Birth-Centered Outcomes Research Engagement (B-CORE) in Medi-Cal: Community-Generated Recommendations to Decrease Maternal Mortality and Severe Maternal Morbidity

by Priya Batra, Gabriela Alvarado, Chloe E. Bird

This Article

RAND Health Quarterly, 2023; 11(1):2


California leads the nation with its relatively low rate of maternal deaths during pregnancy and the postpartum period. However, individuals insured via Medi-Cal suffer a disproportionate share of maternal deaths and severe complications at birth; within this group of publicly insured individuals, certain racial and/or ethnic groups have even higher rates of poor outcomes. The state can attribute part of its success in lowering rates of maternal mortality (MM) to the implementation of a data-driven statewide portfolio of quality improvement activities focused on the leading causes of maternal death. This quality improvement infrastructure has not previously been leveraged to respond in a focused way to the relatively large shares of MM and morbidity still seen in the Medi-Cal-insured population. B-CORE aimed to expand on existing statewide quality improvement efforts to effectively mitigate these adverse outcomes in Medi-Cal births by engaging Medi-Cal stakeholders.

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Medi-Cal and Birth Equity

Through applied research and health care quality improvement, California has achieved a maternal mortality (MM) rate significantly lower than that measured nationally. California accounts for almost one in every eight U.S. births annually; almost half of these births are covered by Medi-Cal. MM—defined as any death of an individual while pregnant or within 42 days of giving birth—affected 23.5 of every 100,000 live U.S. births from 2018–2021. In contrast, California had a MM rate of 10.1 per 100,000 live births during that period (National Vital Statistics System, undated). However, Medicaid (Medi-Cal)-insured births in the state continue to experience disproportionate shares of MM and severe maternal morbidity (SMM) (which often precedes death). A mismatch between (1) current statewide quality improvement priorities for MM and (2) the challenges faced by Medi-Cal patients, providers, health plans, and advocates might explain the gap in maternal deaths by payer status. Involving these Medi-Cal stakeholders in identifying key opportunities for research and improvement could decrease rates of MM and morbidity more specifically among Medi-Cal–covered births.

A Deliberative Democracy Approach

This community engagement project used deliberative democracy methodology to engage stakeholders with lived experience in California's Medi-Cal perinatal care system. Deliberative democracy sessions provide community members with a structured forum in which to learn about the health issues affecting them and to identify shared priorities to solve these problems. Deliberation has previously been used successfully to engage affected individuals to identify community health research priorities and has also been proposed as a means of addressing health equity. The stakeholders generated a specific agenda of recommendations to decrease MM and SMM in the Medi-Cal population.

Key Findings

A total of 37 Medi-Cal stakeholders participated in a series of co-learning sessions on the topics of MM and SMM in the Medi-Cal–insured population. These stakeholders represented individuals who recently had a Medi-Cal–covered birth; providers, including doulas, nurses, and physicians; health plan administrators; and maternal health advocates. Most (75.7 percent) of these stakeholders then participated in deliberative sessions to identify and build consensus around priorities to decrease MM and SMM in Medi-Cal–covered births. Recommendations emerging from these sessions fell into five distinct categories:

  • Medi-Cal health plans should expand coverage, services, and benefits offered to pregnant and postpartum beneficiaries.
  • Medi-Cal should increase reimbursement rates for perinatal care providers.
  • New strategies are needed for MM and SMM data collection, data use, and data sharing (e.g., further data disaggregation to identify additional disparities, user-friendly data sharing with patients).
  • Patient experience should be a guiding principle in measuring quality of care for the Medi-Cal–insured population.
  • Anti-racism should be a top priority in perinatal care, and new approaches are necessary to ensure accountability for racism and bias in the health care system that contribute to MM and SMM.

Within each category, stakeholders articulated concrete recommendations and identified those perinatal care system actors best positioned to implement changes.

Implications for Research, Practice, and Policy

Informed by their lived experiences and participation in co-learning sessions, stakeholders successfully deliberated to generate recommendations for decreasing MM and SMM in Medi-Cal–covered births. Stakeholders intended for many B-CORE recommendations to have a specific audience (see Figure 1). These recommendations were multilevel—some took aim at the patient-provider interaction (e.g., anti-racism training), while others targeted maternal-health surveillance systems (e.g., data disaggregation). Notably, stakeholders saw policy change as a primary lever in preventing maternal death. The implementation of many B-CORE stakeholder recommendations will require statewide policy changes in areas including Medi-Cal eligibility requirements, covered benefits, network characteristics, and provider payments. The stakeholders' agenda offers California's Medicaid agency, and its contracted managed care plans, a list of changes to drive improvement that have been vetted by the community. The stakeholders' mandate for California's quality improvement leaders in maternal health was to look outside the delivery system and into social drivers of health to close the Medi-Cal gaps in MM and SMM. Finally, stakeholders also identified an agenda of research priorities to ensure that these proposed changes would be effective in improving outcomes.

The project also demonstrates the feasibility and value of employing deliberative democracy methodology to generate local solutions to critical problems in health equity. Deliberative democracy methodology could be applied to engage affected communities in identifying solutions to pressing health problems and enhance equity across a multitude of domains.

Figure 1. Policy Wheel

Colorful wheel diagram covering five domains

The wheel shows B-CORE policy recommendations, which are organized into five categories according to their specific audience.

Expand coverage & benefits:
Revise the Medi-Cal eligibility process and criteria to expand access
Extend preconception and postpartum MediCal coverage
Expand & promote covered benefits
Better integrate full-scope mental health services
Data use & sharing:
Share the data
Use the data
Disaggregate the data
Patient experience:
Make patient-centered care the norm and not the exception
Use patient experience measures as quality indicators
Increase reimbursement rates for Medi-Cal to match/surpass what is paid by private insurance
Anti-racism & equity:
Stop repeating ineffective strategies to promote anti-racism
Establish a single equitable standard of perinatal care


National Vital Statistics System, fact sheet, Maternal Deaths and Mortality Rates: Each State, the District of Columbia, United States, 2018–2021, Centers for Disease Control and Prevention, undated.

This research was funded by the Patient-Centered Outcomes Research Institute and carried out within the Quality Measurement and Improvement Program in RAND Health Care.

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