California’s Birthing Care Pathway: Leading the Charge In Transforming Maternal Health

INTRODUCTION

The United States is in the midst of a maternal health crisis, with unacceptably high rates of death and complications—especially among people of color. The urgency to improve maternal healthcare cannot be overstated: it is a matter of saving lives, nurturing the next generation, and breaking cycles of chronic disease. Addressing maternal health is not just a clinical priority; it is a moral imperative that will shape the well-being of our entire population.

In December 2023, the Centers for Medicare & Medicaid Services (CMS) launched a bold initiative: the Transforming Maternal Health (TMaH) Model. Designed to serve Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries, this effort represents a significant commitment to systemic change. In January 2025, CMS announced that 15 states—including California—were selected for this ambitious 10-year model, which began January 1, 2025.

In response, California’s Department of Health Care Services (DHCS) is stepping up to the challenge through the Birthing Care Pathway. This forward-thinking initiative is dedicated to delivering equitable, whole-person care that truly meets the needs of every parent and child. In this article, we explore the Birthing Care Pathway, its transformative potential for maternal and public health, and why it matters so deeply to case management professionals—those on the front lines of coordinating care and advocating for families.

BACKGROUND

The United States maternal mortality rate sharply increased in 2021 to 32.9 deaths per 100,000 births, notably occurring during the COVID-19 pandemic. The rate has since dropped to 22.3 in 2022 and 18.6 in 2023 (American Hospital Association [AHA], 2025; Joseph et al., 2024). Despite this recent decline, the United States continues to have the highest rate of maternal mortality—more than double in most cases—of all high-income nations based on available 2022 data (Gunja et al., 2024). Black women in the United States face an even greater disproportionate rate of maternal mortality at 50.3 (Hoyert, 2025).

In fact, birthing populations of color and those enrolled in Medicaid face more barriers to care and poorer health outcomes, including for their newborns (CMS, n.d.). This reality is seen in California, where Medi-Cal members have higher maternal mortality rates than those with commercial insurance and where Black, American Indian/Alaska Native, and Pacific Islander individuals bear the worst disparities (California Department of Health Care Services [DHCS], n.d.; DHCS, 2025a).

A wide range of social determinants of health (SDoH) increase this risk for birthing populations of color and those enrolled in Medicaid. These include poor access to education, emergency services, and routine healthcare, as well as contributing factors like racism and incidence of poverty, unemployment, and domestic violence (Anderson et al., 2025; Girardi et al., 2023). Maternal mortality is a key indicator of national health and well-being. Relatedly, research shows that investing in birthing populations and focusing on their SDoH needs is key to improving population health (Crear-Perry et al., 2021; Girardi et al., 2023). The TMaH Model, as implemented by California via the Birthing Care Pathway, spotlights the need for targeted reforms and interventions to improve maternal and population health outcomes.

THE CMS TMAH MODEL

The CMS TMaH Model seeks to improve maternal healthcare, boost health outcomes, and lower costs. It does so by helping state Medicaid agencies take a whole-person approach to pregnancy, childbirth, and postpartum care. The model addresses the bio-psycho-social needs of birthing populations (CMS, n.d.). The TMaH Model has three main pillars: 1) access to care, infrastructure, and workforce capacity; 2) quality improvement and safety; and 3) whole-person care delivery (CMS, n.d.). It encourages participation from state Medicaid agencies, managed care organizations, perinatal quality collaboratives, hospitals, birth centers, health centers, rural clinics, providers, and community-based organizations (CMS, n.d.).

PILLAR I: ACCESS, INFRASTRUCTURE, AND WORKFORCE

Pillar I highlights issues such as limited access to maternal healthcare providers, including obstetricians, nurse-midwives, and family physicians; weak access to services provided within local communities; and outdated methods for collecting and storing health data. TMaH Model solutions are: increasing access to birth centers and certified midwives; increasing the use of perinatal community health workers (who provide education and support throughout pregnancy) and doulas (professionals who give non-medical support during birth); improving data collection through the expanded use of electronic health records (digital versions of patients’ medical charts) and information exchanges (ways for health organizations to securely share patient data).

PILLAR II: QUALITY IMPROVEMENT AND SAFETY

Pillar II focuses on the lack of evidence-based safety practices in hospitals. TMaH Model solutions include establishing “patient safety bundles” that reduce unnecessary procedures, supporting the achievement of birthing-friendly designations for hospitals, and promoting shared decision-making between birthing individuals and their providers.

PILLAR III: WHOLE-PERSON CARE DELIVERY

Pillar III highlights several issues, including that: care often follows a “one-size-fits-all” approach, rather than being personalized; screenings for medical risks—including depression—are non-standard; health-related social need screenings are inconsistent; and providers often lack cultural competency training. TMaH Model solutions include the implementation of evidence-based medical and social risk assessments tailored to individual preferences, routine screening and follow-up for perinatal mental health and substance use, and routine screening and follow-up for health related social needs. The model also calls for developing technical assistance in cultural competency for providers.

THE CALIFORNIA BIRTHING CARE PATHWAY

The California DHCS started creating the Birthing Care Pathway in 2023. This comprehensive policy and care roadmap focuses on every Medi-Cal pregnant and postpartum member from conception through 12 months postpartum. It serves as a guide for maternity-serving organizations, such as managed care plans, counties, providers, and social services (DHCS, 2025b). The Birthing Care Pathway is a multi-year effort to advance maternal health and birth equity in California. Its goals are to reduce maternal morbidity and mortality and address racial and ethnic disparities. These disparities disproportionately affect Black, American Indian/Alaska Native, and Pacific Islander individuals (DHCS, n.d.).

The Birthing Care Pathway was developed through collaboration with key stakeholders and representation from critical voices. For example, pregnant and postpartum Medi-Cal members were recruited to share their lived experience and give policy recommendations from their distinct lens. Providers, leaders from community-based organizations, managed care plan representatives, and birth equity advocates also helped develop the Birthing Care Pathway.

In total, there are 42 Birthing Care Pathway policy solutions across the following eight focus areas:

1. Provider Access and Managed Care Plan Oversight and Monitoring
2. Behavioral Health and Trauma-Informed Care
3. Risk Stratification and Assessment
4. Care Management and Social Drivers of Health
5. Perinatal Care for Justice-Involved Individuals
6. Medi-Cal Maternity Care Payment Redesign
7. Data and Quality
8. State Agency Partnerships

The Birthing Care Pathway aligns with and is supported by the TMaH Model. In fact, California has already implemented initiatives such as expanding Medi-Cal to include doula (trained non-medical birth companion), dyadic care (integrated care for parent and child), and community health worker benefits. Other actions include extending Medi-Cal coverage from 60 days to 12 months postpartum and enabling Medi-Cal enrollment for children and newborns through presumptive eligibility. The state also now requires perinatal mental health screenings and assessments, provides for the delivery of Community Supports services (services addressing non-medical needs) previously known as in-lieu of services, and expands high-touch care management for eligible individuals through the Enhanced Care Management benefit’s Birth Equity Population of Focus (DHCS, 2025).

IMPLICATIONS FOR PROFESSIONAL CASE MANAGERS

The role of professional case managers in maternity care must rapidly adapt to the changing environment. Case managers are relied on to bridge care gaps, serving as skilled liaisons for pregnant and postpartum individuals, healthcare providers, and community resources. Their work now includes addressing social needs, facilitating access to new benefits such as doula and community health worker services, and supporting longer postpartum coverage (Anderson et al., 2025). This larger scope requires strong cultural competence as case managers serve populations with diverse backgrounds and needs, especially those historically underserved.

Effective care coordination is the heart of case management, a skill that demands a comprehensive understanding of the complex medical, behavioral, and social factors affecting maternal health. Advocacy and a passion for serving clients are essential, enabling case managers to champion equitable access to services and empower clients to actively participate in and drive their care. Collaboration opportunities have grown, with case managers increasingly working alongside providers, doulas, mental health professionals, and community organizations to deliver holistic, person-centered care. These partnerships foster continuity and enhance the quality of maternal health services.

However, case managers face significant challenges including navigating fragmented systems, overcoming barriers to culturally appropriate care, and addressing persistent disparities in maternal health outcomes. Strategies for success include leveraging enhanced care management models, using data-driven approaches to identify and address health related social needs, and fostering strong relationships with trusted community partners. By embracing these evolving roles and strategies, professional case managers can drive meaningful improvements in maternal health equity and outcomes within California’s Birthing Care Pathway and across similarly expansive state-driven initiatives under the CMS TMaH Model and beyond.

CONCLUSION

California’s Birthing Care Pathway stands at the forefront of a national movement to transform maternal health. This is more than policy—it is a call to action. As we expand benefits, strengthen care coordination, and center culturally competent, holistic support for birthing populations, we have the power to rewrite the story of maternal health in this country. For case managers, the charge is clear: step up, lead, and be relentless advocates to ensure these reforms translate to real, lasting change.

REFERENCES

American Hospital Association. (2025, February 6). CDC: U.S. maternal mortality rate declined in 2023. AHA News. https://www.aha.org/news/headline/2025-02-06-cdc-us-maternal-mortality-rate-declined-2023.

Anderson, P., Neustrom, V., Hepting, S., Menard, M. K., Cash, K., Gbozah, K., & Tang, J. (2025). Integrating social drivers of health screening and management into prenatal care: Protocol for a mixed-methods implementation evaluation. BMJ Open, 15(10), e104837. https://doi.org/10.1136/bmjopen-2025-104837.

California Department of Health Care Services. (2025). Birthing care pathway executive summary. https://www.dhcs.ca.gov/CalAIM/Documents/Birthing-Care-Pathway-Report-Executive-Summary.pdf.

California Department of Health Care Services. (2025, January 6). California selected for new Medi-Cal initiative to improve maternal health and advance birth equity. https://www.dhcs.ca.gov/formsandpubs/publications/oc/Pages/2024/25-01-TMaH-1-6-25.aspx.

California Department of Health Care Services. (n.d.). DHCS birthing care pathway. https://www.dhcs.ca.gov/CalAIM/Pages/BirthingCarePathway.aspx.

Centers for Medicare & Medicaid Services. (n.d.). Transforming maternal health (TMaH) model. https://www.cms.gov/priorities/innovation/innovation-models/transforming-maternal-health-tmah-model.

Crear-Perry, J., Correa-de-Araujo, R., Lewis Johnson, T., McLemore, M. R., Neilson, E., & Wallace, M. (2021). Social and structural determinants of health inequities in maternal health. Journal of Women’s Health, 30(2), 230–235. https://doi.org/10.1089/jwh.2020.8882.

Gunja, M. Z., Gumas, E. D., Masitha, R., & Zephyrin, L. C. (2024, June 4). Insights into the U.S. maternal mortality crisis: An international comparison. The Commonwealth Fund. https://www.commonwealthfund.org/publications/issue-briefs/2024/jun/insights-us-maternal-mortality-crisis-international-comparison.

Hoyert, D. L. (2025). Maternal mortality rates in the United States, 2023. National Center for Health Statistics. https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2023/maternal-mortality-rates-2023.htm.

Joseph, K. S., McCandless, L. C., Metcalfe, A., McDonald, S., & Liston, R. M. (2024). Maternal mortality in the United States: Are increasing rates linked to changes in obstetric factors, maternal health conditions, or reporting? American Journal of Obstetrics & Gynecology, 230(4), 440.e1–440.e13. https://doi.org/10.1016/j.ajog.2023.10.049.