PROJECT SUMMARY Compared to many other high-income countries, the U.S. has stark maternal health outcomes – both severe maternal morbidity (SMM) and maternal mortality (MM) have tripled in the U.S. since 1993. Overall, experts estimate that nearly half of SMM and MM is preventable. Black and Hispanic women have borne the brunt of this maternal health crisis with much higher rates of severe maternal mortality (SMM) and maternal mortality (MM) than White women. To address the growing crisis, states increasingly use quality care collaboratives (QCCs) that aim to train healthcare providers using quality improvement (QI) toolkits. These QI toolkits outline maternal care processes designed to improve the diagnosis and treatment of maternal health conditions with the overall aim of reducing SMM and MM. This project will provide the first detailed analysis of the influence of state QCCs and their QI toolkits on maternal care and health outcomes overall, and across racial/ethnic groups. The limited data evaluating a few states’ QCCs indicate that certain QCCs and certain QI toolkits may improve maternal health overall – but even then, racial/ethnic disparities can persist. To assess the impacts of QCCs on maternal care and health, particularly among Black and Hispanic women, we will (1) conduct a first-of-its-kind survey of state public health departments, QCCs, and QCC collaborating hospitals, (2) construct a national state-level database combining the survey data with key maternal care and health outcomes and other publicly available data for 2003 to 2023. With this novel data, we will estimate the effects of QCCs and their QI toolkits, particularly how their effects vary by maternal race/ethnicity. These results will identify which QCCs and QI toolkits are most effective, particularly in addressing racial/ethnic disparities in maternal health. Specifically, we will use the combined data to assess four research questions: (Aim 1) How do trends in maternal care processes and health outcomes vary by race/ethnicity, geography, and other characteristics? (Aim 2) How do QCCs differ? (Aim 3) Do QCCs and their QI toolkits influence maternal care processes and health outcomes? And, (Aim 4) Which QCCs and QI toolkits most effectively address disparities in maternal care processes and health outcomes? We will test the hypotheses that: (H1) generally, QCCs and QI toolkits improve maternal care processes and health outcomes; (H2) the QCCs and QI toolkits that are most effective in reducing racial/ethnic disparities are those that use QI toolkits that focus on key drivers of disparities (e.g. pre-existing health and social conditions); and/or (H3) the QCCs and QI toolkits that are most effective in reducing racial/ethnic disparities are those that collaborate with hospitals serving greater proportions of the states’ Black and Hispanic women. In so doing, our proposed study lays a strong foundation for a comprehensive research agenda on the effects of QCCs on race/ethnic disparities in maternal health which can accelerate improvements in SMM and MM, particularly among Black and Hispanic women who are disproportionately affected but may not benefit equally from QCCs.

PROJECT NARRATIVE The rates of severe maternal morbidity (SMM) and maternal mortality (MM) have tripled in the U.S. since 1993, with the burden disproportionately falling on Black and Hispanic women. To address this maternal health crisis and growing inequity, states are increasingly turning to quality care collaboratives (QCCs) to disseminate quality improvement (QI) toolkits that are designed to improve maternal care processes and maternal health. We will combine first-of-its-kind QCC survey data with existing public data sources to evaluate the effects of QCCs and their QI toolkits on maternal care processes (cesarean births overall, and nulliparous singleton term vertex cesarean births) and maternal health outcomes (SMM and MM), with a particular focus on the effects among Black and Hispanic women.