What Works

California program cuts maternal deaths in half

The caveats: California stands out as the exception to the rule. And its program is thorough and fairly involved.

Joseph Burns
Contributing Editor

Maternity care in the United States is an international disgrace. More women in this country die of pregnancy- and childbirth-related complications than they do in any other developed country.

In California, though, it is a different story. Twelve years ago, the California Maternal Quality Care Collaborative (CMQCC) was formed after the state Department of Public Health (DPH) began investigating why maternal complications and deaths were rising. By 2013, the CMQCC showed that the average rate of death due to complications during childbirth per 100,000 live births had been cut in half, from 14 to 7, according to Elliott K. Main, MD, and colleagues who reported on these CMQCC’s efforts in the September issue of Health Affairs.

Maternal mortality rates per 100,000 live births in California and the United States, 1999–2013

Source: Main E et al., Health Affairs, September 2018

“We identified four key principles that we’ve used in multiple projects, and they’re all important in reducing the maternal death rate,” says Main, the collaborative’s medical director. The quartet includes linking public health surveillance data to steps needed to improve care, mobilizing public and private health organizations to work collaboratively, establishing a “low-burden,” rapid-cycle data-collection system to support improvement efforts, and implementing large-scale interventions with multiple partners to integrate clinical providers with public health services. Main, a professor of obstetrics and gynecology at Stanford, also chalks up the program’s success to cooperation with the DPH, the California Hospital Association, Covered California (the organization that runs California’s ACA exchange), and insurers.

“That’s why we have done a series of short courses for OB physician and nursing leaders each month and to mentor them as they take on quality improvement projects,” explains Main, a professor of obstetrics and gynecology in the Division of Maternal-Fetal Medicine at Stanford.

Staff from the CMQCC has been working with all 240 hospitals to help them improve the care they deliver to the 500,000 newborns and their mothers each year, Main says. Teams of staff work with hospitals in quality collaboratives to update OB physician and nursing staff on best practices in maternity care.

“They’re introducing the skills needed to improve quality in the OB units while at the same time we’re trying to implement best practices,” he says.

Each month, CMQCC combs through month-old birth certificate data from the DPH and through hospital-­provided discharge records for both mothers and babies looking for data to improve pregnancy-related outcomes. Only four other states (Florida, Maryland, Massachusetts, and Ohio) make such efforts, Main says.

Main says CMQCC has also worked with health plans to put financial incentives in place for implementing safety procedures in maternity care. It also encourages regulatory agencies to view efforts to reduce maternal deaths as important parts of certification programs. CMQCC also works to create awareness of the maternal death problem by publicizing Caesarean section and episiotomy rates, both of which have a negative effect on maternal outcomes.

Change comes when such efforts get into the mainstream news or broadcast television, he adds, pointing out that the hit TV series Grey’s Anatomy focused on reducing maternal mortality over three episodes last year. “Not only did they portray it on the show but also they tweeted about it to their eight million Twitter followers. That’s more than I can do,” Main says.


A Conversation with J. Kevin Croston, MD, and Craig Samitt, MD
By Interview by Peter Wehrwein
A Conversation with Andy Slavitt
By Interview by Richard Mark Kirkner
A Conversation with Daniel Knecht, MD
By Interview by Frank Diamond