Perinatal Quality Improvement Among Medicaid Populations in Hawai'i: Insights from a Statewide Learning Collaborative.

INTRODUCTION: Hawai'i reports favorable perinatal health outcomes compared to national averages (preterm birth rate: 9.8%; infant mortality rate: 4.6 per 1,000 live births), yet disparities persist. Native Hawaiian and Pacific Islander women experience higher rates of preterm birth (12.6%) and lower early prenatal care (62.7%). Med-QUEST, Hawai'i's Medicaid program, supported implementation of a Perinatal Quality Collaborative (PQC) to expand access to evidence-based maternal safety practices across birthing facilities. Hospitals implemented protocols (e.g., training, drills, and equipment changes) aligned with the Alliance for Innovation on Maternal Health (AIM) Patient Safety Bundles, with cross-hospital learning facilitated through structured monthly meetings and peer exchange. This study examines how the PQC operationalized quality improvement (QI) among Medicaid-serving hospitals. METHODS: We used a mixed-methods approach, including observational analysis of severe maternal morbidity (SMM) rates among Hawai'i's Medicaid population and 10 semi-structured interviews from participating birthing facilities. Interviews explored implementation processes, supports, and barriers. Hospitals' progress was tracked through milestone completion. RESULTS: Participants reported structured AIM bundle implementation, gap analyses, and sustained peer exchange within a cooperative, non-competitive culture. SMM rates increased from 2016 to 2022 and stabilized in 2023 to 2024; racial/ethnic disparities persisted throughout the PQC implementation. Qualitative findings emphasized infrastructure and context-specific adaptations rather than targeted disparity-reduction strategies. HEALTH EQUITY IMPLICATIONS: Expanding access to structured implementation support across diverse and rural hospitals may strengthen statewide QI infrastructure; targeted strategies beyond inpatient bundle implementation are likely necessary to reduce disparities. CONCLUSION: The state-level Pay-for-Performance effectively facilitated statewide implementation of AIM bundles and hospital-level QI processes among Medicaid-serving facilities. Observed SMM trends underscore the importance of sustained implementation efforts and complementary strategies to address disparities.