CMQCC History: In 2020, California had 420,000 births or 1 of every 8 births in the United States born at 220 birthing facilities. Residents who identify as Hispanic account for 39% of the state’s population followed by White (38%), Asian (13%) Black (5.5%) and 3% identify as multi-racial. California is the most diverse state with large geographic area, creating implementation challenges.
In 2006, California Maternal Quality Care Collaborative (CMQCC), in collaboration with the California Department of Public Health (CDPH), launched the development and implementation of the first California Pregnancy-Associated Mortality Review committee (PAMR). The purpose of the PAMR committee was to identify preventable causes of maternal mortality and translate quality improvement (QI) lessons (by CMQCC) into actionable clinical pathways to reduce maternal mortality. The early PAMR reports identified five major drivers of maternal mortality: hemorrhage, hypertension, sepsis, cardiac conditions and venous thromboembolism. CMQCC subsequently published QI implementation toolkits on each clinical conditions and pioneered new approaches to large-scale (100-130 hospital) quality collaboratives.
A critical element in QI is timely data which provides evidence of outcome improvement, slippage or sustainability that results in a course continuation or correction. CMQCC’s Maternal Data Center (MDC) was developed in 2011 and merges two existing real-time data sources (birth certificates and hospital discharge files) that identify data outcomes for over 90 maternal quality and process metrics each stratified by race and ethnicity. Currently, 216 of 220 birthing hospitals are MDC members and represent 99% of all births in the state.
A key to success has been the participation and active partnership of many professional organizations in maternity care (obstetricians, nurses, midwives, family medicine, and anesthesiologists); every California hospital system; California Hospital Association; Department of Health Care Services (Medi-Cal); health plans; foundations; March of Dimes, persons with lived experience and multiple state, county and community agencies including Maternal Child Health Division and Vital Records.
Since the launch of CMQCC, California’s maternal mortality rate has dropped by 62%. CMQCC’s quality improvement efforts have contributed greatly to this successful reduction.
Proposal: Capitalizing on the MDC, with race stratification capability and practical equity QI tools developed by the CMQCC pilot Birth Equity Collaborative, a statewide NTSV collaborative will be launched. The goal of the initiative is to ensure all birthing populations in CA meet the Health People 2030 Goal of 23.6%. The statewide NTSV rate for 2020 is 23.3%. However, this NTSV rate masks substantial NTSV variations ranging from 10% - 41.7% and the Black NTSV rate of 26.8%.
CMQCC will work to understand, identify and bring to fruition population level best practices, tools and resources that contribute to deepening community/clinical linkages to improve outcomes. The current Community Equity Advisory Board will be expanded to assist with qualitative interviews and hospital site visits. A goal of these listening sessions is to ascertain potential hospital or community drivers of current inequities in NTSV outcomes or best practices to minimize disparate outcomes.
1. Increase participation of hospitals in birth equity efforts to reduce NTSV cesarean rates to meet the Healthy People 2030 goal of 23.6% for women of all races and ethnicities.
2. Increase participation specifically of hospitals with high rates of NTSV cesarean rates among Black gravidas or other racial groups.
3. Increase community and patient awareness of existing racial disparity in NTSV rates and the unique drivers contributing to an NTSV cesarean delivery.
4. Increase the number of hospitals with patient/community engagement practices to inform the adoption of equitable care practices.