Maternal health outcomes are important measures of the health of a nation.¹ In the United States, these outcomes, including morbidity and mortality, are often negative, with significant differences by demographic, geographic, economic and social factors.^2,3 In 2023, the US pregnancy-related mortality ratio was 18.7 deaths per 100,000 live births, continuing a general upward trend since 1987.³ Severe maternal morbidity (SMM) is also high, with approximately 50,000 cases of SMM per year.¹ Differences in SMM rates also exist by race/ethnicity, age, geography, income, insurance, disability, and hospital type.^1,4 Although factors contributing to maternal morbidity and mortality are complex, evidence from Maternal Mortality Review Committees (MMRCs) indicates that more than 80% of pregnancy-related deaths are preventable, and almost half of pregnancy-related deaths could be prevented with improvements in care quality at the provider, hospital, and system level.^5–8 This makes the quality of health care provided to pregnant women an overarching concern and an important lever for improving outcomes.^5–7 This commentary will provide a broad overview of the quality improvement (QI) activities of Perinatal Quality Collaboratives (PQCs) and their use of patient safety bundles (PSBs) to improve maternal health care quality, with the goal of improving maternal health outcomes.

PQCs are state or multistate multidisciplinary teams of nurses, midwives, physicians, QI experts, public health practitioners, patients, and families working to improve the quality of care for mothers and infants.¹⁶ PQCs support hospitals in implementing QI activities that increase adoption of evidence-informed practices and help to standardize care.¹⁷ Currently, there are maternal and/or infant QI activities occurring in every state in the United States, and a PQC in all 50 states, Washington, DC, and the Defense Health Agency.¹⁸ The Centers for Disease Control and Prevention (CDC) has provided funding and technical assistance to PQCs since 2011, growing from an initial cohort of 3 to 36 funded PQCs in 2025. The National Network of PQCs (NNPQC) was formed in 2016, with the support and partnership of March of Dimes, CDC, and perinatal QI experts.¹⁹ The NNPQC develops tools and trainings to increase the capacity of all PQCs and provides a national platform for PQCs to collaborate and share best practices, barriers, and successes. The NNPQC continues to receive CDC support and has been coordinated by the National Institute for Children’s Health Quality since 2017.¹⁸

PQCs are uniquely positioned to implement QI activities based on state priorities, emerging maternal and infant health issues, recommendations of MMRCs, and changes in best practices identified by clinical membership organizations.¹⁷ Despite differing organizational characteristics, PQCs apply similar methods to identify priority issues and engage hospitals in QI activities. Fig. 1 provides a framework to understand the PQC approach to QI activities. While Fig. 1 may suggest a linear process, the PQC approach to QI implementation is iterative. Each QI activity builds upon the next, feeding back lessons learned throughout the QI implementation process. Additionally, there are often multiple QI activities at various stages being implemented at the same time.

PQC steps to QI implementation are as follows:

Step 1. Identify priority issues

PQCs typically focus on priority issues in their state, frequently working collaboratively with hospitals, QI experts, state health departments, and other partners to identify the most pressing areas in need of improvement.

The concept of a PSB was first introduced by IHI in 2001 and is defined as “a small set of evidence-based interventions for a defined patient segment/population and care setting that, when implemented together, will result in significantly better outcomes than when implemented individually.”²⁹ PSBs organize recommended clinical practices into a readily implemented package, creating a roadmap that hospitals can follow to redesign care processes and improve care quality. PSBs are an effective approach to improving health care quality and outcomes.²⁹ Maternal PSBs originated in 2012 through the grassroots efforts of 22 obstetric care leaders who recognized the need to improve maternal outcomes in the United States.³⁰ This multidisciplinary effort grew through partnerships with professional and advocacy organizations. Subsequently, with the collaboration of clinical experts, the initial maternal PSBs were developed and published in 2014.³⁰ These efforts were formalized with the creation of the Alliance for Innovation on Maternal Health (AIM), which was founded and is fully funded by the Health Resources and Services Administration (HRSA).³¹

AIM bundles play an important role as population-specific PSBs and offer an evidence-informed, structured way to improve patient care and outcomes.³² AIM PSBs are commonly used by PQCs as the foundation of their QI activities. The AIM Technical Assistance Center, overseen by the American College of Obstetricians and Gynecologists through a cooperative agreement with HRSA, also provides PQCs with PSB support and PSB data collection tools.³³ There are currently 8 core PSBs released by AIM, each addressing a specific clinical condition. The AIM PSBs follow a consistent structure, with activities grouped into 5 categories (1) readiness, (2) recognition and prevention, (3) response, (4) reporting and systems learning, and (5) respectful, equitable and supportive care.³² Fig. 1 highlights the role of AIM PSBs within the PQC QI implementation approach.

PQCs provide vital infrastructure that brings hospitals across a state together to implement relevant AIM bundles and other PSBs to improve the quality of care. PQCs support collaboration between hospitals and communities, helping to create clinical-community linkages, which support improved care and outcomes.³⁴ Additionally, while the focus of this article is maternal QI activities, PQCs also work to improve neonatal care through QI activities in both neonatal intensive care units and well-baby nurseries. Due to the intersectionality of maternal and neonatal well-being and shared factors affecting the quality of their care,³⁵ PQCs are increasingly implementing QI activities to improve care for the maternal/neonatal dyad.¹⁸ In their role as conveners, collaborators and QI experts, PQCs are essential to maternal and infant health improvement efforts and have demonstrated success in improving management and outcomes of priority conditions.

Highlighted below are some recent examples of how PQCs have improved the quality of maternity care and positively impacted health outcomes using PSBs.

PQCs are important statewide networks of teams working across multiple levels (health care systems, hospitals, and providers) to reduce variation in care, increase the adoption of evidence-informed practices, and improve the quality of care for all mothers and infants across the United States. PSBs are essential tools that provide a structured implementation approach to evidence-informed practices and health care quality improvement. PQCs have demonstrated success using PSBs in improving maternal and infant care and outcomes across a wide range of hospitals, including rural and urban, all levels of maternal care, and low- and high-volume hospitals.^41,42 PQCs also demonstrated their resilience by continuing successful QI implementation during the COVID-19 pandemic.⁴²

There is a PQC in every state, Washington, DC, and the Defense Health Agency.¹⁸ As PQCs mature, they are beginning to expand their activities outside of the hospital, engaging outpatient clinical practices, community health centers, and women with lived experience.^54,55 These growing networks of partners, along with key strategies like collaborative learning and rapid-cycle data processes, make PQCs well positioned to address emerging perinatal health issues. PQCs serve as conveners, able to leverage their networks to bring together a range of partners and act as force multipliers to improve maternal and infant health. Care coordination is an important means to improving outcomes,^34,56,57 and increased attention is being given nationally to the creation of clinical-community partnerships; for example, new models of care that focus on whole-person care,⁵⁸ recent QI PSBs created for outpatient settings,^32,59 and a new program that links community-based organizations and hospitals.⁶⁰ Like these national efforts, PQCs are also supporting the creation of strong clinical-community linkages through collaborations with a wide range of partners.

In addition to varied partners, the multidisciplinary nature of most PQC teams is also key to their success. Made up of nurses, midwives, physicians, QI experts, public health practitioners, patients and families, PQCs benefit from the knowledge, skills, and perspectives of these various groups. Support from hospital-level providers is also essential for PQCs’ success. There are multiple ways providers can contribute to PQC efforts (Box 2), with the first step being to identify their state PQC on the NNPQC interactive map of PQCs.¹⁸ Second, providers can learn about ongoing statewide QI efforts by visiting their state PQC Web site and reviewing the data reports and resources available. Third, providers can actively engage with their state PQC. Attending PQC sponsored education events is one simple way to participate and often comes with the benefit of continuing education credit. Obstetric clinician champions are essential to successful QI implementation by encouraging the interest of their peers and supporting changes in the culture of the L&D unit.¹⁷ Difficulties in recruiting clinical champions is the most common barrier reported by hospital teams striving to implement QI activities.¹⁷ In addition to clinical champions, PQCs often rely on obstetric clinicians to fill leadership positions, helping to bridge the gap among QI specialists, public health practitioners, and clinical boots on the ground.¹⁷ Finally, endorsing QI efforts to hospital leadership and educating providers in their networks are other important ways obstetric clinicians can support their state PQC.¹⁷

PQCs are composed of implementation experts working to reduce variation in care and increase the adoption of evidence-informed practices through implementation of PSBs and other QI activities. PQCs serve as conveners, bringing broad partners together and moving data on maternal and infant health outcomes to action. By standardizing clinical care, streamlining workflows, and developing and measuring improved processes and protocols for care, PQCs are reducing errors and improving health outcomes.⁶¹ Many PQCs have demonstrated measurable improvements to maternal health outcomes through quality improvement initiatives.^{23,37,38,41,42,47,52,53}

The expansion of PQC activities to settings outside of the hospital may help address the complex social factors that impact maternal morbidity and mortality. For example, care coordination is an important strategy to improve outcomes.^34,56,57 Many PQCs are working to improve care coordination, such as connecting pregnant and postpartum women to needed social services.^62,63 Through partnerships with clinicians, public health advocates, communities and women with lived experience, PQCs are uniquely positioned to connect broad partners to work together to improve maternal and infant health outcomes across the Unites States, improving outcomes for all mothers and their babies.