protocols, tool kits, and other resources to improve system care and response as they relate to maternal complications and warning signs for such conditions as maternal hemorrhage, hypertension, and preeclampsia. These perinatal quality collaboratives serve an important role in providing infrastructure that supports quality improvement efforts addressing obstetric care and outcomes. State-based perinatal quality collaboratives partner with hospitals, physicians, nurses, midwives, patients, public health, and other stakeholders to provide opportunities for collaborative learning, rapid response data, and quality improvement science support to achieve systems-level change. (21) The Centers for Disease Control and Prevention reports that 22 percent of deaths occurred during pregnancy, 25 percent occurred on the day of delivery or within 7 days after the day of delivery, and 53 percent occurred between 7 days and 1 year after the day of delivery. Yet, for women eligible for the Medicaid program on the basis of pregnancy in States without Medicaid postpartum extension, such Medicaid coverage lapses at the end of the month on which the 60th postpartum day lands. (22) The experience of serious traumatic events, such as being exposed to domestic violence, substance use disorder, or pervasive and systematic racism, can over-activate the body’s stress-response system. Known as toxic stress, the repetition of high-doses of cortisol to the brain, can harm healthy neurological development and other body systems, which can have cascading physical and mental health consequences, as documented in the Adverse Childhood Experiences study of the Centers for Disease Control and Prevention. (23) A growing body of evidence-based research has shown the correlation between the stress associated with systematic racism and one’s birthing outcomes. The undue stress of sex and race discrimination paired with institutional racism has been demonstrated to contribute to a higher risk of maternal mortality, irrespective of one’s gestational