ACOG) observed that at least nine counties have no ob/gyn provider, and many more lack the necessary providers to meet the need. A 2023 investigation by CalMatters revealed that at least 46 California hospital maternity units have closed since 2012.

Safe, efficient transfer of care to the hospital, when needed, is an important component of healthcare quality.  National and international organizations, supported by research and a clarion call from community leaders, report that highly skilled and highly personalized midwifery care is an important strategy to improve maternal outcomes and access to care. Until recently, access to midwifery care was not credited as an essential approach to improving perinatal care in America. But times are changing. 

 

Midwives Are an Essential Part of Safe Maternal Care Systems

Robust studies in recent years show that excellent birth and infant outcomes result when midwives are a part of an integrated system of care committed to delivering whole-person safety. Who are midwives in California, and what are the differences between certified nurse midwives (CNMs) and licensed midwives (LMs)?

  • CNMs and LMs attend about 12% of births in California, or about 50,000 births per year
  • There are 1,600 midwives in California
  • CNMs are licensed and regulated by the Board of Registered Nursing and LMs are licensed and regulated by the Medical Board of California
  • CNMs complete a nurse-midwifery education program housed in a school of nursing or health sciences, and then take the certification exam administered by the American Midwifery Certification Board
  • LMs complete an accredited three-year midwifery education program approved by the Medical Board of California and then take the certification exam administered by the North American Registry of Midwives
  • CNMs and LMs can take care of patients determined by the Board of Registered Nursing and the Medical Board of California to be low-risk, and are obligated to transfer higher risk patients
  • CNMs and LMs are Medi-Cal providers and in-network with commercial insurers

 

About Midwives & Community Birth

California has never attempted a statewide program to improve relationships between community midwives and hospital providers, nor has there been any large-scale effort to improve processes for transferring patients between community birth sites (the home or freestanding birth center) and the hospital. 

We want to change that. Every person deserves the safest and most respectful birth possible, regardless of where they intend to give birth. There is so much we can solve if we work together.

 

Where We Are Working 

Currently, we are focusing on two pilot groups/regions. We will take the learnings from this first pilot project to inform expanded work across the state. Hospitals from the greater Sacramento area and the Inland Empire (San Bernardino and Riverside Counties) will be working together with community midwives from their same areas.

 

Goals of the Initiative 

  • Improve relationships and dialogue between hospital and community birth providers;
  • Enhance whole-person safety through the co-design of policies for hospital transfer by community birth midwives and hospital providers;
  • Improve teamwork  and communication between community birth midwives, EMS, and the hospital team to ensure respectful, patient-centered, dignified transfer of care for every patient;
  • Improve understanding of community birth and reduce stigma around home birth and birth in birth centers;
  • Improve the patient experience of transfer; and
  • Partner with community organizations to expand stakeholder understanding of community birth, find opportunities for joint initiatives that meet our collective goals around community birth, and engage patients in telling their stories about community birth.

 

Components of the Initiative 

  • Virtual learning sessions and virtual small group sharing sessions between community midwives and hospital staff;
  • Collaborative work sessions between community midwives and hospital staff to co-design policies for transfer;
  • Virtual and in-person simulations of transfer to practice and improve processes; and
  • Surveys of patient experiences of transfer in order to integrate patient-focused and community-specific change.

 

How EMS Can Collaborate With Community Midwives and Hospitals to Ensure Safe, Respectful Patient Care

  1. Reach out to CMQCC to join the statewide community birth transfer quality improvement (QI) initiative!
  2. The CMQCC team will contact you to set up a one-hour info session about community midwives and community birth in California, as well as the Initiative. Invite your department/co-workers to take part in this session.
  3. Connect with hospitals within your service area that are participating in the Initiative. CMQCC will assist in identifying participating sites and include you in a workgroup.
  4. CMQCC will also facilitate an introduction to community midwives in your local area. After this introduction, reach out to them and ask how you might partner to improve transfer of care (e.g., joint learnings and simulations).
  5. Participate in quarterly transfer QI sessions along with community midwives and hospital teams. During these meetings, transfer processes are reviewed, and areas of improvement are identified. EMS plays a crucial role in these committees and add valuable insight to these discussions.
  6. Work with your local partner agencies to align policies to improve patient transfer from community birth to the hospital. Significant QI in community birth transfers can be achieved through collaboration between all service providers involved in the process. Large-scale strategies to enhance maternal and newborn transfers from community settings to hospitals benefit those we serve by enhancing the safety of care and supporting patient choice.

 

Resources for Community Birth Transfers

 

Want To Learn More?

Email Holly Smith, CBPI Project Lead, at holly@midwiferyrising.org, or Christa Sakowski, CMQCC Clinical Lead, at csakowski@stanford.edu.