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Families press Medical Board over maternal deaths; board data limited, advocates demand CDPH study
Summary
Families and advocates at the Medical Board of California meeting urged the board to obtain comprehensive maternal mortality data and to replicate an opioid‑project style review, saying the board’s complaint data are incomplete and fail to reveal repeat‑offender patterns.
Families who have lost mothers or infants urged the Medical Board of California to do more to identify repeat patterns in maternal care and to work with public health agencies to obtain comprehensive mortality data.
Charlene Smith, enforcement program manager, told the board the office had reviewed complaints meeting the statutory definition of maternal mortality over three fiscal years. The staff summary identified 24 complaints received in that window, 15 referrals for medical consultant review, 18 closed complaints, eight referred to investigation, five referred to the attorney general's office and two accusations filed (one surrender, one revocation).
Many public speakers called the counts too small compared with state maternal mortality estimates and pressed the board to request data from the California Department of Public Health (CDPH) and to commission a dedicated review modeled on the board’s 2015 opioid project. Families described fatal obstetric errors, delays in transfer to higher levels of care, and repeated complaints that they say were not resolved with meaningful discipline.
Board members acknowledged the data’s limits: the board’s dataset reflects only complaints that reach the enforcement pipeline and does not capture all maternal deaths or near‑miss events documented in public health reporting, hospital records or vital statistics. Staff recommended cross‑agency collaboration so the board can better identify patterns and inform enforcement and outreach.
Consumer advocates called for: (1) an interagency data agreement with CDPH or the state health data clearinghouse, (2) a targeted project to identify repeat offenders and systemic breakdowns (a ‘maternal mortality project’), and (3) clearer public reporting of outcomes when discipline is imposed. Board members asked staff to reach out to state public‑health partners and to report back at the next meeting with options for a formal data review or partnership.
Board action and next steps: No immediate enforcement decisions were announced. Staff will contact CDPH and other state partners about potential data sharing or a joint analysis and will report back to the board.
