Earlier this year Covered California, the state health insurance exchange, issued an ultimatum to hospitals: lower the rates of cesarean (C-sections) for low-risk first-time mothers by 2020 or get bounced out of the allowed network of hospitals.

In June, the California Health Care Foundation (CHCF) extended that effort by engaging first-time mothers with a new campaign called My Birth Matters.

The campaign includes animated videos that highlight pregnant women who are white and of color, as well as flyers and posters for providers’ offices. “The goal,” said Stephanie Teleki, director of the campaign at CHCF, “is to support the state’s effort by educating women about the overuse of C-sections and encouraging conversations between expectant moms and their providers.”

“The campaign is designed to give mothers on the full range of health literary levels the language and tools to discuss the delivery,” Teleki said. In an effort to have mothers identify fully with the videos, several show mothers of different races and ethnicities, including African American mothers, who have the highest rates of C-sections in the state.

According to CHCF, in recent years nearly one-third of low-risk, first-birth deliveries occurred via C-section in California. That rate is higher than the federal Healthy People 2020 goal of 23.9 percent, which also is the goal set by Covered California. Health experts in California also worry about the variations at individual California hospitals where rates of C-sections can range from 11 percent to more than 60 percent.

C-sections can be lifesaving if a baby or mother is in immediate distress or a mother is at risk if she delivers vaginally. Long labors, for example, can exacerbate high blood pressure and diabetes.

But C-sections are not without their own risks which can include higher rates of hemorrhage, transfusions, infection, and blood clots for mothers. For babies, the risks include higher rates of infection, breathing complications and lower breastfeeding rates.

“Those risks are unwarranted if the C-section isn’t needed,” said Elliot Main, clinical professor of Obstetrics and Gynecology at Stanford University and the medical director of the California Maternal Quality Care Collaborative, a partner with CHCF on the new campaign. The collaborative, based at Stanford Medical School, was launched in 2006 to help end preventable deaths, complications and racial disparities in California maternity care.

The My Birth Matters campaign is aimed at every demographic, but experts are also keenly focused on lowering C-section rates for African-American mothers. While births to African American mothers comprise only 5.5 percent of births in California, their rate of C-sections is on average 5 percentage points higher than other racial and ethnic groups, said Main.

Explanations for the high rates of C-sections include time management by doctors and hospitals—C-sections take about 45 minutes, while women can labor for hours to days—fear of lawsuits, and a culture in hospitals “where abdominal surgery to deliver a baby has come to be seen as routine,” said Teleki. (Preference by mothers, often cited as a reason for high rates of C-section is a very tiny reason for the high rate, Teleki noted.)

For black mothers the reasons appear to be more complex, Main said.  “Risk factors in black women (such as obesity and diabetes, which raise risks for vaginal deliveries) account for a piece, but not a large piece. We think there is a high likelihood that black women are treated differently than white women. We’re now in speculation as to why.”

A key question, said Dr. Main, is whether black women are treated with dignity and respect. “Are they listened to? Are they included as part of the team?”

Rahwa Neguse did not feel like she was part of the team when she had her daughter, Deta, almost three years ago. When Neguse’s labor failed to progress, a doctor came in and said that while it wasn’t an emergency, he wanted to raise the idea of a C-section. Neguse said no, but soon another doctor came in to suggest a C-section as well, but repeated that there was no emergency.

“If there was no emergency, why did they send two doctors in, one right after the other, to talk to me?” asked Neguse. Neguse, 35, is the executive director of Healthy Black Families, an advocacy group based in Berkeley. She felt as though the decision to perform a C-section was made “outside my room without me.”

Although her only adverse effect was pain following the surgery, she is supportive of giving women tools to have a conversation about their delivery. “Women should ask for a better understanding of whether there is indeed a risk for the baby or herself if a C-section isn’t done,” Neguse said.

In addition to the new campaign for mothers, the California Maternal Quality Care Collaborative has released a toolkit for providers, to slow down the decision making process that takes a normally progressing labor to a C-section. The toolkit includes strategies to help improve communication among nurses and doctors involved in a delivery, and techniques that can aid labor, such as a variety of positions for the mother and space for the mother to walk during labor to induce delivery.

Payment shifts can help as well, said Main. C-sections cost at least $5,000 more than vaginal deliveries. The toolkit includes strategies aimed at helping hospitals and doctors shift away from payment models that reward doctors for performing C-sections and towards payment models that reward quality outcomes, said Main.

In 2014, the American Academy of Obstetricians and Gynecologists issued guidelines to help reduce C-sections. “There’s a need to balance many things when assessing risk including more careful reading of maternal and baby monitoring and being patient with the process of labor,” said Aaron Caughey, chair of the Department of Obstetrics and Gynecology at the Oregon Health & Science University School of Medicine in Portland and an author of the guidelines.

Next month the National Partnership for Women & Families will release survey data from California mothers about their birth experiences. “Stakeholders are excited to use the data for quality improvement in deliveries,” said Carol Sakala, Director of Childbirth Connection Programs at the National Partnership.

And count Yelp in the effort as well. CHCF is partnering with the review site to allow women to see the C-section rate at every hospital in the state.