Improving Birth Equity in California’s Health Care System


Family at home with infant.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 still three to four 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.

Our Approach

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 longstanding 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 the 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.

A summary of CHCF’s portfolio of birth equity projects can be found below.

Project Highlights


  • A research team led by Karen A. Scott, MD, MPH, at UCSF is leading 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. (In process)
  • 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 on development of 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 release. (In process)
  • The CHCF Almanac report Maternity Care in California describes the state of maternity care in California, including available statewide data that highlights disparities in maternity care and maternal outcomes. (November 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. (August 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. (September 2018)

Delivery System Interventions

  • 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)
  • Diversity Uplifts is leading an effort to support Black women / 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 [Inland Empire]) and establishing a statewide doula hotline. (In process)
  • The California Black Women’s Health Project is providing training and support to Black birth workers who are supporting Black mothers / birthing people during the COVID-19 pandemic, including training on maternal mental health, capacity building for providing care virtually, and virtual safe spaces to help address stress and burnout during the pandemic. (In process)
  • Funded by a program-related investment from the CHCF Health Innovation Fund, Docent Health is scaling and tailoring their 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 this CHCF blog post. (In process)
  • Led by Rachel Hardeman, PhD, a team at Diversity Science developed a set of online learning (e-learning) modules to assist hospitals in meeting the stipulations of California Senate Bill 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. (April 2021)
  • The National Health Law Program conducted focus groups to better understand on-the-ground issues impacting doulas who provide care in California (e.g., scope of practice, training/certification, reimbursement), and produced educational materials for key decisionmakers, including policymakers, to help inform the discussion about Medi-Cal coverage for doulas. (June 2020)
  • The Pacific Business Group on Health has 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 practices. (February 2020)

Lived Experience and Community Voice



Learn More

For information, please contact Stephanie Teleki.

*We use the term “birthing people” to recognize that not all people who become pregnant and give birth identify as a woman or a mother.