Why This Work Matters
In California, as in much of the US, Black mothers / birthing people* experience the highest rates of maternal morbidity (serious complications) and mortality (death) of any racial/ethnic group. Despite impressive reductions in maternal mortality for all racial/ethnic groups in California, Black mothers / birthing people are four to six times as likely to die (PDF) from pregnancy/birth-related causes and twice as likely to suffer a maternal morbidity (such as hemorrhage and infection) than those in all other racial/ethnic groups. These statistics are especially concerning, given that maternal morbidity and mortality metrics are widely considered to be some of the most fundamental barometers of public health.
Importantly, these variations cannot be explained away by factors such as age, income, educational level, and health insurance status. Evidence points to implicit bias and racism, not race, as key causes of disparities in maternity care and maternal outcomes for Black mothers / birthing people. For example, a Black mother / birthing person with a college education is still twice as likely to die than a White counterpart with a high school education. Implicit biases and racism are known to exist both at the level of the health care system and at the individual provider level.
As found in the 2018 Listening to Mothers in California survey (PDF), our health care system does not listen to mothers in general, and Black mothers / birthing people in particular are among the least listened to, costing them their health and, in some cases, their lives.
Through our investments in birth equity, CHCF aims to improve maternity care and maternal outcomes by, with, and for Black mothers / birthing people in California. We have chosen to focus on mothers / birthing people because they are an often-overlooked population, forgotten once the baby is born, and are critical members of our families and our society.
CHCF focuses specifically on improving the way the health care system serves the needs of Californians. At the same time, we acknowledge that the health care that people receive represents only a small part of what contributes to their overall health. CHCF focuses on the health care system because, as a society, we spend (and waste) many resources in health care, sometimes causing harm and even death. Although not all drivers of birth inequities can be addressed via the health care system, we believe there are meaningful opportunities for significant improvements within the system and its institutions that can impact maternal morbidity, mortality, and patient experience.
In approaching this work that aims to address long-standing inequities, we know the road will be challenging and that CHCF, as a funder, will not always get it right. We are committed to listening, to approaching the work with cultural humility (PDF), and to partnering with those most impacted by the inequities to find spreadable, scalable approaches for improvement in California’s health care system. We work in deep collaboration with our grantee partners and have established a CHCF Birth Equity Advisory Group composed of leaders in the field from whom we seek periodic input regarding the portfolio’s direction.
To advance birth equity, we must know about the health care system’s performance in key areas like health outcomes, patient experience, and equity at baseline and be able to track its progress (or lack thereof) over time. CHCF invests in the development of trusted, reliable, and valid measures; data collection; and reporting.
- Black Women for Wellness (BWW) is leading an effort to convene an independent advisory committee of Black community leaders and members to provide guidance to the UCSF Center for Health Equity. The center will develop a draft report to the California Department of Public Health on Black maternal and infant health. BWW will also initiate dissemination and community action activities around the report’s release. (In process)
- A research team led by Karen A. Scott, MD, MPH, at UCSF conducted the SACRED Birth Study to develop patient-reported experience measures to solicit feedback (via a survey) specifically from Black mothers / birthing people about their hospital care experiences, with the goal of informing quality improvement efforts in the hospital. (2021)
- The CHCF Almanac report Maternity Care in California describes the state of maternity care in California, including available statewide data that highlight disparities in maternity care and maternal outcomes. (2019)
- The California Maternal Quality Care Collaborative (CMQCC) has developed a birth equity dashboard in its maternal data center that contains data from hospitals representing 95% of the births in the state. Currently, these data are available to CMQCC’s hospital members for quality improvement purposes. (2019)
- The Listening to Mothers in California survey (cofunded with the Yellow Chair Foundation), fielded in English and Spanish by the National Partnership for Women & Families, highlights the attitudes and experiences of mothers around maternity care. Black mothers / birthing people were oversampled, and an issue brief (PDF) detailing findings is available, along with many other resources. (2018)
The maternal health care workforce can provide better care by reflecting the diversity of the birthing people it serves, as well as the diversity of provider types that evidence shows yields strong outcomes.
- Researchers at the School of Public Health at UC Berkeley are conducting research to understand and document the perspectives of payers regarding investment in community doula care in California. They are especially interested in learning about facilitators and barriers to community doula care. (In process)
- The StarLion Collective is conducting a process evaluation of Health Net’s community doula pilot. (In process)
- The Center for Health Care Strategies is conducting an environmental scan of state Medicaid efforts to cover doula services. The project will produce a brief to help California stakeholders understand approaches from other state Medicaid programs and incorporate their lessons into Medi-Cal’s efforts to incorporate doula services and promote health equity. (In process)
- The National Health Law Program conducted focus groups to better understand the on-the-ground issues (e.g., scope of practice, training and certification, reimbursement) impacting doulas who provide care in California. NHeLP produced educational materials for key decisionmakers, including policymakers, to help inform the discussion about Medi-Cal coverage for doulas. (2020)
It is now leading work to select early lessons learned from community doula pilots in California. (In process)
- Diversity Uplifts led an effort to support Black mothers / birthing people during the COVID-19 pandemic in several ways, including providing virtual doula care in five California counties (Alameda, Contra Costa, Los Angeles, Sacramento, and San Bernardino/Riverside) and establishing a statewide doula hotline. (2021)
- The UCSF School of Nursing’s Nurse-Midwifery Program and Cal State Fullerton School of Nursing’s Nurse-Midwifery Program are collaborating to build a robust program to mentor, retain, and launch nurse-midwives of color in their careers. (In process)
- The California Nurse-Midwives Foundation is leading work to implement SB 1237 (nurse-midwives scope-of-practice bill), support access to quality reproductive health and maternity care in the community, and engage its own staff in anti-racism training. (In process)
- Researchers at the Healthforce Center at UCSF are surveying nurse-midwives and licensed midwives in California to describe their practice, the populations they serve, facilitators and barriers to their work, and intentions for future practice. (In process)
- Purchaser Business Group on Health developed resources to promote access to and use of certified nurse midwives (CNMs), as well as tools to assist providers in integrating CNMs into their practice. (2020)
- The Urban Institute is conducting a study to understand training and workforce pathways that develop and retain Black maternal health clinicians (e.g., ob/gyns, registered nurses, midwives) in California. (In process)
- The California Black Women’s Health Project provided training and support to Black birth workers who supported Black mothers / birthing people during the COVID-19 pandemic. The trainings covered maternal mental health, capacity building for virtual care, and virtual safe spaces to help address stress and burnout during the pandemic. (2021)
Delivery System Interventions
Providers need assistance to improve birth equity. CHCF supports on-the-ground efforts to help individual providers and health care systems improve care delivery and try new, innovative models.
- Cherished Futures for Black Moms & Babies, a multisector collaborative in LA County, is working with key decisionmakers from local delivery hospitals, public health departments, health plans, and Black community leaders to implement systems-change interventions at the clinical, institutional, and community levels. CHCF is providing funding to support the core effort, an evaluation, and the development of a hospital-community engagement toolkit. (In process)
- Funded by a program-related investment from the CHCF Innovation Fund, GetWell Docent (formerly Docent Health) is scaling and tailoring its technology-enabled maternity care coordination platform, which pairs local, culturally responsive navigators with digital engagement tools to serve more birthing people enrolled in Medi-Cal. The investment, which includes funding an evaluation of the effort, builds on a growing partnership between Docent and CommonSpirit Health, the health system that delivers the most Medi-Cal births in California. Learn more about this project. (In process)
- Led by Rachel Hardeman, PhD, MPH, a team at Diversity Science developed a set of online learning (e-learning) modules to assist hospitals in meeting the stipulations of California SB 464 that requires hospitals to train their maternity care staff about implicit bias. The modules were developed with stakeholder input and are available at no cost. (2021)
CHCF is now partnering with Health Engagement Strategies to conduct outreach to increase uptake of these tools. (In process)
Lived Experience and Community Voice
A key tenet of CHCF’s birth equity work is centering the voices and experiences of Black birthing people.
- Narrative Nation developed an inaugural podcast series called Birthright to share joyful Black birth stories, with the goal of lifting up the positive for Black mothers / birthing people and their families, educating communities, and informing health care providers. (2021)
Birthright is now in its second season, co-funded by CHCF and the Commonwealth Fund. (In process)
- Narrative Nation launched a national platform called Irth (“birth without the bias”) to collect Black maternity care and birth experiences, with an emphasis on screening for bias and racism. CHCF funded testing and engagement in California. (2021)
- CHCF is funding Hollywood, Health & Society, a program of the USC Annenberg Norman Lear Center, to help screenwriters more accurately depict maternity care on television. A key topic of focus in this work is birth equity for Black mothers / birthing people. Stories such as this one on The Resident help to educate the public. (In process)
- CHCF provided grants to the following community-based organizations that are rooted in Black communities and collaborate with California’s health care system to improve maternity care: African American Breastfeeding Cultural Outreach Taskforce, Black Women for Wellness, iDREAM for Racial Health Equity, Kindred Space LA / Birthing People Foundation, and Roots of Labor Birth Collective. (2020)
- CHCF is supporting the March of Dimes in its California efforts to advance birth equity. (In process)
- KFF developed a series of COVID-19 vaccine FAQ videos in English and Spanish to encourage birthing people in the perinatal period to get vaccinated. The videos are part of The Conversation: Between Us, About Us, KFF’s campaign to provide Black and Latinx communities with credible information about the COVID-19 vaccines. (In process)
* We use “birthing people” to recognize that not all people who become pregnant and give birth identify as a woman or a mother.