resources for participation. In fact, some QI pro- jects require hospitals to pay to participate. Based on our experience of enrolling hospitals in the AWHONN PPH Project, it was concerning that too often the hospitals that were likely to have the greatest need to improve and likely served more African American women than women of other races and ethnicities opted not to participate. The hospital leaders were individually contacted and invited to participate in the free AWHONN PPH Project, which would provide them with additional support and education. Some leaders expressed interest in joining the PPH Project but ultimately decided that they could not participate. The reason most often provided for opting out was the lack of staff resources necessary to implement the recommended improvements and continue to meet the needs of patients.