[Congressional Bills 115th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5977 Introduced in House (IH)]

<DOC>






115th CONGRESS
  2d Session
                                H. R. 5977

 To improve Federal efforts with respect to the prevention of maternal 
                   mortality, and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                              May 25, 2018

Ms. Kelly of Illinois introduced the following bill; which was referred 
                to the Committee on Energy and Commerce

_______________________________________________________________________

                                 A BILL


 
 To improve Federal efforts with respect to the prevention of maternal 
                   mortality, and for other purposes.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Mothers and Offspring Mortality and 
Morbidity Awareness Act'' or the ``MOMMA's Act''.

SEC. 2. FINDINGS.

    Congress finds the following:
            (1) Every year, across the United States, four million 
        women give birth, about 700 women suffer fatal complications 
        during pregnancy, while giving birth, or during the postpartum 
        period, and 65,000 women suffer near-fatal, partum-related 
        complications.
            (2) The maternal mortality rate is often used as a proxy to 
        measure the overall health of a population. While the infant 
        mortality rate in the United States has reached its lowest 
        point, the risk of death for women in the United States during 
        pregnancy, childbirth, or the postpartum period is higher than 
        such risk in any all other developed nations. The estimated 
        maternal mortality rate (per 100,000 live births) for the 48 
        contiguous States and Washington DC increased from 18.8 percent 
        in 2000 to 23.8 percent in 2014 to 26.6 percent in 2018. This 
        estimated rate is on par with such rate for underdeveloped 
        nations such as Iraq and Afghanistan.
            (3) International studies estimate the 2015 U.S. maternal 
        mortality rate as 26.4 per 100,000 live births, which is almost 
        twice the 2015 World Health Organization (WHO) estimation of 14 
        per 100,000 live births.
            (4) It is estimated that almost half of all maternal 
        mortalities in the United States are preventable.
            (5) African-American women experience maternal-related 
        deaths at three to four times the rate of non-Hispanic White 
        women.
            (6) The findings described in paragraphs (1) through (5) 
        are of major concern to researchers, academicians, and 
        epidemiologists at the Centers for Disease Control and 
        Prevention (CDC); providers across the obstetrical continuum 
        represented by organizations such as the Preeclampsia 
        Foundation; the American College of Obstetricians and 
        Gynecologists; the Association of Women's Health, Obstetric, 
        and Neonatal Nurses; the California Maternal Quality Care 
        Collaborative; Black Women's Health Imperative; the National 
        Birth Equity Collaborative; Black Mamas Matter Alliance; the 
        National Association of Certified Professional Midwives; and 
        the American College of Nurse Midwives.
            (7) According to the CDC, the maternal mortality rate 
        varies drastically for women by race and ethnicity. There are 
        12.7 deaths per 100,000 live births for White women, 43.5 
        deaths per 100,000 live births for African-American women, and 
        14.4 deaths per 100,000 live births for women of other 
        ethnicities. While maternal mortality disparately impacts 
        African-American women, the phenomenon traverses race, 
        ethnicity, socioeconomic status, educational background, and 
        geography.
            (8) Hemorrhage, cardiovascular and coronary conditions, 
        cardiomyopathy, infection, embolism, mental health conditions, 
        preeclampsia and eclampsia, infection or sepsis, and anesthesia 
        complications are the predominant causes of maternal-related 
        deaths and complications. Such conditions are largely 
        preventable or manageable.
            (9) The United States has not been able to submit a formal 
        maternal mortality rate to international data repositories 
        since 2007. Thus, no official maternal mortality rate exists 
        for the Nation. There can be no maternal mortality rate without 
        streamlining maternal mortality-related data from the State 
        level and extrapolating such data to the Federal level.
            (10) In the United States, death reporting and analysis is 
        a State function rather than a Federal process. States report 
        all deaths--including maternal deaths--on a semi-voluntary 
        basis, without standardization across States. While the CDC has 
        the capacity and system for collecting death-related data based 
        on death certificates, these data are not sufficiently reported 
        by States in an organized and standard format across States 
        such that the CDC is able to identify causes of maternal death 
        and best practices for the prevention of such death.
            (11) Vital registration systems often underestimate 
        maternal mortality and are insufficient data sources from which 
        to derive a full scope of medical and social determinant 
        factors contributing to maternal deaths. While the addition of 
        pregnancy checkboxes on death certificates since 2003 have 
        likely improved States' abilities to identify pregnancy-related 
        deaths, they are not generally completed by obstetrical 
        providers or persons trained to recognize pregnancy-related 
        mortality. Thus, these vital forms may be missing information 
        or may capture inconsistent data. Due to varying maternal 
        mortality-related analyses, lack of reliability, and 
        granularity in data, current maternal mortality informatics do 
        not fully encapsulate the myriad medical and socially 
        determinant factors that contribute to such high maternal 
        mortality rates within the United States compared to other 
        developed nations. Non-standardization of data and lack of data 
        sharing across States and between Federal entities, health 
        networks, and research institutions keep the Nation in the dark 
        about ways to prevent maternal deaths.
            (12) Having reliable and valid State data aggregated at the 
        Federal level are critical to the Nation's ability to quell 
        surges in maternal death and imperative for researchers to 
        identify long-lasting interventions.
            (13) Leaders in maternal wellness highly recommend that 
        maternal deaths be investigated at the State level first. Then, 
        have data regarding maternal deaths be standardized across 
        States, streamlined, de-identified, and sent once a year to a 
        federally supervised database, managed by a Federal agency at 
        the discretion of the Secretary of Health and Human Services. 
        Such data standardization and collection would be similar in 
        operation and effect to the National Program of Cancer 
        Registries housed at the CDC and akin to the Confidential 
        Enquiry in Maternal Deaths Programme in the United Kingdom. 
        Such a maternal mortality and morbidities registry and 
        surveillance would help providers, academicians, lawmakers, and 
        the public to address questions concerning the types of, causes 
        of, and best practices to thwart, pregnancy-related or 
        pregnancy-associated mortalities and morbidities.
            (14) The United Nations' Millennium Development Goal 5a 
        aimed to reduce by three quarters, between 1990 and 2015, the 
        maternal mortality rate, yet this metric has not been achieved. 
        In fact, the maternal mortality rate in the United States has 
        been estimated to have more than doubled between 2000 and 2014. 
        Yet, because national data are not fully available, the United 
        States does not have an official maternal mortality rate.
            (15) Many States have struggled to establish or maintain 
        Maternal Mortality Review Committees (MMRC). On the State 
        level, MMRCs have lagged because States have not had the 
        resources to mount local reviews. State-level reviews are 
        necessary as only the State departments of health have the 
        authority to request medical records, autopsy reports, and 
        police reports critical to the function of the MMRC.
            (16) The United Kingdom regards maternal deaths as a health 
        systems failure and a national committee of obstetrics experts 
        review each maternal death or near-fatal childbirth 
        complication. Such committee also establishes the predominant 
        course of maternal-related deaths from conditions such as 
        preeclampsia. Consequently, the United Kingdom has been able to 
        reduce their incidences of preeclampsia to less than one in 
        10,000 women--its lowest rate since 1952.
            (17) The United States has no comparable, coordinated 
        Federal process by which to review cases of maternal mortality, 
        systems failures, or best practices. Many States have active 
        MMRCs and leverage their work to impact maternal wellness. For 
        example, the State of California has worked extensively with 
        their State health departments, health and hospital systems, 
        and research collaborative organizations, including the 
        California Maternal Quality Care Collaborative and the Alliance 
        for Innovation on Maternal Health, to establish MMRCs, wherein 
        they have determined the most prevalent causes of maternal 
        mortality and recorded and shared data with providers and 
        researchers, who have developed and implemented safety bundles 
        and care protocols related to preeclampsia, maternal 
        hemorrhage, and the like. In this way, the State of California 
        has been able to leverage its maternal mortality review board 
        system, generate data, and apply those data to effect changes 
        in maternal care-related protocol. To date, the State of 
        California has stymied its maternal mortality rate, which is 
        now comparable to the low rates of the United Kingdom.
            (18) Hospitals and health systems across the United States 
        lack standardization of emergency obstetrical protocols before, 
        during, and after delivery. Consequently, many providers are 
        delayed in recognizing critical signs indicating maternal 
        distress that quickly escalate into fatal or near-fatal 
        incidences. Moreover, any attempt to address an obstetrical 
        emergency that does not take into account both clinical and 
        public health approaches falls woefully under the mark of 
        excellent care delivery. State-based maternal quality 
        collaborative organizations, including the Alliance for 
        Innovation on Maternal Health (AIMs) and California Maternal 
        Quality Care Collaborative, have formed obstetrical 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. State perinatal quality collaboratives are 
        working to identify health care processes that need to be 
        improved and use the best available methods to make those 
        changes as quickly as possible, while the Alliance for 
        Innovation on Maternal Health is working with States and health 
        systems to align national, State, and hospital level quality 
        improvement efforts through the creation and dissemination of 
        maternal safety bundles to improve overall maternal health 
        outcomes.
            (19) The CDC reports that more than half of all maternal 
        deaths occur in the immediate postpartum period--between 42 
        days up to a full year--whereas more than one-third of 
        pregnancy-related or pregnancy-associated deaths occur while a 
        person is still pregnant. Yet, for pregnant women, Medicaid 
        coverage lapses at the end of the month on which the 60th 
        postpartum day lands.
            (20) A growing body of evidence-based research has shown 
        the correlation between the stress associated with one's race--
        the stress of racism--and one's birthing outcomes. The stress 
        of sex and race discrimination and institutional racism has 
        been demonstrated to contribute to a higher risk of maternal 
        mortality, irrespective of one's gestational age, maternal age, 
        socioeconomic status, or individual-level health risk factors, 
        including poverty, limited access to prenatal care, and poor 
        physical and mental health (although these are not nominal 
        factors). African-American women remain the most at risk for 
        pregnancy-associated or pregnancy-related causes of death. When 
        it comes to preeclampsia, for example--which is related to 
        obesity--African-American women of normal weight remain the 
        most at risk of dying during the perinatal period compared to 
        non-African-American obese women.
            (21) The rising U.S. maternal mortality rate is 
        predominantly driven by the disproportionately high rates of 
        African-American maternal mortality.
            (22) African-American women are three to four times more 
        likely to die from pregnancy or maternal-related distress than 
        are White women, yielding one of the greatest and most 
        disconcerting racial disparities in public health.
            (23) Compared to women from other racial and ethnic 
        demographics, African-American women across the socioeconomic 
        spectrum experience prolonged, unrelenting stress related to 
        racial and gender discrimination, contributing to higher rates 
        of maternal mortality, giving birth to low-weight babies, and 
        experiencing pre-term birth. Racism is a risk-factor for these 
        aforementioned experiences. This cumulative stress often 
        extends across the life course and is situated in everyday 
        spaces where African-American women establish livelihood. 
        Structural barriers, lack of access to care, and genetic 
        predispositions to health vulnerabilities exacerbate African-
        American women's likelihood to experience poor or fatal 
        birthing outcomes, but do not fully account for the great 
        disparity.
            (24) African-American women are twice as likely to 
        experience postpartum depression, and disproportionately higher 
        rates of preeclampsia compared to White women.
            (25) Racism is deeply ingrained in United States systems, 
        including in health care delivery systems between patients and 
        providers, often resulting in disparate treatment for pain, 
        irreverence for cultural norms with respect to health, and 
        dismissiveness. Research has demonstrated that patients respond 
        more warmly and adhere to medical treatment plans at a higher 
        degree with providers of the same race or ethnicity or with 
        providers with great ability to exercise empathy. However, the 
        provider pool is not primed with many people of color, nor are 
        providers (whether student-doctors in training or licensed 
        practitioners) consistently required to undergo implicit bias, 
        cultural competency, or empathy training on a consistent, on-
        going basis.

SEC. 3. IMPROVING FEDERAL EFFORTS WITH RESPECT TO PREVENTION OF 
              MATERNAL MORTALITY.

    (a) Technical Assistance for States With Respect to Reporting 
Maternal Mortality.--Not later than one year after the date of 
enactment of this Act, the Director of the Centers for Disease Control 
and Prevention (referred to in this section as the ``Director'') shall 
provide technical assistance to States that elect to report on maternal 
mortality for the purpose of encouraging uniformity in the reporting of 
such data and to encourage the sharing of such data among the 
respective States.
    (b) Best Practices Relating to Prevention of Maternal Mortality.--
Not later than one year after the date of enactment of this Act, the 
Director shall issue best practices to State maternal mortality review 
committees on how best to identify, review, and prevent maternal 
mortality. In issuing such best practices, the Director shall take into 
account any data made available by States relating to maternal 
mortality.
    (c) Alliance for Innovation on Maternal Health Grant Program.--
            (1) In general.--Not later than one year after the date of 
        enactment of this Act, the Secretary of Health and Human 
        Services, acting through the Associate Administrator of the 
        Maternal and Child Health Bureau of the Health Resources and 
        Services Administration, shall establish a grant program to be 
        known as the Alliance for Innovation on Maternal Health Grant 
        Program (referred to in this subsection as ``AIM'') under which 
        the Secretary shall award grants to eligible entities for the 
        purpose of directing widespread adoption and implementation of 
        maternal safety bundles through collaborative State-based teams 
        and collecting and analyzing process, structure, and outcome 
        data to drive continuous improvement in the implementation of 
        such safety bundles by such State-based teams with the ultimate 
        goal of eliminating preventable maternal mortality and severe 
        maternal morbidity in the United States.
            (2) Eligible entities.--In order to be eligible for a grant 
        under paragraph (1), an entity shall--
                    (A) submit to the Secretary an application at such 
                time, in such manner, and containing such information 
                as the Secretary may require; and
                    (B) demonstrate in such application that the entity 
                is an interdisciplinary, multi-stakeholder national 
                organization with a national data-driven maternal 
                safety and quality improvement initiative based on 
                implementation approaches that have been proven to 
                improve maternal safety and outcomes in the United 
                States.
            (3) Use of funds.--An eligible entity that receives a grant 
        under paragraph (1) shall use such grant funds--
                    (A) to develop and implement, through a robust, 
                multi-stakeholder process, maternal safety bundles to 
                assist States and health care systems in aligning 
                national, State, and hospital-level quality improvement 
                efforts to improve maternal health outcomes, 
                specifically the reduction of maternal mortality and 
                severe maternal morbidity;
                    (B) to ensure, in developing and implementing 
                maternal safety bundles under subparagraph (A), that 
                such maternal safety bundles--
                            (i) satisfy the quality improvement needs 
                        of a State or health care system by factoring 
                        in the results and findings of relevant data 
                        reviews, such as reviews conducted by a State 
                        maternal mortality review committee; and
                            (ii) address topics such as--
                                    (I) obstetric hemorrhage;
                                    (II) maternal mental health;
                                    (III) the maternal venous system;
                                    (IV) obstetric care for women with 
                                opioid use disorder;
                                    (V) postpartum care basics for 
                                maternal safety;
                                    (VI) reduction of peripartum racial 
                                and ethnic disparities;
                                    (VII) reduction of primary 
                                caesarean birth;
                                    (VIII) severe hypertension in 
                                pregnancy;
                                    (IX) severe maternal morbidity 
                                reviews;
                                    (X) support after a several 
                                maternal morbidity event; and
                                    (XI) thromboembolism; and
                    (C) to provide ongoing technical assistance at the 
                national and State levels to support implementation of 
                maternal safety bundles under subparagraph (A).
            (4) Maternal safety bundle defined.--For purposes of this 
        subsection, the term ``maternal safety bundle'' means 
        standardized, evidence-informed processes to improve variation 
        in response to maternal care.
            (5) Authorization of appropriations.--For purposes of 
        carrying out this subsection, there is authorized to be 
        appropriated $5,000,000 for each of fiscal years 2019 through 
        2023.
    (d) Expansion of Medicaid and CHIP Coverage for Pregnant and 
Postpartum Women.--
            (1) Extending medicaid coverage for pregnant and postpartum 
        women.--Section 1902 of the Social Security Act (42 U.S.C. 
        1396a) is amended--
                    (A) in subsection (e)--
                            (i) in paragraph (5), by striking ``60-
                        day'' and inserting ``one-year''; and
                            (ii) in paragraph (6), by striking ``60-
                        day'' and inserting ``one-year''; and
                    (B) in subsection (l)(1)(A), by striking ``60-day'' 
                and inserting ``one-year''.
            (2) Extending medicaid coverage for lawful residents.--
        Section 1903(v)(4)(A) of the Social Security Act (42 U.S.C. 
        1396b(v)(4)(A)) is amended by striking ``60-day'' and inserting 
        ``one-year''.
            (3) Extending chip coverage for pregnant and postpartum 
        women.--Section 2112(d)(2)(A) of the Social Security Act (42 
        U.S.C. 1397ll(d)(2)(A)) is amended by striking ``60-day'' and 
        inserting ``one-year''.
            (4) Maintenance of effort.--
                    (A) Medicaid.--Section 1902(l) of the Social 
                Security Act (42 U.S.C. 1396a(l)) is amended by adding 
                at the end the following new paragraph:
    ``(5)(A) Subject to subparagraph (B), during the period that begins 
on the date of enactment of this paragraph and ends on the date that is 
five years after such date of enactment, as a condition for receiving 
any Federal payments under section 1903(a) for calendar quarters 
occurring during such period, a State, including a State described in 
paragraph (4)(B) that elects to meet the requirement of subsection 
(a)(10)(A)(i)(IV), shall not have in effect, with respect to women who 
are eligible for medical assistance because of such subsection 
(a)(10)(A)(i)(IV) or section 1903(v)(4)(A)(i), eligibility standards, 
methodologies, or procedures under the State plan (or a waiver of such 
plan) that are more restrictive than the eligibility standards, 
methodologies, or procedures, respectively, under such plan (or waiver) 
that are in effect on the date of enactment of this paragraph.
    ``(B) A State's determination of income in accordance with 
subsection (e)(14) shall not be considered to be eligibility standards, 
methodologies, or procedures that are more restrictive than the 
standards, methodologies, or procedures in effect under the State plan 
(or a waiver of such plan) on the date of enactment of this paragraph 
for purposes of determining compliance with the requirement of 
subparagraph (A).''.
                    (B) CHIP.--Section 2105(d) of the Social Security 
                Act (42 U.S.C. 1397ee(d)) is amended by adding at the 
                end the following new paragraph:
            ``(4) In eligibility standards for targeted low-income 
        pregnant women.--During the period that begins on the date of 
        enactment of this paragraph and ends on the date that is five 
        years after such date of enactment, as a condition of receiving 
        payments under subsection (a) and section 1903(a), a State that 
        elects to provide pregnancy-related assistance to targeted low-
        income pregnant women (as defined in section 2112(d)), or women 
        who are eligible for such assistance through the application of 
        section 1903(v)(4)(A)(i) under section 2107(e)(1), shall not 
        have in effect, with respect to such women, eligibility 
        standards, methodologies, or procedures under the State child 
        health plan (or a waiver of such plan) that are more 
        restrictive than the eligibility standards, methodologies, or 
        procedures, respectively, under such plan (or waiver) that are 
        in effect on the date of enactment of this paragraph.''.
            (5) Effective date.--
                    (A) In general.--Except as otherwise provided and 
                subject to subparagraph (B), the amendments made by 
                this subsection shall take effect with respect to 
                eligibility determinations made with respect to a State 
                plan under title XIX of the Social Security Act or a 
                State child health plan under title XXI of such Act on 
                or after the date that is one year after the date of 
                enactment of this Act.
                    (B) Exception for state legislation.--In the case 
                of a State plan under title XIX of the Social Security 
                Act or a State child health plan under title XXI of 
                such Act that the Secretary of Health and Human 
                Services determines requires State legislation in order 
                for the respective plan to meet any requirement imposed 
                by amendments made by this subsection, the respective 
                plan shall not be regarded as failing to comply with 
                the requirements of such title solely on the basis of 
                its failure to meet such an additional requirement 
                before the first day of the first calendar quarter 
                beginning after the close of the first regular session 
                of the State legislature that begins after the date of 
                enactment of this Act. For purposes of the previous 
                sentence, in the case of a State that has a 2-year 
                legislative session, each year of the session shall be 
                considered to be a separate regular session of the 
                State legislature.
    (e) Regional Centers of Excellence.--Part P of title III of the 
Public Health Service Act is amended by adding at the end the following 
new section:

``SEC. 399V-7. REGIONAL CENTERS OF EXCELLENCE ADDRESSING IMPLICIT BIAS 
              AND CULTURAL COMPETENCY IN PATIENT-PROVIDER INTERACTIONS 
              EDUCATION.

    ``(a) In General.--Not later than one year after the date of 
enactment of this section, the Secretary, in consultation with such 
other agency heads as the Secretary determines appropriate, shall, 
subject to the availability of appropriations, award cooperative 
agreements for the establishment or support of regional centers of 
excellence addressing implicit bias and cultural competency in patient-
provider interactions education for the purpose of enhancing and 
improving how health care professionals are educated in implicit bias 
and delivering culturally competent health care.
    ``(b) Eligibility.--To be eligible to receive a cooperative 
agreement under subsection (a), an entity shall--
            ``(1) be an entity specified by the Secretary that provides 
        educational opportunities for students in a health care 
        profession, which may include a health system, teaching 
        hospital, birthing center, community health center, physician's 
        office, medical school, school of public health, or any other 
        health professional school or a program at an institution of 
        higher education focused on the prevention, treatment, or 
        recovery of health conditions that contribute to maternal 
        mortality and the prevention of maternal mortality;
            ``(2) demonstrate community engagement and participation 
        through community partners such as mental health counselors and 
        social workers; and
            ``(3) provide to the Secretary such information, at such 
        time and in such manner, as the Secretary may require.
    ``(c) Diversity.--In awarding a cooperative agreement under 
subsection (a), the Secretary shall take into account any regional 
differences among eligible entities and make an effort to ensure 
geographic diversity among award recipients.
    ``(d) Dissemination of Information.--
            ``(1) Public availability.--The Secretary shall make 
        publicly available on the Internet website of the Department of 
        Health and Human Services information submitted to the 
        Secretary under subsection (b)(3).
            ``(2) Evaluation.--The Secretary shall evaluate each 
        regional center of excellence established or supported pursuant 
        to subsection (a) and disseminate the findings resulting from 
        each such evaluation to the appropriate public and private 
        entities.
    ``(e) Maternal Mortality Defined.--In this section, the term 
`maternal mortality' means death that occurs to a woman during 
pregnancy or within the one-year period following the end of such 
pregnancy.
    ``(f) Authorization of Appropriations.--For purposes of carrying 
out this section, there is authorized to be appropriated $5,000,000 for 
each of fiscal years 2019 through 2023.''.
    (f) Definitions.--In this section:
            (1) Maternal mortality.--The term ``maternal mortality'' 
        means death that occurs to a woman during pregnancy or within 
        the one-year period following the end of such pregnancy.
            (2) Severe maternal morbidity.--The term ``severe maternal 
        morbidity'' includes unexpected outcomes of labor and delivery 
        that result in significant short-term or long-term consequences 
        to a woman's health.
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