Overview of Perinatal Quality Collaboratives and their activities to advance perinatal healthcare in the USA, 2022–2023

Abstract

Introduction

Perinatal Quality Collaboratives (PQCs) are state multidisciplinary teams working to improve maternal and infant healthcare by implementing quality improvement (QI) initiatives and other activities (initiatives/activities). This study aimed to improve understanding of the scope of PQCs and their work across the USA from 2022 to 2023.

Methods

The National Network of PQCs conducted an online assessment of PQCs representing all 50 US states and the District of Columbia during May–July 2023. While the assessment included some historical questions, most questions asked PQCs to report on work conducted from 1 April 2022 to 31 March 2023. Descriptive statistics of assessment data—including PQC characteristics, participation, community partner engagement, QI initiatives, and activities—were calculated.

Results

The 45 responding PQCs were primarily housed in departments of health (35.6%), academic institutions (33.3%), or non-profit organisations (22.2%). Sixty-two percent of PQCs were established within the past 10 years (2014–2023). On average, 72.6% of birthing hospitals in each state participated in their PQC. Among the 26 PQCs with neonatal intensive care unit (NICU) participation, an average of 77.1% of NICUs in the state participated in their PQC. Thirty-two PQCs (71.1%) engaged with ≥1 patient/family member, and 30 PQCs (66.7%) engaged with ≥1 community-based organisation. PQCs reported on 195 initiatives/activities that they worked on during the reporting period. Twenty-six PQCs (57.8%) were working on 3–5 initiatives/activities. Most initiatives/activities were maternal-focused (n=105, 54.4%), followed by mother–infant–dyad-focused (n=53, 27.5%), and neonatal-focused (n=30, 15.5%). The most frequent initiative/activity topics were hypertensive disorders of pregnancy; substance use disorders among pregnant women; respectful care and non-medical factors that impact health; neonatal abstinence syndrome; and mental health among pregnant/postpartum women.

Conclusion

These findings illustrate the breadth of PQC work and how PQCs could contribute to national efforts to improve perinatal care.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Perinatal Quality Collaboratives (PQCs) are state multidisciplinary teams working to improve maternal and infant health by implementing quality improvement (QI) initiatives and other activities in hospitals and healthcare settings.

• While some specific coordinated perinatal QI efforts occurred as early as the 1990s, only a few PQCs existed and had implemented statewide QI initiatives prior to 2011.

WHAT THIS STUDY ADDS

• This comprehensive overview of PQCs examines their characteristics, collaborations, and the wide range of QI initiatives and activities on which they work.

• It highlights the expansion of state PQCs in recent years and how they could play an important role in improving quality care for all pregnant women, postpartum women, and infants across the USA.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• Findings from this study can guide best practices for collaborative perinatal QI and support decision-making that can strengthen and sustain PQC infrastructure nationwide.

Introduction

Maternal and infant mortality and morbidity rates are high in the USA, and there are differences by demographics such as race/ethnicity and geography.1,4 The US Centers for Disease Control and Prevention (CDC) uses the Pregnancy Mortality Surveillance System to track national data on pregnancy-related deaths—which are maternal deaths that occur during pregnancy or within one year of the end of pregnancy, from any cause related to or aggravated by the pregnancy.¹ The US pregnancy-related mortality ratio for 2023 was 18.7 maternal deaths per 100 000 live births, which is lower than the yearly ratios during 2020–2022 but is still higher than every yearly ratio from 1987 to 2019.¹ By race/ethnicity, non-Hispanic Black women had the highest ratio of pregnancy-related mortality (49.4). Women in rural US communities also had higher pregnancy-related mortality ratios than women in urban communities.¹ For example, women living in the most rural communities in 2023 had a pregnancy-related mortality ratio of 26.8, whereas women living in the most urban communities had a pregnancy-related mortality ratio of 19.5.¹

Severe maternal morbidity (SMM), defined as unexpected outcomes of labour and delivery that can result in significant short- or long-term health consequences, is another important metric for assessing perinatal health.⁵ SMM is approximately 65–95 times as common as maternal mortality, and US SMM rates appear to be increasing.5,7 For example, a study published in 2023 found that SMM prevalence per 10 000 delivery hospitalisations increased steadily from 72.9 in 1993 to 177.1 in 2015.⁷ There are also differences in SMM by race/ethnicity.²

US infant mortality and morbidity rates are also high, and differences by race/ethnicity are similar to the differences seen with maternal outcomes.^{3 4} In 2022, the national infant mortality rate was 5.6 per 1000 live births.³ The mortality rate for infants born to non-Hispanic Black women was the highest by racial/ethnic group (10.9) and was substantially higher than the national rate.³ Also, 14.6% of non-Hispanic Black infants born in 2023 were born preterm (ie, born before completing 37 weeks of gestation), which is higher than the national preterm birth rate (10.4%).⁴

Perinatal Quality Collaboratives (PQCs) are state multidisciplinary teams striving to improve maternal and infant healthcare quality and outcomes.^{8 9} They primarily support the implementation of quality improvement (QI) initiatives and other activities in hospitals and healthcare facilities to facilitate adoption of evidence-informed clinical practices.10,12 PQCs work to address gaps in perinatal healthcare in many ways, such as working with clinical teams, perinatal QI experts, and patient/family partners to support uptake of best practices in care at hospitals and other healthcare facilities within their jurisdictions.¹² PQCs’ activities are guided by QI methodology and continuous, systematic data collection, which are used to standardise clinical practices and reduce variation in patient care.^{12 13} Increasingly, PQCs are expanding their work beyond hospitals to collaborate with community partners and incorporate perinatal patient perspectives (ie, lived experience of women who have been pregnant) into their QI initiatives and other activities.^{14 15}

Some specific coordinated perinatal QI efforts began as early as the 1990s.^{16 17} However, statewide unified implementation of QI initiatives organised by PQCs has grown rapidly since the early 2010s.^{10 13} As of 2025, most US states and the District of Columbia (DC) have PQCs that work on a variety of maternal-, neonatal-, or dyad- (maternal-neonatal) focused QI initiatives.^{9 18} Since 2011, CDC has supported PQCs with funding and technical assistance, which has contributed to their growth and expansion.11,13 CDC funding and technical assistance began with 3 PQCs in 2011 and expanded to 36 PQCs in 2023.⁹

The National Network of Perinatal Quality Collaboratives (NNPQC) was developed to support PQC capacity-building and information-sharing across all 50 US states and DC. It was established in late 2016 when key organisations and experts working in perinatal healthcare quality came together to determine goals for a national platform intended to support PQCs to improve perinatal health outcomes on a broad scale.^{12 18} The NNPQC aims to increase the capacity of all PQCs to improve maternal and infant healthcare and outcomes. It supports PQCs by providing collaborative learning opportunities, technical assistance, and mentoring.¹⁸ Since 2017, the NNPQC has been coordinated and led by the National Institute for Children’s Health Quality (NICHQ) and supported by CDC funding and technical assistance.

In 2023, the NNPQC began annually assessing the characteristics, participation, community partner engagement, QI initiatives, and activities of PQCs, as well as PQCs’ needs. This information is used to develop tailored training and technical assistance for PQCs, thereby building their capacity to improve perinatal healthcare and achieve quality care for all pregnant and postpartum women and infants. This study describes findings from the first NNPQC annual assessment, which improves understanding of the scope and work of the responding PQCs across the USA between 1 April 2022 and 31 March 2023.

Methods

NICHQ developed questions for the NNPQC annual assessment in consultation with the NNPQC Executive Committee (including PQC representatives from across the country) and CDC. Once the questions were finalised, the assessment was distributed via an online link to representatives of all PQCs (representing all 50 US states and DC) during May–July 2023. PQCs were instructed to select the person most knowledgeable about their PQC’s historical and current work to complete the assessment. The assessment included quantitative and qualitative (open text) questions about PQCs’ background, current QI initiatives and other activities (eg, participation in maternal mortality review committees (MMRCs)), and their capacity to conduct QI initiatives. While the assessment included some historical questions (eg, year of establishment), most questions asked PQCs to report on work conducted from 1 April 2022 to 31 March 2023. Forty-five PQCs responded to the assessment.

Definitions of participation and engagement

PQCs reported on birthing hospitals, neonatal intensive care units (NICUs), and other healthcare facilities (ie, well-baby units and emergency departments) participating in PQC work in their states. In the assessment, participation was defined as working with a PQC on evidence-based QI efforts/activities to improve perinatal health and achieve quality care. For the purposes of this manuscript, ‘efforts’ is synonymous with ‘initiatives’. PQCs also reported on community partners (ie, patients/family members and community-based organisations (CBOs)) engaged in their PQC activities. Engagement was defined as regular participation in PQC activities, and examples were provided, such as serving on a PQC committee or participating in informational meetings to provide feedback on PQC products.

Definitions of initiatives/activities

PQCs were asked to provide information on up to 10 QI initiatives or other activities they were working on during the reporting period. An initiative was defined as a 12–18-month results-based QI project focused on a specific topic area structured using any QI methodology. Two common examples include initiatives to address obstetric haemorrhage and initiatives to safely reduce primary caesarean births. An activity was defined as focused work on perinatal health that is not part of a longer, results-based initiative. Examples of activities were provided (eg, baby-friendly accreditation or conducting a series of provider trainings on perinatal health). The assessment questions did not differentiate between initiatives and activities; therefore, data from these questions are presented as ‘initiatives/activities’.

Patient and public involvement statement

Patients were not directly involved in this study, as its purpose was to assess the structure and activities of PQCs. However, patient involvement in PQC initiatives/activities is growing.

Data collection, management, and analysis

Data were collected through the Alchemer survey platform,¹⁹ and then they were reviewed and cleaned. In some cases, project staff contacted PQCs to clarify unclear or inconsistent responses. Three project scientists worked together through a consensus-based process to perform minor recategorisations of some responses. Recategorisations consisted of reviewing open text responses and either (1) reclassifying some of them to applicable predetermined response categories, or (2) creating new categories when a common theme not overlapping with existing categories became apparent. Data management was conducted in Microsoft Excel.

Descriptive statistics (counts, percentages, means, medians, and ranges) using the assessment data were calculated independently by two project scientists, reconciled, and validated to ensure accuracy. Microsoft Excel and SAS V.9.4 were used for the analysis.

Results

Perinatal Quality Collaborative (PQC) characteristics

Table 1 outlines characteristics of the 45 responding PQCs. Almost two-thirds of PQCs reported being established between 2014 and 2023 (n=28, 62.2%). Most PQCs were housed in departments of health (n=16, 35.6%), academic institutions (n=15, 33.3%), or non-profit organisations (n=10, 22.2%). PQCs also provided information about how they choose which initiatives/activities to implement. Most (80%) of responding PQCs (n=36) use multiple strategies to choose which initiatives/activities to implement—most common were using MMRC recommendations (n=35 PQCs, 77.8% of PQCs); steering, oversight, or executive committees (n=32 PQCs, 71.1% of PQCs); and/or PQC leadership decision (n=26, 57.8% of PQCs).

Table 1. PQC characteristics, 2023 (n=45 PQCs).

	Number of PQCs	Percent (%) of PQCs
Year established
2008 and before	7	15.6
2009–2013	10	22.2
2014–2018	15	33.3
2019–2023	13	28.9
Where PQC is housed
Department of health	16	35.6
Academic institution	15	33.3
Non-profit organisation	10	22.2
Hospital association	3	6.7
Other	1	2.2
Decision-making about initiatives/activities*†
Maternal mortality review committee recommendations	35	77.8
Steering/oversight/executive committee	32	71.1
PQC leadership decision	26	57.8
Hospital vote	15	33.3
Other, write in‡	10	22.2

^*The options for this question were not mutually exclusive. PQCs were instructed to select all options that applied to them.

^†An initiative was defined as a 12–18-month results-based quality improvement (QI) project focused on a specific topic area structured using any QI methodology. An activity was defined as focused work on perinatal health that is not part of a longer, results-based initiative. PQCs were asked to consider how they generally choose the initiatives/activities on which they work when responding to this question.

^‡Examples of ‘other, write in’ responses included reviewing other state and national data sources, partner or state needs assessment surveys, annual meeting ‘grass roots’ votes, state and national quality requirements, and currently working on better defining their decision-making processes.

PQC, Perinatal Quality Collaborative.

Healthcare facility participation and community partner engagement in PQCs

Birthing hospital participation in PQCs was calculated among all 45 responding PQCs. (table 2). Across PQCs, the average percent of birthing hospitals participating in a PQC out of the total number of birthing hospitals in the state was 72.6% (median=80.0%). NICU participation was calculated only among the 26 PQCs that noted working with at least one NICU (table 3). An average of 77.1% (median=89.0%) of NICUs participated in their state’s PQC. Other healthcare facility participation was calculated only among PQCs that reported at least one well-baby unit or at least one emergency department participating in the PQC (table 3). Among the 25 PQCs with well-baby units participating in their initiatives/activities, there was an average of 38 well-baby units (median=33; range=1–161) participating. For the 10 PQCs with emergency departments participating in their initiatives/activities, an average of 26 emergency departments (range=1–54) were participating.

Table 2. Participation^* of birthing hospitals^† in PQCs, 1 April 2022–31 March 2023 (n=45 PQCs).

	Birthing hospitals participating in PQCs	Birthing hospitals per state	Percent of state’s birthing hospitals participating in the state’s PQC‡ (%)
Mean	42	56	72.6
Median	33	48	80.0
Range	0–215	5–221	0.0–100.0
Total	1901	2530	–

^*Participation was defined as working with a PQC on evidence-based quality improvement initiatives/activities to improve perinatal health and achieve quality care.

^†Birthing hospital was defined as a hospital with a labour & delivery (L&D) unit and the necessary licensure (if available), staff, and training to provide obstetric care, regardless of the number of annual births. An L&D unit is a hospital unit dedicated to providing antepartum, intrapartum, and postpartum care.

^‡Percent of state’s birthing hospitals participating in the state’s PQC was calculated as follows: (1) the percent participation was calculated individually for each PQC by dividing the number of birthing hospitals participating in the PQC by the number of birthing hospitals in each PQC’s state and converting that number into a percent; (2) the mean and the median of these percentages were calculated across PQCs.

PQC, Perinatal Quality Collaborative.

Table 3. NICU^* participation,^† other healthcare facility participation, and community partner engagement^‡ in PQCs, 1 April 2022–31 March 2023 (n=45 PQCs).

	NICU participation in PQCs			Other healthcare facility participation in PQCs		Community partner engagement with PQCs
	NICUs participating in PQCs	NICUs per state	Percent of state’s NICUs participating in the state’s PQC§ (%)	Well-baby units¶ participating in PQCs	Emergency departments** participating in PQCs	Patients and family members engaged with PQCs	CBOs engaged with PQCs
Number of PQCs reporting ≥1 facility or partner	26	–	–	25	10	32	30
Mean	19	31	77.1	38	26	6	11
Median	11	17	89.0	33	27	3	6
Range	1–116	1–226	14.7–100.0	1–161	1–54	1–26	1–59
Total	506	794	–	962	262	187	329

^*NICU was defined as a hospital unit separate from the well-baby unit that provides care for medically unstable or critically ill newborns requiring constant nursing, complicated surgical procedures, continual respiratory support, or other intensive interventions. NICUs may include Level II, III, and IV facilities.

^†Participation was defined as working with a PQC on evidence-based quality improvement initiatives/activities to improve perinatal health and achieve quality care. It was calculated based on PQCs that reported at least one of the above healthcare facilities participating in the PQC.

^‡Engagement was defined as regular participation in PQC activities. It was calculated based on PQCs that reported at least one of the above community partners engaged with the PQC.

^§Percent of state’s NICUs participating in the state’s PQC was calculated as follows: (1) the percent participation was calculated individually for each PQC by dividing the number of NICUs participating in the PQC by the number of NICUs in that state and converting that number into a percent; (2) the mean and median of these percentages were calculated across PQCs. Only the 26 PQCs with at least one NICU participating in the PQC were included in this calculation. Ten PQCs that selected do not know/unknown and nine PQCs that reported zero NICUs participating in the PQC were excluded from this calculation.

^¶Well-baby unit was defined as a hospital unit, sometimes referred to as the nursery, able to evaluate and provide postnatal care to stable term and near-term infants; able to stabilise ill and preterm infants until transfer to higher level of care.

^**Emergency department was defined as any department or facility of a hospital, regardless of whether it is located on or off the main hospital campus, that is licensed as an emergency department and held out to the public as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment.

CBO, Community-based organisation; NICU, Neonatal intensive care unit; PQC, Perinatal Quality Collaborative.

Community partner engagement was calculated among PQCs with at least one engaged partner (table 3). Thirty-two responding PQCs (71.1%) had at least one patient or family member engaged with their PQC. These 32 PQCs had an average of 6 (median=3; range=1–26) engaged patients or family members. Thirty responding PQCs (66.7%) noted at least one CBO engaged with their PQC. These 30 PQCs had an average of 11 (median=6; range=1–59) CBOs engaged with them.

PQC initiatives or other activities (initiatives/activities)

The 45 PQCs reported on 195 initiatives/activities that they worked on during the reporting period. Twenty-two percent of PQCs (n=10) reported they were working on 0–2 initiatives/activities, 58% of PQCs (n=26) were working on 3–5 initiatives/activities, and 20% of PQCs (n=9) were working on six or more initiatives/activities.

For each initiative/activity reported by a PQC, the assessment asked about the phase, focus, topic, and whether it incorporated elements to reduce differences in perinatal care or outcomes. Of note, two missing responses were excluded from the question about focus, and 16 ‘other, write in’ responses were excluded from the question about reducing differences in perinatal care or outcomes due to written responses not being applicable to the question. Of all the reported initiatives/activities, the majority were in the active phase (44.1%) or the planning phase (29.2%) (table 4). Initiatives/activities were most commonly maternal-focused (n=105, 54.4%), yet almost half of the initiatives/activities involved infant care either exclusively or through a mother–infant–dyad approach (n=83, 43.0%). PQCs reported that 91.1% of initiatives/activities (163 of the 179 applicable initiatives/activities) incorporated elements to reduce differences in perinatal care or outcomes.

Table 4. Number and percentage of PQC initiatives/activities^* by phase, focus, and incorporation of elements to reduce differences in perinatal care or outcomes, 1 April 2022–31 March 2023 (n=195 initiatives/activities).

	Number of initiatives/activities	Percentage (%) of all initiatives/activities
Phase (n=195)
Planning	57	29.2
Pilot	15	7.7
Active	86	44.1
Sustainability	32	16.4
Other, write in†	5	2.6
Focus (n=193)‡
Maternal	105	54.4
Neonatal	30	15.5
Dyad	53	27.5
Other, write in§	5	2.6
Incorporation of elements to reduce differences in perinatal care or outcomes (n=179)¶
Yes	163	91.1
No	16	8.9

^*PQCs were asked to report on up to 10 initiatives or other activities they were working on from 1 April 2022 to 31 March 2023. They were asked multiple questions about each initiative or other activity they reported. An initiative was defined as a 12–18-month results-based quality improvement (QI) project focused on a specific topic area structured using any QI methodology. An activity was defined as focused work on perinatal health that is not part of a longer, results-based initiative. These questions did not differentiate between initiatives and activities; therefore, data from these questions are presented as the combined number of ‘initiatives/activities’.

^†Examples of ‘other, write in’ responses included that the work did not have a phase (eg, an activity focused on educational activities and/or resource development), that they were in the process of determining the status, or that they were awaiting approvals.

^‡Two initiatives/activities were missing information about the focus.

^§Examples of ‘other, write in’ responses included other populations of emphasis (eg, providers and other professionals, early childhood, whole family, and community) as well as an initiative/activity focused broadly on obstetric readiness in the emergency department.

^¶The 16 initiatives/activities that were marked as ‘other, write in’ on this question were not included in the final calculation. This is because project scientists read the accompanying text explanations and determined that the responses were unknown or not applicable for incorporating elements to reduce differences in perinatal care or outcomes.

PQC, Perinatal Quality Collaborative.

PQCs were asked to categorise each initiative/activity by topic, selecting one or more topics from a prepopulated list and/or providing an open text response (table 5). The most frequently reported initiative/activity topics included hypertensive disorders of pregnancy (16.9% of initiatives/activities; 64.4% of PQCs); substance use disorders (SUDs) among pregnant women (15.4% of initiatives/activities; 57.8% of PQCs); respectful care and non-medical factors that impact health (11.3% of initiatives/activities; 35.6% of PQCs); neonatal abstinence syndrome (8.7% of initiatives/activities; 37.8% of PQCs), and mental health among pregnant or postpartum women (6.7% of initiatives/activities; 26.7% of PQCs).

Table 5. Top 10 most frequently reported PQC initiative/activity^* topics,^†‡ 1 April 2022–31 March 2023 (n=195 initiatives/activities; n=45 PQCs).

Topic	Number of initiatives/activities§	Percent (%) of initiatives/activities	Number of PQCs	Percent (%) of PQCs
Hypertensive disorders of pregnancy (including pre-eclampsia)	33	16.9	29	64.4
Substance use disorders among pregnant women (including but not limited to opioids)	30	15.4	26	57.8
Respectful care and non-medical factors that impact health	22	11.3	16	35.6
Neonatal abstinence syndrome	17	8.7	17	37.8
Mental health among pregnant or postpartum women	13	6.7	12	26.7
Access to care (can include maternal antepartum, postpartum, and/or neonatal care)	11	5.6	8	17.8
Obstetric haemorrhage	11	5.6	11	24.4
Caesarean delivery reduction, promotion of vaginal birth	9	4.6	9	20.0
Breastfeeding, human milk	8	4.1	6	13.3
Emergency department services for pregnant or postpartum women	7	3.6	7	15.6

^*PQCs were asked to report on up to 10 initiatives or other activities they were working on from 1 April 2022 to 31 March 2023. They were asked multiple questions about each initiative or other activity they reported. An initiative was defined as a 12–18-month results-based quality improvement (QI) project focused on a specific topic area structured using any QI methodology. An activity was defined as focused work on perinatal health that is not part of a longer, results-based initiative. These questions did not differentiate between initiatives and activities; therefore, data from these questions are presented as the combined number of ‘initiatives/activities’.

^†PQCs could select one or more topics from the provided list that best described the initiative/activity they were reporting.

^‡Eleven PQCs (24.4%) noted working on 16 initiatives/activities categorised as ‘other, write in’ because they did not fit into any of the topics provided. Some examples of these write-in topics included newborn admission temperature, updates to neonatal hyperbilirubinaemia guidelines, and chronic lung disease. ‘Other, write in’ does not appear in the table because it was not a topic in and of itself but rather a list of individual topics that did not fit into any provided topic categories.

^§The table is sorted in descending order by the number of initiatives/activities addressing each topic.

PQC, Perinatal Quality Collaborative.

Discussion

These 2023 NNPQC annual assessment findings represent a comprehensive compilation of PQC activities to date, and they highlight the range of PQCs’ efforts to improve care for perinatal populations across the USA. Most PQCs are relatively new, having been established within the past decade (2014 or later), and where PQCs are housed varies considerably. On average, 72.6% of birthing hospitals participated in their state PQC. PQCs were involved in many different QI initiatives or other activities, with most being in either the planning or active phases. Although 54.4% of initiatives/activities were focused on maternal health, almost half of initiatives/activities involved infant health either exclusively or through a mother–infant–dyad approach. Many PQCs have engaged with at least one patient/family member and at least one CBO. PQC initiative/activity topics were varied, and most incorporated elements to reduce differences in perinatal care or outcomes.

Findings from this assessment show that most PQCs are taking MMRC recommendations into consideration when choosing initiatives/activities to improve perinatal healthcare and outcomes, which may indicate that they are committed to implementing data-driven interventions aimed at preventing leading causes of maternal mortality. Indeed, most responding PQCs reported using MMRC recommendations when choosing their initiatives/activities. Furthermore, 57.8% of PQCs worked on initiatives/activities addressing SUDs, and 26.7% of PQCs worked on initiatives/activities addressing mental health. MMRC data from 38 states revealed that mental health conditions (including suicide and overdose/poisoning related to SUD) were the leading underlying cause of pregnancy-related deaths in 2020, and SUD was specifically documented as a circumstance that contributed to 25% of all pregnancy-related deaths.²⁰ Furthermore, the most common topic on which PQCs worked was hypertensive disorders of pregnancy, which was the sixth leading cause of pregnancy-related deaths according to 2020 MMRC data.²⁰ These findings suggest that PQCs play an important role in implementing actionable recommendations derived from data gathered and interpreted by MMRCs. MMRCs determined that 84% of pregnancy-related deaths in 2020 were preventable,²⁰ and PQCs are directly addressing these critical and preventable causes of pregnancy-related deaths.

Almost two-thirds of PQCs were conducting initiatives/activities to address SUD among pregnant women and/or neonatal abstinence syndrome. PQCs are uniquely positioned to support healthcare facilities, clinicians, and community partners in taking a comprehensive approach to addressing SUD and its sequelae among pregnant and postpartum women and their infants.^{14 15 21} Examples of strategies conducted by PQCs include supporting implementation of protocols for universal screening of pregnant women with validated tools, helping facilities connect pregnant or postpartum patients with SUD to treatment and recovery resources, incorporating patient lived experience into healthcare provided to families impacted by substance use, facilitating training of clinicians in providing respectful care to pregnant women who use substances, and emphasising non-pharmacological treatment of substance-exposed infants.^{14 15 21} Other work broadly examining the role of PQCs in addressing SUD found that PQC infrastructure enabled widespread sharing of comprehensive resources and trainings and facilitated uptake of best practices.^{22 23}

Research indicates that patient- and family-centred approaches can improve care and health.²⁴ Many PQCs have traditionally focused on QI initiatives in hospital settings¹³; however, findings from this assessment indicate that PQCs have increasingly embraced the importance of incorporating varied perspectives and participation of patients, family members, and CBOs to enrich their work. Meadows and colleagues (2023) described examples of how PQCs can incorporate patients and communities into QI initiatives.²⁵ Examples include patients, family members, and CBOs participating in PQC committees or workgroups to help develop and guide PQC activities to benefit the communities involved; sharing lived experience (eg, through testimonials and presentations) to increase understanding of and support for the work; and providing input on PQC education and dissemination materials.²⁵ Specific examples of PQCs carrying out these activities are documented in published literature^{14 15 26} and in less formal PQC outputs (eg, reports and websites). Additionally, Meadows and colleagues (2023) emphasised that PQCs can more broadly incorporate community context and consideration of health-related social needs into their perinatal care efforts.²⁵

PQCs also demonstrated a strong commitment to reducing differences in perinatal care or outcomes, either directly through focused initiatives/activities or indirectly by incorporating elements of respectful care into ongoing initiatives/activities. Indeed, there has been increasing attention to PQCs and their pivotal role in both reducing differences in perinatal healthcare and improving respectful care practices.^{15 25 27 28} PQCs use multifaceted approaches in their work to support perinatal populations at increased risk of negative outcomes, such as using disaggregated data to identify and track differences by demographic characteristics, engaging patients and families, and educating providers about respectful care.^{25 27} A key area of continued growth for PQCs is fostering organisational and state commitments to addressing health-related social needs, as well as variations in care quality.²⁷ While PQCs have had successes supporting improved care and outcomes for perinatal populations at increased risk of negative outcomes, more work is needed to enhance respectful care for all perinatal populations across all PQC initiatives/activities.

Strengths and limitations

This study has several strengths, including the robust response rate. Forty-five out of 50 PQCs (90.0%) that received the annual assessment responded. As such, our study is among the most comprehensive published assessments of PQCs and their characteristics, participation, community partner engagement, QI initiatives, and other activities to date.

Nonetheless, since the response rate was less than 100%, information obtained may not represent all existing PQCs across the USA. Also, two of the responding PQCs were maternal-only PQCs, which means that they only work on maternal care. Their states had two separate PQCs when the assessment was fielded; however, their infant-only PQCs (that work specifically on infant care) were not invited to respond. We do not have specific information about the non-responders to compare to the responders.

Another limitation pertains to the questions about PQCs’ initiatives/activities. First, this question was combined to ask about initiatives or other activities together rather than separately. A QI initiative typically has more distinct methodology than an activity. A clearer distinction between initiatives and activities would improve understanding of PQCs’ work and capacity-building or technical assistance needs. Second, PQCs could only provide information on up to 10 initiatives/activities they were working on during the reporting period. Although only two PQCs noted working on 11 or more initiatives/activities, the 195 initiatives/activities reported on in this manuscript may not represent the total number of initiatives/activities on which PQCs had worked.

An additional limitation is that these data were self-reported. While this can be viewed as a strength since PQCs are best positioned to report on their own activities and operations, it also introduces the potential for bias. An independent assessment of PQCs conducted by an external team could have yielded different results. Additionally, there may be instances in which PQCs misunderstood or misinterpreted instructions or questions. Furthermore, we did not explore differences in responses based on PQC characteristics such as size, location, and length of existence, which presents an opportunity for future study.

Moreover, these data are purely descriptive. Although PQC work is aimed at improving maternal and infant healthcare and outcomes, these data cannot be specifically used to evaluate the impact of PQCs on healthcare and outcomes. Future studies evaluating the impact of PQCs at the national level would build on the work conducted in this study.

A final limitation is that this study cannot be used to directly compare the work of state PQCs to other international perinatal improvement networks. In addition to a lack of outcome data, differences in health system structure limit any direct comparisons.

Conclusion

This comprehensive assessment of PQCs highlights their characteristics, collaborations, and the wide range of QI initiatives and activities they undertake, which demonstrates the depth and breadth of PQC efforts to improve the quality of maternal and infant healthcare across the USA. The assessment findings also identify opportunities for improvement and growth for PQCs, such as continuing to increase engagement with patient/family partners with lived experience and further expanding collaborations beyond hospitals (eg, with other healthcare facilities and CBOs).

PQCs play a unique and important role in national efforts to improve maternal and infant healthcare and outcomes. These findings demonstrate the networks that PQCs have developed across hospitals and communities, creating important clinical-community linkages and partnerships that can increase the reach of PQCs and their positive impact on perinatal health in the USA. As PQCs continue to evolve, their efforts to address differences in perinatal care and improve care quality could contribute to achieving better health outcomes for all pregnant and postpartum women and infants across the USA.

The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Data availability statement

The data are not publicly available as they were collected for internal program evaluation and to assess PQCs’ technical assistance needs.