Context and problem(s) addressed
Over the past two decades, the United States – including California – has seen its maternal mortality rates increase by 50-70%, with rates of severe maternal morbidity more than doubling. Additionally, the rate of low-risk first-birth cesarean deliveries, as measured by the Healthy People 2020 initiative, has also risen by more than 50%, without any improvement noted in infant outcomes. The US maternity care sector is facing systemic issues such as overtreatment of many low-risk women and lack of advanced care for some high-risk patients. Additionally, disparities across racial and ethnic groups exacerbates the problem, with Black women dying at a rate three to four times higher than that of white women or Hispanic women.
It is important to note that health systems in the United States are largely governed at the state level, resulting in significant disparities between states. This case study therefore focuses specifically on California.
Intervention and financing model
Noting this rise in maternal deaths and complications, the California Department of Public Health established the California Maternal Quality Care Collaborative in 2006. The Collaborative was developed as a hub for bringing together a broad set of stakeholders, including state agencies, payers, purchasers, professional societies, hospital systems, key clinician leaders, and patient and public groups, to effectively engage with the wide range of hospitals serving California’s mothers.
The Collaborative was designed as a public-private partnership, supported by state funding, contributions from public entities such as the Hospital Engagement Network, and private funding from initiatives like Merck for Mothers. The intervention targeted over 130 hospitals and was multifaceted, involving real-time data collection, the launch of a large-scale quality improvement program, and an awareness-raising campaign among hospital staff. Additionally, the Maternal Data Center was established as part of the intervention, providing hospitals with rapid-cycle data feedback to guide quality improvement efforts. This data also included analyses by subpopulation to identify potential disparities based on race, ethnicity, or payer status.
Key outcomes (if applicable) and associated measurements
The engagement and joint leadership of partners from across the health care spectrum – from funders to professional societies – ensured a common vision and provided the leverage needed to engage a large number of hospitals and clinicians.
While the US maternal mortality rate has worsened in the 2010s, California nearly halved its rate from an average of 13.1 per 100,000 live births in the baseline period of 2005–09 to a three-year average of 7.0 during 2011–13. This level is comparable to the average rate of 7.2 in Western European countries in 2015. However, the mortality disparity ratio between Black and White mothers remained unchanged, pointing towards causes beyond the quality of care received, such as health care delivery issues, social determinants, or chronic racism.