[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]


              BETTER DATA AND BETTER OUTCOMES: REDUCING MATERNAL 
                             MORTALITY IN THE U.S.

=======================================================================

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED FIFTEENTH CONGRESS

                             SECOND SESSION

                               __________

                           SEPTEMBER 27, 2018

                               __________

                           Serial No. 115-169
                           
                           
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]                           


      Printed for the use of the Committee on Energy and Commerce
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                    COMMITTEE ON ENERGY AND COMMERCE

                          GREG WALDEN, Oregon
                                 Chairman
JOE BARTON, Texas                    FRANK PALLONE, Jr., New Jersey
  Vice Chairman                        Ranking Member
FRED UPTON, Michigan                 BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois               ANNA G. ESHOO, California
MICHAEL C. BURGESS, Texas            ELIOT L. ENGEL, New York
MARSHA BLACKBURN, Tennessee          GENE GREEN, Texas
STEVE SCALISE, Louisiana             DIANA DeGETTE, Colorado
ROBERT E. LATTA, Ohio                MICHAEL F. DOYLE, Pennsylvania
CATHY McMORRIS RODGERS, Washington   JANICE D. SCHAKOWSKY, Illinois
GREGG HARPER, Mississippi            G.K. BUTTERFIELD, North Carolina
LEONARD LANCE, New Jersey            DORIS O. MATSUI, California
BRETT GUTHRIE, Kentucky              KATHY CASTOR, Florida
PETE OLSON, Texas                    JOHN P. SARBANES, Maryland
DAVID B. McKINLEY, West Virginia     JERRY McNERNEY, California
ADAM KINZINGER, Illinois             PETER WELCH, Vermont
H. MORGAN GRIFFITH, Virginia         BEN RAY LUJAN, New Mexico
GUS M. BILIRAKIS, Florida            PAUL TONKO, New York
BILL JOHNSON, Ohio                   YVETTE D. CLARKE, New York
BILLY LONG, Missouri                 DAVID LOEBSACK, Iowa
LARRY BUCSHON, Indiana               KURT SCHRADER, Oregon
BILL FLORES, Texas                   JOSEPH P. KENNEDY, III, 
SUSAN W. BROOKS, Indiana                 Massachusetts
MARKWAYNE MULLIN, Oklahoma           TONY CARDENAS, California
RICHARD HUDSON, North Carolina       RAUL RUIZ, California
CHRIS COLLINS, New York              SCOTT H. PETERS, California
KEVIN CRAMER, North Dakota           DEBBIE DINGELL, Michigan
TIM WALBERG, Michigan
MIMI WALTERS, California
RYAN A. COSTELLO, Pennsylvania
EARL L. ``BUDDY'' CARTER, Georgia
JEFF DUNCAN, South Carolina
                         Subcommittee on Health


                       MICHAEL C. BURGESS, Texas
                                 Chairman
BRETT GUTHRIE, Kentucky              GENE GREEN, Texas
  Vice Chairman                        Ranking Member
JOE BARTON, Texas                    ELIOT L. ENGEL, New York
FRED UPTON, Michigan                 JANICE D. SCHAKOWSKY, Illinois
JOHN SHIMKUS, Illinois               G.K. BUTTERFIELD, North Carolina
MARSHA BLACKBURN, Tennessee          DORIS O. MATSUI, California
ROBERT E. LATTA, Ohio                KATHY CASTOR, Florida
CATHY McMORRIS RODGERS, Washington   JOHN P. SARBANES, Maryland
LEONARD LANCE, New Jersey            BEN RAY LUJAN, New Mexico
H. MORGAN GRIFFITH, Virginia         KURT SCHRADER, Oregon
GUS M. BILIRAKIS, Florida            JOSEPH P. KENNEDY, III, 
BILLY LONG, Missouri                     Massachusetts
LARRY BUCSHON, Indiana               TONY CARDENAS, California
SUSAN W. BROOKS, Indiana             ANNA G. ESHOO, California
MARKWAYNE MULLIN, Oklahoma           DIANA DeGETTE, Colorado
RICHARD HUDSON, North Carolina       FRANK PALLONE, Jr., New Jersey (ex 
CHRIS COLLINS, New York                  officio)
EARL L. ``BUDDY'' CARTER, Georgia
GREG WALDEN, Oregon (ex officio)
  
                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Michael C. Burgess, a Representative in Congress from the 
  State of Texas, opening statement..............................     1
    Prepared statement...........................................     3
Hon. Gene Green, a Representative in Congress from the State of 
  Texas, opening statement.......................................     4
Hon. Greg Walden, a Representative in Congress from the State of 
  Oregon, opening statement......................................     6
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     7

                               Witnesses

Jaime Herrera Beutler, a Representative in Congress from the 
  State of Washington............................................     9
    Prepared statement...........................................    11
Charles S. Johnson, IV, Founder, 4Kira4Moms......................    14
    Prepared statement...........................................    17
Stacey D. Stewart, President, March of Dimes.....................    42
    Prepared statement...........................................    44
Lynne Coslett-Charlton, M.D., Pennsylvania District Legislative 
  Chair, the American College of Obstetricians and Gynecologists.    51
    Prepared statement...........................................    53
Joia Crear Perry, M.D., Founder and President, National Birth 
  Equity Collaborative...........................................    58
    Prepared statement...........................................    60

                           Submitted Material

Statement of MomsRising.org, submitted by Mr. Burgess............    95
Statement of the Alexis Joy Foundation, submitted by Mr. Burgess.    97
Statement of the Society for Maternal Fetal Medicine, submitted 
  by Mr. Burgess.................................................   105
Report of the Maternal Mortality and Morbidity Task Force from 
  the State of Texas, submitted by Mr. Burgess \1\
Statement of Dr. Gary D.V. Hankins of UTMB Health, submitted by 
  Mr. Burgess....................................................   108
Article entitled, ``Obstetric Hemorrhage Toolkit Hospital Level 
  Implementation Guide,'' 2010, submitted by Mr. Burgess \2\
Statement of March for Moms, submitted by Mr. Burgess............   111
Statement of Postpartum Support Virginia, 2010, submitted by Mr. 
  Burgess........................................................   114
Statement of the Association of Maternal & Child Health Programs, 
  submitted by Mr. Burgess.......................................   116
Statement of Heart Safe Motherhood at Penn Medicine, submitted by 
  Mr. Burgess....................................................   118
Statement of various patient groups, submitted by Mr. Burgess....   120
Statement of Americans United for Life, submitted by Mr. Burgess.   123
Statement of the Nurse-Family Partnership, submitted by Mr. 
  Burgess........................................................   126
Statement of the Preeclampsia Foundation, submitted by Mr. 
  Burgess........................................................   127
Statement of Timoria McQueen Saba, submitted by Mr. Burgess......   132
Statement of the American College of Surgeons, submitted by Mr. 
  Burgess........................................................   137
Study entitled, ''Reducing Infant Mortality in Indiana,'' KSM 
  Consulting, 2014, submitted by Mr. Burgess \3\
Statement of SAP America, submitted by Mr. Burgess...............   139
Study entitled, ``Analytics Paves the Way for Better Government, 
  Forbes Insights, 2014, submitted by Mr. Burgess................   141
Statement of Johnson & Johnson Services, Inc., submitted by Mr. 
  Burgess........................................................   145

----------
\1\ The information can be found at: https://docs.house.gov/
  meetings/IF/IF14/20180927/108724/HHRG-115-IF14-20180927-
  SD022.pdf.
\2\ The information can be found at: https://docs.house.gov/
  meetings/IF/IF14/20180927/108724/HHRG-115-IF14-20180927-
  SD023.pdf.
\3\ The information can be found at: https://docs.house.gov/
  meetings/IF/IF14/20180927/108724/HHRG-115-IF14-20180927-
  SD004.pdf.

 
  BETTER DATA AND BETTER OUTCOMES: REDUCING MATERNAL MORTALITY IN THE 
                                  U.S.

                              ----------                              


                      THURSDAY, SEPTEMBER 27, 2018

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:00 a.m., in 
room 2123 Rayburn House Office Building, Hon. Michael Burgess 
(chairman of the subcommittee) presiding.
    Members present: Representatives Burgess, Guthrie, Barton, 
Shimkus, Latta, Lance, Griffith, Bilirakis, Long, Bucshon, 
Brooks, Mullin, Hudson, Carter, Walden(ex officio), Green, 
Engel, Schakowsky, Castor, Schrader, Kennedy, Cardenas, 
DeGette, and Pallone (ex officio).
    Staff present: Mike Bloomquist, Staff Director; Samantha 
Bopp, Staff Assistant; Daniel Butler, Staff Assistant; Adam 
Fromm, Director of Outreach and Coalitions; Zach Hunter, 
Director of Communications; Ed Kim, Policy Coordinator, Health; 
Ryan Long, Deputy Staff Director; Drew McDowell, Executive 
Assistant; Brannon Rains, Staff Assistant; Austin Stonebraker, 
Press Assistant; Josh Trent, Deputy Chief Health Counsel, 
Health; Hamlin Wade, Special Advisor, External Affairs; 
Jacquelyn Bolen, Minority Professional Staff; Jeff Carroll, 
Minority Staff Director; Evan Gilbert, Minority Press 
Assistant; Waverly Gordon, Minority Health Counsel; Tiffany 
Guarascio, Minority Deputy Staff Director and Chief Health 
Advisor; Tim Robinson, Minority Chief Counsel; and Samantha 
Satchell, Minority Policy Analyst.

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE 
              IN CONGRESS FROM THE STATE OF TEXAS

    Mr. Burgess. And the Subcommittee on Health will now come 
to order. I recognize myself 5 minutes for purpose of an 
opening statement. And I want to thank everyone for joining us 
this morning to discuss a topic that is important to each and 
every one of us. This is a subject matter that has been brought 
to the forefront by members of this subcommittee, members of 
Congress generally, actions of state legislators, and the 
media.
    Having spent 3 decades myself practicing OB/GYN, I believe 
it should be a national goal to eliminate all preventable 
maternal mortality. Even a single maternal death is too many. 
All too often we have read about the stories of seemingly 
healthy pregnant women who are thrilled to be having a child 
and then to everyone's surprise suffers severe complications, 
death, or near death during a pregnancy, birth, or postpartum. 
The death of a new or expecting mother is a tragic event that 
devastates everyone involved, and if there are preventable 
scenarios we need to do what we can to stop that.
    The alarming trend in our country's rate of maternal 
mortality first came to my attention in September 2016 reading 
a copy of the American College of Obstetricians and 
Gynecologists, The Green Journal. The original research found 
that the maternal mortality rate had increased in 48 states and 
Washington, D.C. from 2000 to 2014, while the international 
trend was moving in the opposite direction. Since reading that 
article, I have spoken to providers, hospital administrators, 
state task forces, and public health experts. The more I looked 
into this troubling issue, the more I realized that we have got 
much more we need to understand.
    This subcommittee had an informational briefing last year 
on this topic to inform members and to start the road toward 
this hearing. This is an issue that we cannot solve without 
accurate data. There were efforts in our nation to address 
maternal and infant mortality in the first half of the 20th 
century and the data showed that these efforts were indeed 
successful.
    But according to the Centers for Disease Control and 
Prevention the United States' maternal mortality rate, 7.2 
deaths per 100,000 in 1999 and increased to 18 deaths per 
100,000 live births in 2014. The Centers for Disease Control 
began conducting national surveillance of pregnancy related 
deaths in 1986 due to a lack of data on causes of maternal 
death.
    In 2003, the Centers for Disease Control National Center 
for Health Statistics revised standards for certain death 
certificates and added a pregnancy checkbox. While this 
checkbox has led to increased data collection on maternal 
deaths, it does not provide enough insight as to why or how 
these deaths occurred. Representative Jaime Herrera Beutler 
joining us this morning, the discussion draft that she has put 
forward will address the complex issue of maternal mortality by 
enabling states to form maternal mortality review committees to 
evaluate, improve, and standardize their maternal death rate.
    This is a critical step in the right direction as 
physicians, public health officials, and Congress are unable to 
reach conclusions based upon current data as to what the causes 
for maternal mortality increases are. Once we establish what 
these are, there will be an opportunity to use the data to 
implement the best practices toward a solution.
    Texas is a good example of a state that has enacted 
legislation to create and sustain a Maternal Mortality and 
Morbidity Task Force. Texas has put time and effort in funding 
and to reviewing maternal deaths in order to find the trends in 
the increases and the causes of death. The Task Force's 
September 2018 report, which I have here and later on we will 
ask unanimous consent to be made part of the record, stated 
that the leading causes of pregnancy-related death in 2012 
included cardiovascular, obstetric hemorrhage, infection 
sepsis, and cardiomyopathy.
    This report is just a snapshot of the national picture as 
causes do vary from state to state. Additionally, this May, 
various researchers involved in the review of Texas' maternal 
deaths published a paper, again in The Green Journal, detailing 
that unintentional user error and other issues led to 
inaccurate reporting of maternal mortality. The researchers 
concluded that relying solely on obstetric codes for 
identifying maternal deaths appears to be insufficient and can 
lead to inaccurate ratios.
    The moral of this story is we must ensure accurate data to 
accurately pinpoint the clinical issues contributing to these 
tragic deaths. I would like to submit a statement for the 
record from Dr. Gary Hankins and, without objection, so 
ordered, the chairman of the Department of OB/GYN at the 
University of Texas Medical Branch in Galveston.
    [The information appears at the conclusion of the hearing.]
    Mr. Burgess. And Dr. Hankins was one of those doctors who 
briefed us during the briefing last year. Dr. Hankins has 
subspecialty training in maternal fetal medicine and served as 
vice chair for the Texas Morbidity and Mortality Review 
Committee.
    At one time we were scheduled to be joined by Dr. Lisa 
Hollier, also of Texas, who is also part of that committee. I 
think we had to postpone last week because of a hurricane and 
she could not accommodate the reschedule. But Dr. Hollier has 
also been integral in working on this at the state level.
    So I certainly look forward to hearing from our panel of 
witnesses today as how we can address this vital and 
devastating issue.
    [The prepared statement of Mr. Burgess follows:]

             Prepared statement of Hon. Michael C. Burgess

    Good morning. Thank you to everyone for joining us this 
morning to discuss a topic that is important to each and every 
one of us, maternal mortality. This is a subject matter that 
has been brought to the forefront by Members of this 
Subcommittee, actions of State Legislatures, and the media. 
Having spent nearly three decades as an OB/GYN, I believe it 
should be a national goal to eliminate all preventable maternal 
mortality--even a single maternal death is too many.
    All too often do we read about stories of seemingly healthy 
pregnant women who are thrilled to be having a child, and to 
everyone's surprise, suffers severe complications, or death 
during pregnancy, birth, or post-partum. The death of a new or 
expecting mother is a tragic event that devastates everyone 
involved, but in many cases these are preventable scenarios.
    The alarming trend in our country's rate of maternal 
mortality first came to my attention in September 2016, when I 
was reading my copy of the Green Journal. The original research 
found that the maternal mortality rate increased in 48 states 
and Washington DC from 2000 to 2014, while the international 
trend was moving in the opposite direction. Since reading that 
article, I have spoken with providers, hospital administrators, 
state task forces, and public health experts. The more I dove 
into this troubling issue, the more I realized how little we 
understand. This Subcommittee held an informational briefing 
last year on this topic to inform members and pave the road to 
this hearing.
    This is an issue that we cannot solve without accurate 
data. There were great efforts in our nation to address 
maternal and infant mortality in the first half of the 20th 
Century, and the data showed that those efforts were 
successful. Yet, according to the Centers for Disease Control 
and Prevention (CDC), the U.S. maternal mortality rate was 7.2 
deaths per 100,000 live births in 1999, and increased to 18 
deaths per 100,000 live births in 2014.
    CDC began conducting national surveillance of pregnancy-
related deaths in 1986 due to a lack of data on causes of 
maternal death. In 2003, the CDC National Center for Health 
Statistics revised standards for certain death certificates, 
and added a pregnancy checkbox. While this checkbox has led to 
increased data collection on maternal deaths, it does not 
provide enough insight into why or how these mothers are dying.
    Representative Jamie Herrera-Beutler's discussion draft 
will address the complex issue of maternal mortality by 
enabling States to form maternal mortality review committees to 
evaluate, improve, and standardize their maternal death data. 
This is a critical step in the right direction, as physicians, 
public health officials, and Congress are unable to reach 
conclusions based upon current data as to what the causes for 
maternal mortality are. Once we establish what these are, there 
will be an opportunity to use the data to implement best 
practices.
    Texas is a great example of a state that has enacted 
legislation to create and sustain a maternal mortality and 
morbidity task force. Texas has put much time, effort, and 
funding into reviewing maternal deaths in order to find trends 
in the causes of death. The Task Force's September 2018 report 
stated that leading causes of pregnancy-related death in 2012 
included cardiovascular and coronary conditions, obstetric 
hemorrhage, infection/sepsis, and cardiomyopathy. This report 
is just a snapshot of the national picture, as causes vary from 
state to state.
    Additionally, this May, various researchers involved in the 
review of Texas maternal deaths published a paper in the Green 
Journal detailing that unintentional user error and other 
issues led to inaccurate reporting of maternal mortality. The 
researchers also concluded that ``relying solely on obstetric 
codes for identifying maternal deaths appears to be 
insufficient and can lead to inaccurate maternal mortality 
ratios.'' The moral of this story is that we must ensure 
accurate data to accurately pinpoint the clinical issues 
contributing to these tragic deaths.
    I would like to submit a statement for the record from Dr. 
Gary Hankins, Chairman of the Department of OB/GYN at The 
University of Texas Medical Branch. He has subspecialty 
training in Maternal Fetal Medicine and served as Vice Chair 
for the Texas Maternal Morbidity and Mortality Review 
Committee.
    I look forward to hearing from our expert panel of 
witnesses as to how we can address this vital yet devastating 
issue.

    Mr. Burgess. The chair recognizes the ranking member of the 
subcommittee, Mr. Green, 5 minutes for your opening statement, 
please.

   OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN 
                CONGRESS FROM THE STATE OF TEXAS

    Mr. Green. Thank you, Mr. Chairman, for calling today's 
hearing on maternal mortality in the United States, and I would 
also like to thank our colleague who is in our distinguished 
panelists for joining us this morning.
    I would like to take just a moment, Mr. Chairman. My deputy 
chief of staff, LD/LA, Sergio Espinosa, this will be his last 
committee hearing and he has been working with me on health 
care in our office for many years--8 years, it has been 8 or 9. 
This is his last hearing. And those of you who someday decide 
you are not going to run for reelection, you will know that you 
will be losing staff members in the last 2 or 3 months. But I 
just want to thank Sergio for his work in the office on many 
issues, but particularly in the last number of months on health 
care.
    So--and I will continue with my statement.
    [Applause.]
    Mr. Green. The Centers for Disease Control and Prevention 
reports that more than 700 women in the United States die each 
year due to complications related to pregnancy and childbirth, 
and more than 50,000 women experience a life-threatening 
complication. Maternal mortality in our country has more than 
doubled between 1987 and 2014, from 7.2 to 18 maternal deaths 
per 100,000 live births. In comparison, a recent World Health 
Organization study found that maternal mortality is on the 
decline in 157 of the 183 countries.
    These numbers are troubling as we are because even more 
acute when you look at the existing racial, socioeconomic, and 
geographic disparities, for example, African American women are 
nearly three times as likely to die of complications relating 
to pregnancy and childbirth compared to white women. In America 
in the 21st century, no woman should ever die of complications 
related to pregnancy and childbirth.
    Congress has a duty to act and reverse this terrible trend. 
I would like to thank my colleagues both Congresswoman Diane 
DeGette and Congresswoman Jaime Herrera Beutler for offering 
their discussion draft, The Preventing Maternal Deaths Act that 
will help protect pregnant and postpartum mothers. This 
legislation will provide grants to states and tribes to help 
establish and support already existing maternal mortality 
review committees, MMRCs, to identify and review pregnancy-
related and pregnancy-associated deaths.
    MMRCs which are currently operating in over 30 states have 
been helping strengthen public health surveillance by linking 
vital data to the multidisciplinary healthcare professionals 
practicing in women's health. I support the bipartisan 
legislation and hope our committee will recommend it in 
consideration before the full House before the end of the year.
    My Preventing Maternal Deaths Act is an important first 
step. Our committee can and must do more to protect our 
nation's mothers. Despite the gains made under the Affordable 
Care Act, nearly one in seven women of childbearing age remain 
uninsured. The biggest barrier to women of childbearing age 
receiving healthcare coverage is continuing refusal of 19 
states, including my home State of Texas, to expand Medicaid. 
Continuing of a comprehensive health insurance is critical for 
expecting and postpartum mothers to receive the post and 
postnatal care they need for themselves and their babies.
    Medical research shows chronic conditions such as 
hypertension, diabetes, heart disease, and obesity which are 
becoming more common for expecting mothers can increase their 
risk for complications during pregnancy. Ensuring continuing of 
coverage preceding pregnancy will help women of childbearing 
age best manage these chronic conditions before they become a 
problem.
    Last year I introduced Incentivizing Medicaid Expansion 
Act, H.R. 2688, in order to incentivize states to provide 
critical Medicaid coverage for uninsured Americans and avoid 
the kinds of tragedy that has led to the rising rate of 
mortality in my home State. My legislation would guarantee that 
the Federal Government covers a hundred percent of expansion 
costs for the first 3 years for states that have not yet 
expanded, and no less than 90 percent afterwards. I ask the 
committee to give this legislation the serious consideration 
that it deserves and help reverse the public health crisis that 
maternal mortality and severe maternal morbidity have become 
too many for our communities and our country.
    And in my last 39 seconds, UTMB in Galveston has been the 
catchment for most of the births in East Texas and South Texas 
and for decades, and I appreciate that university and that 
medical school for doing that for our families. In the Houston 
area we have a hospital district, but Medicaid would at least 
help get them reimbursed. But UTMB is the catchment for problem 
pregnancies in South Texas and East Texas.
    Thank you, Mr. Chairman. I yield back.
    Mr. Burgess. The chair thanks the gentleman. The gentleman 
yields back. The chair recognizes the gentleman from Oregon, 
the chairman of the full committee, Mr. Walden, 5 minutes for 
your opening statement, please.

  OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF OREGON

    Mr. Walden. Well, thank you, Chairman Burgess.
    Doctor, we are glad that you are chairing this subcommittee 
and this subcommittee hearing especially given your many 
decades of real-world experiences in OB/GYN. So we are glad to 
have you at the helm for this hearing especially. It is a 
difficult topic and it is one that is close to many of us.
    Far too many mothers die because of complications during 
pregnancy, and the effects of such a tragedy on any family is 
impossible to fully understand. What is both surprising and 
devastating is that despite massive innovation and advances in 
health care and technology we have experienced recent reports 
that have indicated that the number of women dying due to 
pregnancy complications is actually increasing. It is actually 
going up.
    According to the Centers for Disease Control and 
Prevention, maternal mortality rates in America have more than 
doubled since 1987, and I think we are all asking how can that 
be? Well, this is not a statistic any of us wants to hear. 
There are questions as to whether the increases due to data 
collection are broader questions about healthcare delivery. The 
bill before us today will help us answer these really important 
questions and hopefully ensure that expectant newborn mothers 
receive even better care.
    I want to thank Congresswoman Herrera Beutler, my neighbor 
to the north in Washington State, for bringing this issue to 
our attention. She has been a real leader on this effort for 
many, many months, if not years. And especially given what you 
have been through in your own situation, we are proud of you 
and of your children and so we are glad to have you before the 
committee.
    I also want to thank my colleague and friend from Colorado, 
Diana DeGette, for her partnership on the draft legislation 
that is before us today. She has been a real leader on 21st 
Century Cures and other public health issues that are so 
important. And I want to extend a sincere thank you to the 
members of our second panel. Mr. Johnson, it is good to see you 
again. We appreciate you coming back here. I am sorry for what 
you have been through, but I appreciate your willingness to 
come share with us. Your testimony makes a difference in public 
policy.
    The draft bill we are examining today is the Preventing 
Maternal Deaths Act of 2018. The bill would enhance our Federal 
efforts to support maternal mortality review committees in each 
of our states. And earlier this year, the Oregon legislature 
passed a bill to establish such a committee in my home State 
which brings a wide range of medical providers together with 
community organizations and with public health experts to study 
maternal mortality and figure out its underlying causes. That 
information and lessons learned will then be shared with law 
enforcement and healthcare providers across Oregon. Congress 
should support and it should build off of these efforts and 
others across the country so many of these deaths could be 
prevented if best practices for maternal health care were 
followed and more widely understood.
    So that is what this hearing is all about. We appreciate 
you being here and we look forward to the testimony from our 
other panelists and of course from our colleague. I will tell 
you in advance we actually have two subcommittees going on 
simultaneously, and as chairman of the overall committee I have 
to bounce back and forth between them. But thank you for being 
here and we look forward to moving forward to find solutions.
    And with that, Mr. Chairman, I yield back.
    Mr. Burgess. The chair thanks the gentleman. The gentleman 
yields back. The chair recognizes the gentleman from New 
Jersey, Mr. Pallone, the ranking member of the full committee, 
5 minutes for an opening statement, please.

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. Thank you, Mr. Chairman. Hundreds of women die 
each year from pregnancy-related or pregnancy-associated 
complications in the United States, and more than 60 percent of 
these deaths are preventable. Shamefully, the maternal 
mortality rate in the U.S. has increased while most of the rest 
of the developed world has actually fallen. And this is not 
just alarming, it is unconscionable. We have a responsibility 
to understand why this is happening and what we should be doing 
to combat this crisis.
    Mr. Green and I wrote a letter to Chairman Burgess and 
Chairman Walden on this issue in May and I am pleased we are 
finally holding a hearing today. Today we will discuss a draft 
of the Preventing Maternal Deaths Act, which mirrors a version 
that passed out of the Senate Health Committee. This is a good 
bill. It is critical that we have the necessary data to 
understand the underlying causes of maternal deaths and 
identify strategies that can help us combat it.
    This bill encourages states to implement maternal mortality 
review committees to study this data and make recommendations 
on ways to combat maternal death. Review committees that are 
diverse and interdisciplinary can identify trends, patterns, 
and disparities that contribute to preventable maternal deaths. 
And with this information, healthcare providers can monitor the 
effectiveness of their policy and practice changes.
    Now my home State of New Jersey was the second state in the 
nation to institute a maternal mortality review committee which 
has worked extensively to review New Jersey's maternal death 
cases to better understand their root causes and prevent deaths 
in the future. However, New Jersey's maternal mortality rate 
remains much too high and much more work still needs to be 
done.
    Extensive public reporting has vividly described the risks 
American woman face in childbirth and the postpartum period and 
has also highlighted the vast disparities in outcome. While 
women of all backgrounds are at risk for pregnancy-related 
complications, it is critical we also examine why maternal 
death rates are disproportionately higher for women of color, 
low-income women, and women living in rural areas. And we must 
understand why, and work together to address these disparities.
    However, we must also consider other ways we can combat 
maternal mortality, including by expanding health insurance 
coverage and ensuring all women have access to the reproductive 
health services they need. Unfortunately, efforts by the Trump 
administration to sabotage the Affordable Care Act, curtail the 
Medicaid program, and limit family planning services have only 
served to harm women and their families. Reducing maternal 
deaths in the United States must be a public health priority. I 
look forward to working with my colleagues to advance this bill 
and to begin addressing this crisis in a meaningful way.
    And I would like to now yield 2 minutes to my colleague, 
the Democratic sponsor of H.R. 1318, Ms. DeGette.
    Ms. DeGette. Thank you very much for yielding.
    Mr. Chairman, thank you so much for having this hearing. 
And I know my co-sponsor, Congresswoman Herrera Beutler, and I 
very much hope that we can mark this bill up and pass it during 
the lame duck session. In my opinion, it has been far too 
delayed given what we are seeing in this country.
    Maternal mortality rose in the United States between 2000 
and 2014 by 26 percent. This is really shocking to people who I 
talk to about this because other developed nations in the world 
have slashed their maternal mortality rates in half. And here 
is what is even worse, maternal mortality disproportionately 
affects women of color. Pregnancy-related death is nearly four 
times higher among African American women. And there are 
multiple factors that contribute to these maternal mortality 
rates--the high incidence of preeclampsia, obstetric 
hemorrhaging, and mental health conditions.
    Now to combat this trend, 33 states have established 
maternal mortality review committees. These panels bring 
together local healthcare professionals who collectively review 
individual maternal deaths and then target individual policy 
solutions towards them. The panels have been very effective. In 
California, for example, which established one in 2006, they 
have reduced their maternal mortality by more than 55 percent. 
And that is why what this bill does is it provides federal 
support for state-based maternal mortality review committees 
including for states, critically, that have not yet established 
these panels. It also promotes efforts to standardize data 
collection practices for maternal mortality which will help 
public health experts, researchers, and policymakers develop 
evidence-based solutions to address this crisis.
    The bill has 171 co-sponsors and a number of organizations, 
some which are here in the audience today. The March of Dimes, 
the American College of Obstetrics and Gynecologists, and 
others all support it and so I really hope we can quickly 
advance the bill. I hope we can pass it by the end of the year 
and send it to the President's desk. Thank you and I yield 
back.
    Mr. Burgess. The chair thanks the gentlelady. The 
gentlelady yields back and this concludes with member opening 
statements. The chair would remind all members that pursuant to 
committee rules, members' opening statements will be made part 
of the record.
    We do want to thank our witness on the first panel for 
being here today and taking time to testify before the 
subcommittee.
    I do want, as a housekeeping note, after Representative 
Herrera Beutler testifies we will move immediately to the 
second panel. We will not break in between the panels of 
witnesses. And again as is the custom, when we have a Member at 
the witness table there will not be questions from the dais to 
the Member, so we will go right into the second panel after 
Representative Herrera Beutler testifies.
    So our first witness is Representative Herrera Beutler from 
the State of Washington who is principal author of this 
legislation. We appreciate you being here today and you are 
recognized 5 minutes for your opening statement, please.

 STATEMENT OF HON. JAIME HERRERA BEUTLER, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF WASHINGTON

    Ms. Herrera Beutler. Thank you, Mr. Chairman, for having 
this hearing and for your work in this field. This isn't an 
issue of the moment for you, but this is what you have 
dedicated your life to and we are very grateful.
    Thank you, Ranking Member Green, for your support of this 
critical issue, and members of the subcommittee today for 
participating in this effort to reduce maternal mortality in 
the United States and for giving me this opportunity to speak 
in strong support of this discussion draft of the Preventing 
Maternal Mortality Deaths Act that is before us.
    So you either are a mom or you have a mom, so this issue 
impacts you. The very title of this bill speaks to why I have 
introduced this bipartisan legislation with my co-sponsor Ms. 
DeGette from Colorado. We have to take vital steps towards 
moving this bill in Congress and I believe we are going to save 
lives and prevent more families from suffering the profound 
loss of a cherished family member.
    The testimonies today will shed light on a truly disturbing 
trend in our nation. More mothers die from pregnancy-related or 
pregnancy-associated deaths here in the U.S. than in any 
developed country in the world. Although the assumption is 
often that a nation with some of the most advanced obstetric 
and emergency care would also demonstrate low maternal 
mortality rates, tragically, an estimated 700-900 maternal 
deaths occur in the U.S. every year.
    And not only does the U.S. rank 47th for maternal mortality 
globally, we have actually seen an increase in maternal deaths 
in recent years. This makes us one of only eight nations in the 
world with rising maternal mortality rates. It is unacceptable. 
In fact, Iran has a better maternal mortality rate than we do 
here in the United States.
    In New Jersey where Mr. Pallone is from, and he knows this, 
if you are a woman of color, a black woman, out of 100,000 
deaths, 79 are likely to pass away from a pregnancy-associated 
or pregnancy-related death. You are three or four times more 
likely as a woman of color to experience this tragedy in our 
country. It is unacceptable. For families, single fathers, 
grandparents, and children who have all lost a mother, perhaps 
the most heart-wrenching of all of this is that according to 
the CDC 60 percent of these maternal deaths could have been 
prevented.
    As a mother, as a citizen, and a lawmaker, I believe we can 
and we must do better. It is time for this to become a national 
priority, which is why I am proud to speak in support of the 
Preventing Maternal Deaths Act. This legislation would enable 
states to establish and strengthen maternal mortality review 
committees. MMRCs bring together local experts in maternal, 
infant, and public health to review each and every instance of 
a pregnancy-related or pregnancy-associated death. We are going 
to investigate every single one because these moms are worth 
it. This is going to give us the information to understand why 
it is happening and what we need to do to fix it. This is how 
we are going to save future mothers' lives.
    As members of the committee are aware, we know many of the 
conditions that contribute to high maternal mortality rate such 
as preeclampsia, gestational diabetes, obstetric hemorrhage, as 
well as emerging challenges such as suicide and substance use 
disorder. However, the truth is that the available data is 
woefully inadequate, which greatly hinders our ability to 
understand why mothers are dying. The Preventing Maternal 
Deaths Act seeks to address this data deficiency by empowering 
states to participate in national information sharing through 
the CDC, allowing for increased collaboration and the 
development of best practices.
    Now before closing, I want to note that the legislation 
before us was crafted from key policy recommendations made by 
multiple organizations supporting this bill including the 
Association of Maternal & Child Health Programs, the American 
College of Obstetricians and Gynecologists, the March of Dimes, 
Preeclampsia Foundation, the Society for Maternal-Fetal 
Medicine--thank you to all of you tireless warriors in this 
fight.
    Finally, and most importantly, I would like to extend my 
deepest gratitude to the families, fathers--one of whom you are 
going to hear from today, sitting behind me. Charles Johnson is 
going to tell you the story of the preventable death of his 
hero and hopefully this will be a tribute to ending those 
tragedies. He wants no one else to go through what he has gone 
through.
    And to every advocate who has spoken out, shared their 
stories, and called for change, these courageous individuals 
are the champions of this movement and this bill. With wide 
bipartisan support and well over a 160 co-sponsors in the 
House, I remain committed to passing the Preventing Maternal 
Deaths Act into law and I look forward to working with this 
committee, you, Mr. Chairman, and my colleagues in Congress to 
accomplish this imperative goal.
    With that I thank you and I yield back.
    [The prepared statement of Ms. Herrera Beutler follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

    
    Mr. Burgess. We thank you, Representative Herrera Beutler, 
for, number one, putting forward the discussion draft and 
working on it so hard over this past year in bringing all of 
the different people together that had to finally come together 
to get this hearing a reality today. And I know it took a lot 
of work on your part and we really appreciate your dedication. 
So thank for being with us this morning and we will move 
immediately to our second panel.
    And while the transition is occurring, I will just use this 
time to thank all of our witnesses for being here today and 
taking time to testify before the subcommittee. Each witness 
will be given the opportunity to deliver an opening statement 
followed by questions from members.
    Mr. Green. Mr. Chairman?
    Mr. Burgess. For what purpose does the gentleman from Texas 
seek recognition?
    Mr. Green. I would like to submit the following letters, 
ask unanimous consent to submit the following letters for the 
record. From the Moms Rising, Alexis Joy Foundation, and the 
Society for Maternal Fetal Medicine into the record.
    Mr. Burgess. Without objection, so ordered.
    [The information appears at the conclusion of the hearing.
    Mr. Burgess. Do we have copies of those?
    Mr. Green. Yes.
    Mr. Burgess. So today we are going to hear from Mr. Charles 
Johnson, founder of 4Kira4Moms; Ms. Stacey Stewart, president 
of the March of Dimes; Dr. Lynne Coslett-Charlton, Pennsylvania 
District Legislative Chair, The American College of 
Obstetricians and Gynecologists; and Dr. Joia Crear Perry, 
president of the National Birth Equity Collaborative. We 
appreciate each of you being here today.
    And Mr. Johnson, you are now recognized 5 minutes for an 
opening statement. Please turn your microphone on. Pull it 
close. This is the premier technology committee in the United 
States House of Representatives and we have fairly rudimentary 
amplification devices.
    So Mr. Johnson, you are recognized.

  STATEMENTS OF CHARLES S. JOHNSON, IV, FOUNDER, 4KIRA4MOMS; 
  STACEY D. STEWART, PRESIDENT, MARCH OF DIMES; LYNNE COSLETT-
 CHARLTON, M.D., PENNSYLVANIA DISTRICT LEGISLATIVE CHAIR, THE 
AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS; AND, JOIA 
CREAR PERRY, M.D., FOUNDER AND PRESIDENT, NATIONAL BIRTH EQUITY 
                         COLLABORATIVE

                  STATEMENT OF CHARLES JOHNSON

    Mr. Johnson. I think I will manage. Thank you so much. So, 
first and foremost, to members of this committee, thank you. It 
is an honor to be here speaking on behalf of the tens of 
thousands of families that have been affected by this maternal 
mortality crisis and hundreds of thousands of women who have 
been affected by near misses.
    So let me just begin by telling you about the woman that 
absolutely changed my life. My wife, Kira Dixon Johnson, was 
the closest thing that I had ever met to a superhero. She made 
me far better than I ever thought I could be and she was far 
better than I ever deserved. We are talking about a woman that 
ran marathons; that raced cars; that spoke five languages 
fluently.
    So we were blessed to welcome our first son, Charles, on 
September 18th of 2014. We always wanted back-to-back boys, 
Chairman Burgess, and we were blessed to find out we were going 
to welcome our second son, Langston, in April of 2016. We 
walked into Cedars-Sinai Medical Center on April 12th of 2016 
with a woman that just wasn't in good health, she was in 
exceptional health. This picture that you see on the screen is 
literally taken 10 days before Kira went in for the procedure.
    We went in for what was supposed to be a routine scheduled 
C-section on what was supposed to be the happiest day of our 
lives and we walked right into what was a nightmare. Shortly 
after the procedure took place around 2 o'clock, shortly 
afterwards we went back to recovery. As I am sitting there 
reflecting in all this glow and pride of being a new father for 
the second time, Kira is resting, my new baby is resting, and 
as I look at her bedside I begin to see the catheter begin to 
turn red with blood.
    I brought it to the attention of the staff, the nurses at 
Cedars-Sinai. They came in. They said we are going to do a 
couple of things. We are going to order a set of tests and we 
are going to order a CT scan to be performed stat. I was 
concerned, but I said you know what, my wife is healthy and we 
are at what is supposed to be one of the best hospitals in the 
world. I am concerned but we have got a plan, OK.
    Blood work comes back, it is showing that it is abnormal 
and she is hemorrhaging and they ordered a CT scan that was 
supposed to be performed stat. Keep in mind this is around 4 
o'clock. 5 o'clock comes, no CT scan. Her blood level was 
continuing to drop. By this time she is beginning to shiver 
uncontrollably. 6 o'clock and no CT scan. She is beginning to 
become pale, she is in extreme pain. 7 o'clock, 8 o'clock 
comes, no CT scan. I am begging, I am pleading the staff to do 
something.
    And around 9 o'clock as I continue to plea for my wife's 
life, the staff at Cedars-Sinai Medical Center tells me, sir, 
your wife just isn't a priority right now. 8 o'clock comes, 9 
o'clock, 10 o'clock. They said, well, we need to do a blood 
transfusion. I am saying, well, where is the CT scan? It wasn't 
until after midnight that they finally took my wife back to 
surgery, after I begged and pleaded for them to take action for 
more than 10 hours. When they took Kira back to surgery they 
opened her up and there were three and a half liters of blood 
in her abdomen and she coded immediately.
    Now I am here to tell you this. I am not here to tell you 
what I think. I am here to tell you what I know. There are 
people on this panel that are far more intelligent than I will 
ever be that are going to talk to you about the statistics and 
how horrifying they are. What I am here to tell you is this. 
That there is no statistic that can quantify what it is like to 
tell an 18-month-old that his mother is never coming home. 
There is no matrices that can quantify what it is like to 
explain to a son that will never know his mother just how 
amazing she was.
    My wife deserved better. Women all over this country 
deserve better. I am so grateful to my shero, Congresswoman 
Jaime Herrera Beutler. Thank you so much, Congresswoman 
DeGette. And for those of you all who have supported this bill, 
I honest to goodness would love to come up there and just give 
you a big hug, but I have been explained that that is not 
protocol.
    And let me say this for those that choose to stand in 
opposition of this bill, you don't owe me an explanation. You 
owe an explanation to my boys. You owe Tara Hansen's son an 
explanation. You owe Mustafa Shabazz and his son an 
explanation. We have an opportunity to do something, here and 
now, to send a loud, definitive message to this country that 
women and babies matter.
    Lastly, Kira and I always talked about raising men that 
would change the world. It is time for us to stop telling our 
children that they can change the world and show them how it is 
done. Thank you for your time.
    [The prepared statement of Mr. Johnson follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

    
    Mr. Burgess. Mr. Johnson, we do sincerely appreciate your 
testimony and as a committee I will say we are terribly sorry 
for your loss, but grateful for your courage to be here today 
and present your testimony to us. Thank you, Mr. Johnson.
    Ms. Stewart, you are recognized for 5 minutes.

                  STATEMENT OF STACEY STEWART

    Ms. Stewart. Thank you, Mr. Chairman.
    Mr. Burgess. I know, he is tough to follow.
    Ms. Stewart. Very hard to follow that so--and I am known by 
my family to be one of the biggest crybabies, but it is for 
good reason.
    So thank you for inviting me to testify at this very 
important hearing today. I am Stacey Stewart. I am President of 
the March of Dimes. March of Dimes is leading the fight for the 
health of all moms and babies. And I would like everyone in 
this room to take a look at this blanket. Just about everyone 
that has had a child will never forget the very moment when a 
doctor placed a precious baby boy or baby girl into our arms 
wrapped into one of these blankets.
    More than 700 times a year, beautiful babies are wrapped 
into these blankets, in one just like this one, but 
unfortunately there is no mother to hold a child that is 
wrapped in that blanket. So that is not just a statistic. There 
are 700 mothers that die every single year and almost and over 
50,000 who experience dangerous complications that could have 
killed them, making the U.S. the most dangerous place in the 
developed world to give birth.
    And we think and we know that you agree that this situation 
is completely unacceptable. Our nation is in the midst of a 
crisis of maternal and child health. Across this nation, 
virtually every measure of the health of pregnant women, new 
mothers, and infants is going in the wrong direction. The 
number of babies born premature is rising in this country. In 
many communities, infant mortality, rates of infant mortality 
exceed those in developing nations. Nations such as Slovenia 
and French Polynesia have better infant mortality rates than 
here in the United States.
    Women are tragically dying, women like Kira, from 
pregnancy-related causes and are suffering from severe health 
consequences like infertility. While other countries have 
reduced their infant mortality rates, the number of women who 
die from pregnancy-related causes in the U.S. has doubled in 
the last 25 years. And as we have heard this morning already, 
black women are three to four times more likely to die from 
pregnancy-related causes than white women, which is a truly 
shocking and appalling disparity.
    Maternal mortality is also significantly higher in rural 
areas where obstetrical providers may not be available and 
delivery in rural hospitals is associated with higher rates of 
postpartum hemorrhage. March of Dimes will release a report in 
the coming weeks that will show that maternity care deserts 
exist in this country and in these deserts pregnant women face 
serious challenges in receiving appropriate care.
    The state of maternal health in the United States is dire, 
but there are things we can do and we must do. Many factors are 
contributing to the maternal health crisis in this nation and 
our work to address it is important and it must be equally 
multifaceted. The bill before the subcommittee today is a 
critical step towards preventing death or serious health 
outcomes for pregnant women and new mothers.
    The discussion draft of H.R. 1318, the Preventing Maternal 
Deaths Act, would provide grants to states and tribes to help 
establish or improve maternal mortality review committees or 
MMRCs. MMRCs are interdisciplinary groups of local experts that 
come together in maternal, infant, and public health to 
investigate the cases of maternal death, identify those 
systemwide factors that contributed to these deaths, and then 
develop recommendations that would help prevent future cases.
    MMRCs are unique in that they identify solutions. Not just 
collect the data, but then identify solutions that are targeted 
to the needs of pregnant women and mothers in specific states, 
cities, and communities. The discussion draft of H.R. 1318 
would also establish a demonstration project to determine how 
best to address disparities in maternal health outcomes.
    Mr. Chairman and members of the subcommittee, while this 
bill is extremely important, maternal mortality is not a single 
problem with a single solution. The causes of maternal 
mortality and severe maternal morbidity are diverse. They 
include physical health, mental health, social determinants, 
and much more. They can be traced back to the issues in our 
healthcare system including the quality of care as we just 
heard so passionately from Charles, systems problems, and of 
course the issue of implicit bias that exist in our healthcare 
system. They stem from factors in our homes, our workplaces, 
and our communities.
    Mr. Chairman and members of the subcommittee, thank you for 
recognizing the urgency and the magnitude of this public health 
crisis. Our nation's mothers and babies cannot wait any longer. 
We must act now to save the lives and the health of pregnant 
women, new mothers, and their babies. Thank you.
    [The prepared statement of Ms. Stewart follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

    
    Mr. Burgess. Thank you, Ms. Stewart.
    Dr. Coslett-Charlton, you are now recognized for 5 minutes, 
please.

              STATEMENT OF LYNNE COSLETT-CHARLTON

    Dr. Coslett-Charlton. Chairman Burgess, Ranking Member 
Green, Chairman Walden, Ranking Member Pallone, and 
distinguished members of the Energy and Commerce Subcommittee 
on Health, thank you for inviting me to speak with you today on 
behalf of the American College of Obstetricians and 
Gynecologists at this hearing entitled, Better Data and Better 
Outcomes: Reducing Maternal Mortality in the U.S.
    ACOG, with a membership of more than 58,000, is the leading 
physician organization dedicated to advancing women's health. 
Today's hearing will focus on a discussion draft of H.R. 1318, 
the Preventing Maternal Deaths Act, sponsored by 
Representatives Jaime Herrera Beutler, Diana DeGette, and Ryan 
Costello. I want to extend a special thank you to the bill 
sponsors for working so diligently on this bipartisan 
legislation, a critical first step in improving maternal health 
outcomes for women in this country.
    A special thanks also to you, Dr. Burgess, my colleague OB/
GYN, for your leadership highlighting this critically important 
issue and making maternal mortality a top priority.
    As many of you know, the United States has a maternal 
mortality crisis. Too many women die each year in the United 
States from pregnancy-related and pregnancy-associated 
complications. We have higher maternal mortality rates than any 
other developed country. At a time when 157 of 183 countries in 
the world report decreases in maternal mortality, ours is 
rising. Black women are disproportionately affected and are 
three to four times more likely to lose their lives than white 
women. And for every maternal death in the United States there 
are a hundred women who experience severe maternal morbidity or 
near misses.
    This is all unacceptable and the time for action is now. We 
know that over 60 percent of maternal deaths are preventable. 
Common causes include hemorrhage, cardiovascular and coronary 
conditions, cardiomyopathy, or infection. Overdose and suicide, 
driven primarily by the opioid epidemic, are also emerging as 
the leading causes of maternal mortality in a growing number of 
states including my own. If we have a clear understanding of 
why these deaths are occurring and what we can do to prevent 
them in the future, we can save women's lives.
    The Preventing Maternal Death Act assists states in 
creating or expanding maternal mortality review committees 
through the Center of Disease Control and Prevention. MMRCs are 
multidisciplinary groups of local experts in maternal and 
public health as well as patient and community advocates that 
closely examine maternal death cases and identify locally 
relevant ways to prevent future deaths. While traditional 
public health surveillance using vital statistics can tell us 
about trends and disparities, MMRCs are the vehicle best 
positioned to comprehensively assess maternal deaths and 
identify, most importantly, opportunities for prevention.
    As ACOG's Pennsylvania Section Chair and incoming District 
III Legislative Chair and a practicing physician for over 20 
years, addressing maternal mortality is of critical importance 
to me. As an OB/GYN, seeing a woman die while pregnant or after 
delivering a baby is something that sticks with you for life 
and has stuck with me throughout my career. Preventing that 
kind of tragedy and ensuring the health and safety of the women 
we care for is central to our mission.
    When I took over as ACOG's Pennsylvania Section Chair, 
Pennsylvania did not have MMRC, though the city of Philadelphia 
did. And over the past 2 \1/2\ years I have worked diligently 
to organize the campaign with other OB/GYNs and other advocates 
in my state and the Department of Health to urge the state 
legislators to pass legislation to form our first statewide 
MMRC. Finally, on May 9th, Governor Wolf signed the Maternal 
Mortality Review Act. Our first meeting is next week. 
Enthusiasm like this for MMRCs is growing all over the country. 
Today, approximately 33 states have MMRC and as many of those 
33, including Pennsylvania, are brand new this year.
    But states like ours need help. The CDC plays a vital role 
in assisting these states to ensure their MMRCs are robust, 
multidisciplinary, and using standardized reporting, which is 
why it is important to have this federal legislation as 
mechanisms. The Building U.S. Capacity to Prevent Maternal 
Deaths Initiative, a partnership between the CDC's National 
Center for Chronic Disease Prevention and Health Promotion, the 
CDC Foundation, the Association for Maternal & Child Health 
Programs, and Merck for Mothers has made tremendous progress 
giving technical assistance to states to help them establish 
MMRCs or ensure established MMRCs are operating with evidence-
based practices.
    In Pennsylvania we need to ensure that this type of 
technical assistance is amplified so that we can get our MMRC 
off the ground and working correctly. Once MMRCs are up and 
running they lead to opportunities for quality improvement. For 
example, to participate in the Alliance for Innovation on 
Maternal Health, or AIM, a state must first have an MMRC. AIM 
convened under ACOG's leadership is a national alliance of 
clinicians, hospital administration, patient safety 
organizations, and patient advocates that work to reduce 
maternal mortality and severe morbidity by creating condition-
specific bundles which are evidence-based toolkits to improve 
maternal outcomes. Some of these bundles include severe 
hypertension, maternal mental health, obstetric care for women 
with opioid use disorder, obstetric hemorrhage, and racial 
disparities in maternity care. To participate in AIM, a state 
must first have MMRC. The data recommendations from MMRCs 
instruct states where they need to invest to address specific 
conditions that affect women in their community and ensure 
proper appropriate targeting of limited resources.
    For us to clearly understand why women are dying from 
preventable maternal complications across the country and make 
lasting improvements, every state must have a robust MMRC. The 
Preventing Maternal Death Act will help us reach that goal and 
ultimately improve maternal health across this country. Thank 
you very much for the opportunity to speak to you about this 
pressing issue and in support of this very important 
legislation.
    [The prepared statement of Dr. Coslett-Charlton follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

    
    Mr. Burgess. Thank you, Dr. Charlton.
    Dr. Crear Perry, you are recognized for 5 minutes, please.

                 STATEMENT OF JOIA CREAR PERRY

    Dr. Perry. So, thank you fellow ACOG member, Dr. Burgess.
    Mr. Burgess. And if you will suspend for a moment, in the 
interest of full disclosure I am a dues-paying member of the 
American College of Obstetricians and Gynecologists.
    Dr. Perry. Here we go.
    Mr. Burgess. And I am current on that. And I don't do the 
emeritus stuff, I pay the full freight. You may proceed.
    Dr. Perry. And Ranking Member Green, thank you as well, and 
to my fellow colleagues on the panel. I really feel like going 
last is always a great way to go because you can hear what the 
gap might be in explaining this.
    I get to work with the 33 states who are doing the MMRCs. 
As an organization we provide technical assistance. We also get 
to work in places like Philadelphia. We have been doing it for 
awhile. So a concrete example would be in Philadelphia they had 
a lot of women who were dying from cardiomyopathy, which sounds 
really medical, right, because your heart fails, it won't pump 
as well. When they actually reviewed the deaths, many of the 
women had heroin addiction, right, so it was something you 
could prevent if you actually put in mental healthcare services 
for addiction. So it is important for us to have a broader 
view.
    Someone brought up California, which is really important. 
So California has decreased their deaths, but they still have a 
racial disparity. Still, in California despite having these 
great outcomes, they have had increased deaths for black women. 
So what they are doing now is really going back to look at 
implicit bias that was mentioned, making sure that their 
providers are culturally cognizant and having really some rules 
around what does it mean if you don't value a woman and she is 
not seen for several hours, how does that system respond to 
that and what can we do differently to ensure that people are 
seen in an appropriate amount of time.
    So just wanted to give some teeth to how important this is 
and how having the ability to actually look at the deaths 
individually and to talk to family members and to have mental 
health there really can help us to get to some answers.
    So now I want to tell you a little bit of my own story, 
because every woman's story needs to be heard and this is what 
the MMRC allows you to do. So when I was a third-year medical 
student in my home of Louisiana after attending Princeton for 
undergrad, my then-husband and I were expecting our planned 
second child. At about 5 \1/2\ months pregnant, my water broke. 
My mother, who is here and a pharmacist, still recounts how 
panic-stricken she was when she was counseled by my physician 
about the risk of infection to my son and I that included 
death.
    I had access to excellent health care for him provided by 
my health insurance coverage, but the stress of racism was my 
only risk factor for the premature birth of my son. The 
hospital where I was training was named Confederate Memorial 
just 20 years prior to this. Luckily, my 22-year-old son and I 
survived, but the sad reality is that my 25-year-old daughter 
has a higher risk of dying in childbirth than I did when I had 
her. The same is true for all of us who have daughters in the 
United States. We are failing our daughters, especially our 
black daughters who are dying at three to four times the rate 
of their white counterparts.
    So, ultimately, what we are asking for this bill, when you 
think about what Charles said and what all of us have said, is 
we can no longer delay acting. This bill has been reiterated 
many times in Congress and I am excited to hear that maybe we 
can have it done by the end of this year, because it is 
important for us to say that we as a country--I got to testify 
at the U.N. about this very issue--the world is watching us. 
The world sees us. I get flown to Geneva to talk about how 
important it is for the United States to actually value women 
and to pay for and look at why women are dying, so this is an 
opportunity for us to say yes, we do value women and yes, we do 
want to see what is actually happening to them.
    So ultimately what women, especially black women, in the 
United States need is accountability. We need to know that our 
lives are valued. We need to know that this accountability 
might be difficult, it might be complicated, but government 
still has an obligation to act. Accountability is a value that 
all Americans can agree upon, yet racism, classism, and gender 
oppression are killing all of us from rural to urban America. 
This is not about intentions. Lack of action is unintentionally 
killing us. It is a human rights imperative. We just ensure 
that prevention efforts and resources are being directed 
towards the areas of greatest need and be willing to name the 
problem directly.
    Much can be accomplished through improving monitoring and 
data collection.
    Me and my big writing because my eyes are getting bad, I am 
getting old.
    H.R. 1318 is a tremendous step forward in showing that we 
do recognize, yes, black mamas matter. That is it.
    [The prepared statement of Dr. Perry follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

    
    Mr. Burgess. Thank you, Dr. Perry, Dr. Crear Perry. I 
appreciate your testimony and appreciate all of our witnesses 
for being here.
    I will move to the question part of the hearing and I will 
recognize myself 5 minutes for questions. And Dr. Coslett-
Charlton, let me ask you as a--we have heard the stories and 
yes, the review committees are important, legislation is 
important. But honestly, doctor to doctor, it is decisions that 
are made at the bedside and I honestly don't know how you 
legislate correct decisions to be made at the bedside.
    So as part of this effort and as a fellow member in the 
American College of OB/GYN, it is really incumbent upon our 
professional societies, medical societies, our specialty 
society. This is where the rubber meets the road. We have to 
be--I don't know how I can legislate something that stops what 
Mr. Johnson went through. I just don't know how I can do that. 
Here was a situation where all the signs and symptoms pointed 
to exsanguination and he describes unfortunately in very 
painful detail what the natural consequence of exsanguination 
is, and I don't know how I write legislation to stop that from 
happening. That is on us as a profession, right?
    Dr. Coslett-Charlton. I totally agree. And I think that is 
why we are here and that is why we are sitting beside Mr. 
Johnson because those stories, I think, affect. And I know, Dr. 
Burgess, because you practiced for so long, I look at my intern 
year, I was on my internal medicine critical care rotation, 
probably the second month of rotation and I was called for a 
code for one who had a very rare condition called an amniotic 
fluid embolism, which I don't know if you have seen one in your 
career, but I was like what could this be--one in 300,000--and 
she died in front of me.
    I was an intern observing, I wasn't actively participating 
in the care at that time, but I seriously questioned whether or 
not I wanted to go into this field at that time because--and I 
am so glad I did, because the joy of being an OB/GYN far 
outweighs the unfortunate things that happen to patients 
sometimes. But I think seeing that, if we can prevent one 
death, if we can educate our members, and really the best way 
to do that is to understand where the problems lie.
    And the AIM programs are a great success story and if we 
are able to roll them out across the country and really see 
where we can use best practices to prevent things from 
happening that couldn't otherwise, and really obstetric 
hemorrhage is a perfect example where having the beauty of the 
AIM program is that it is, really, readiness first, so the four 
Rs, readiness and then recognize that there is a problem. So 
the readiness includes things like having suture available, 
having medication available on the labor floor so that you are 
not calling a pharmacist to come, I need this medicine now not 
an hour from now while you approve it.
    So being ready, being able to recognize that there is a 
problem and educating staff members. Not just physicians, but 
also people that are on the front lines caring for the patients 
first. And also the response and having protocols for response 
that are appropriate, having blood products readily available 
for women when they are in transfusion protocols we have shown 
to be effective.
    And, finally, reporting, because when we talk about 
maternal mortality and we talk about the deaths that is very 
important, but also the near misses are equally devastating and 
equally important that we know how to identify them. And not 
only, we are seeing the iceberg, if we can really get to the 
crux of that where we are truly going to improve the way we 
care for women in this country and I am positive we are going 
to see fewer maternal deaths.
    Mr. Burgess. Well, and that is what is critical about this. 
Maternal mortality review committees, I think that is an 
excellent idea. I am all in favor of that. I will just say in 
the 1970s at Parkland Hospital it was called grand rounds. And 
you didn't ever want to present at grand rounds. That probably 
meant your patient hadn't done well, but what it really meant 
was you weren't going to do well for the next couple of hours. 
And Dr. Jack Pritchard was the head of the department back 
then. He was pretty critical and had a way of asking those 
insightful questions that exposed any perhaps weakness in your 
clinical judgment or your thought process as you worked through 
a complicated issue.
    Let me just ask you, have we gotten away as a profession 
from that type of introspection that you probably were exposed 
to in residency? I know I was.
    Dr. Coslett-Charlton. No, I think if you speak to any 
residents those processes still happen, but they happen mainly 
in academic centers. And really a part of this problem is that 
we have to better reach the communities. I practice in a small 
community hospital right now and it is very different. I think 
and educating practitioners in the community hospitals we know 
is equally as important, and access to care obviously as we 
have spoken to is equally important.
    So I think being able to collect the data, being able to 
see where the deficiencies and having a mechanism and a vehicle 
and support nationally down to the state levels and the 
tentacles that can get the boots on the ground to make sure 
that none of these things happen anywhere in the United States 
is critical.
    Mr. Burgess. Well, Mr. Green gets extremely critical of me 
if I run over, so I will yield back my time and recognize the 
gentleman from Texas for 5 minutes for questions.
    Mr. Green. I just ask equal time, Mr. Chair. I want to 
thank all our witnesses. And, Mr. Johnson, being a father of 
two children and now a grandfather, I just, and as the chair 
said, I don't think there is anything we can do. Of course 
there is no shortage. We have a lot of doctors in Congress but 
we also have a lot of lawyers. And so people say well, you can 
go to the tort system, and but that is not going to bring back 
your wife or your second baby. And it just, how do you do that? 
But we understand, those of us who have children and I know 
physicians particularly.
    So I want to thank all of our witnesses today being here 
and discussing the U.S.'s maternal mortality rate, which I 
would be remiss if I didn't acknowledge my home state's 
maternal mortality crisis as well. As widely reported in 2016, 
published in Obstetrics & Gynecology found the Texas maternal 
rate was doubled between 2010 and 2012. The study's authors 
acknowledge these statistics were unexplainably high.
    In the wake of this report, Texas' Maternal Mortality and 
Morbidity Task Force underwent review of all pregnancy-related 
deaths in Texas to determine the accuracy of these findings. 
What the task force found was that data collection errors and 
lack of standardization in reporting has resulted in varying 
statistics. If we can't depend on the research, that is a 
problem.
    Dr. Coslett-Charlton, can you explain why the 
standardization of data collection is so critical when 
discussing maternal death rates?
    Dr. Coslett-Charlton. That is a very important question, 
Representative Green. And I think the crux of the issue is that 
the vehicles of looking at vital statistic records we are able 
in the pregnancy checkboxes, if someone pregnant within a year 
or 42 days in Texas of delivery that those measures certainly 
can identify and are inherent to error.
    But the important thing and why we are here today is to 
make sure that all of those deaths are reviewed so that we can 
have accurate data. And that is why these maternal mortality 
review committees are essential, because not only are they 
going to review the deaths but they are going to be able to 
determine if they could have been preventable deaths and that 
is where the impact truly could be made.
    Mr. Green. What can we learn from this study in Texas, and 
tell me Texas is not the only state that has that kind of 
statistics that you can't depend on. Is it other states, in 
Pennsylvania, or other states in the country?
    Dr. Coslett-Charlton. Well, in Pennsylvania we have had the 
checkbox for the past 5 years and I think that in Philadelphia 
there has been a small community that they have been able to 
focus on that data. But I think like I was saying, the 
essential part of this is that having accurate data is really, 
really, truly important and the Texas studies truly exemplify 
that how important these MMRCs are.
    The Texas committee at that time was not as sophisticated 
as it is now and their means of collecting aren't as 
sophisticated, so I think that going forward it is a perfect 
example of why this is essential.
    Mr. Green. The Texas Maternal Mortality and Morbidity Task 
Force put out a series of recommendations on ways to improve 
maternal health and prevent pregnancy-related complications. 
Just this last month, the task force released its joint 
biannual report for our Department of State Health Services. 
Their first recommendation is we increase access to healthcare 
services to improve the health of women, facilitate continuity 
of care, and enable an effective care transitions and promote 
safe birth spacing.
    Dr. Crear Perry, would you agree with the recommendation to 
improve maternal health we must improve the access to care?
    Dr. Perry. Sure. And I want to also piggyback on the last 
question a little bit about the data because it is important 
that we--it is a common phenomenon across the country, so it is 
not just Texas and it is not just Pennsylvania. A lot of states 
need this money to help with collect more accurate data, it 
would be really helpful.
    And as far as access it is a big barrier. We see that 
places where closing rural hospitals in Texas, in Georgia, that 
when women have to travel an hour to have a baby they are more 
likely to hemorrhage. They are more likely to have a heart 
attack. They are more likely to have these medical conditions. 
So if you don't have a systemic review you can't look at the 
match between where your access is being denied and where women 
are also dying in the same place. So having a more robust 
review of the deaths will allow you to look at that.
    Mr. Green. From my perspective coming from Texas, one way 
to improve access to care is expanding access to Medicaid and 
ensuring low-income individuals have the care that they need. 
And do you agree with that?
    Dr. Perry. Sure. I am from the great State of Louisiana and 
so we have seen actual data since Louisiana expanded Medicaid. 
We are one of the few deep southern states that expanded 
Medicaid where we have had improved outcomes. Our governor, 
really it was important for him to ensure that we had access to 
Medicaid expansion. Women are getting preventive services so 
you know that you have diabetes before you become pregnant and 
you don't show up at the hospital pregnant with uncontrolled 
blood sugars. So it is important that we have expanded 
Medicaid.
    Mr. Green. And in my last 9 seconds, there is no 
replacement for prenatal care and having a mother who has a 
relationship with their doctor and that is why we need to have 
that access no matter who pays for it--Medicare, private sector 
or whatever.
    So, Mr. Chairman, thank you for your time.
    Mr. Burgess. The chair thanks the gentleman. The gentleman 
yields back. The chair recognizes the gentleman from Kentucky, 
Mr. Guthrie, the vice chair of the committee, 5 minutes for 
questions.
    Mr. Guthrie. Thank you, Mr. Chairman, and I appreciate 
everybody being here.
    Mr. Johnson, I appreciate you coming here and being willing 
to share your story. I know that a lot of times we have policy 
developed and things develop because people went through tragic 
things and they are willing to bring that to our attention and 
share. And I know it is difficult to do, but it is one way that 
they live on and it is a way that it actually changes what is 
going on in the country, so we appreciate that.
    And this is something that has been on the mind of the 
committee, I know the chairman, I know from his background, but 
also I remember being in a meeting earlier and we were trying 
to just get down to the policy that needs to happen. And your 
story, I remember one of the roundtables that the chairman has 
talking about the--it is not just access to care. It sounds 
like your wife was in a fantastic hospital situation and 
everything and it seems C-sections were something that could be 
common.
    And we are the most, it is not that people aren't getting 
care. A lot of people are getting C-sections. And my wife has 
had--I have three children, we have had three, so it really 
made me cringe when I heard that in your story, because it 
seems the second or third or whatever, C-sections seem to be 
something that is something we need to address in moving 
forward and that gets to just finding the right data.
    And Dr. Coslett-Charlton--Charlton or Charlton? Charlton. I 
know you are with ACOG and in this bill today we are looking at 
data and how to move data. I know ACOG has endorsed--a number 
of medical societies and ACOG has endorsed this bill and it is 
my hope that we can get sound data to see exactly the actions 
that we need to take. So can you speak to ACOG's perspective on 
the role of data in your efforts to reduce maternal mortality?
    Dr. Coslett-Charlton. So I think to some degree when you 
are speaking about specific situations like C-section rates and 
talking about, you know, once a woman has a first C-section, 
second C-section, third C-section, we know each time that a 
woman has a C-section risk can increase with subsequent 
pregnancies. And those are important reasons why, number one, 
we need access to good care.
    But also, the part of the AIM bundles where we talk about 
preparedness or readiness is that when we know a woman has a 
third C-section, knowing that you could--if she has the ability 
to have important prenatal care to recognize the potential 
complications and be ready for those complications, that is 
critical and essential.
    And the last thing, if we talk about the AIM bundles, one 
of the bundles is looking at how to improve primary Caesarean 
section rates so that is something that is good data that is 
coming out of California that we hope can translate, sharing 
data across state lines. Women are women in Pennsylvania the 
same as in Arizona. So, it really isn't rocket science. We 
should be able to share data and establish best practices and 
the way to do that is to have the vehicle or the mechanism to 
accurately be able to identify and look through that data.
    Mr. Guthrie. It just seems standard--not being a physician 
at all, I am a manufacturing person--but it just seems to be 
standard now that if somebody is having their second or third 
C-section that the symptoms your wife showed seems to be clear 
from what you said that maybe there should be a team waiting to 
see if something happens and being ready for any type of those. 
I would love if you wanted to comment.
    Mr. Johnson. Absolutely. I think that the astronomical C-
section rates are something that needs to be examined. When we 
talk about Kira's case, there was a C-section, indeed, but it 
wasn't the C-section that led to her ultimate passing. And I 
will share this with the committee and I didn't share--what I 
had shared earlier was a very condensed version of what was 
happening to Kira.
    But what we found subsequently when we go back and look at 
the medical records, which I shared as part of my record, is 
that in Kira's case she was exceptionally healthy, she went in 
for a routine scheduled C-section. And from what I understand, 
and Dr. Burgess and some of the medical people here, is what I 
understand is that for a woman who is having a Caesarean 
section, the cut timing and the time that they make the 
incision until the time that the baby is born, for a healthy 
woman and the baby is not under stress should be between 12 and 
15 minutes. Is that fair, Dr. Burgess? OK. And in a situation 
where a woman has had a previous Caesarean you should add 
another 3 to 5 minutes so that you can cut around the scar 
tissue.
    Mr. Guthrie. The problems with scar tissue in the second or 
third, Dr. Burgess explained that to me.
    Mr. Johnson. Yes. So this is the point I would like to make 
is, so we are talking about between 15 to 20 minutes, ballpark, 
for a woman that is healthy, second Caesarean section, the baby 
is not in distress. When we received the medical records from 
Cedars-Sinai Hospital, the cut time on the delivery for my 
second son, Langston, was less than 2 minutes. Less than 2 
minutes. And in the process of him rushing he lacerated her 
bladder.
    But once again, and so the way that has been described is 
that this was not a medical tragedy, this was a medical 
catastrophe meaning that everything that could have gone wrong 
did go wrong.
    So let's talk a minute about AIM which is a phenomenal 
program. And I want to salute ACOG for the work that they are 
doing in conjunction with AIM and being rolled out in various 
states. California, where we were where my son was delivered, 
is one of the trademark states for AIM and what they have done 
to reduce the maternal mortality rate with their hemorrhage 
bundle. But as long as we have these tools that are a 
suggestion and they are not a protocol, women are going to 
continue to pass away.
    So the AIM bundle was available in Kira's case. It is one 
of the--it is ground zero for the wonderful work they have done 
reducing the maternal mortality rate in California, but they 
just chose to ignore it and I continued to beg and plead while 
her condition deteriorated.
    So Caesareans are a challenge, but in Kira's----
    Mr. Guthrie. Different.
    Mr. Johnson. She was extremely healthy and they just let 
her continue to deteriorate. So we have got to have a 
fundamental standard of care that is not just a suggestion as 
AIM, as it is in the situation with AIM--and it is phenomenal--
but if we can make a fundamental standard of care across the 
board that will make a big difference.
    Mr. Guthrie. Thank you. Thank you for sharing and my time 
has expired. I yield back.
    Mr. Burgess. Thank you, Mr. Guthrie.
    Mr. Cardenas, you are recognized for 5 minutes, please, for 
questions.
    Mr. Cardenas. Thank you very much. And to Mr. Johnson, it 
is just amazing and incredible that you are doing what you are 
doing and thank you so much. You are saving lives and I 
appreciate that very much and so does everybody in this country 
and the world who will benefit from hopefully good decisions 
that we make, all of your efforts.
    First, I would like to ask some questions if the doctors 
would--I recently read about a program in California that has 
been very successful since both the March of Dimes and the 
College of Obstetricians and Gynecologists are part of the 
California Maternal Quality Care Collaborative. I am hoping 
that both Dr. Coslett-Charlton and Ms. Stewart can tell us more 
about this program.
    But in California's private-public partnership it was 
stressed that it was because of the views from a diverse panel 
of experts that they could avoid missing important details on 
women's deaths. And one of the things that I think it is 
important for us to understand is--I have been given a chart 
about the red line shows the mortality rate across the country 
while the highlighted yellow line actually shows California's. 
And we see a dramatic drop since 2007 when California has 
implemented the process of teaching each other, learning from 
each other, sharing data. And you are looking at California 
that has a mortality rate of 7.3 per 100,000 and across the 
country it is still up at 22.
    So what I would like to see happen is we as Congress and 
those of us who are involved, or those of you who are involved 
on the day-to-day process that we can come together and create 
a national best practices, and I hope that that is the outcome 
not only at this hearing but of this Congress.
    Dr. Coslett-Charlton and Ms. Stewart, if you can, can you 
talk a bit about how the diversity of these panels has changed 
and improved the maternal outcomes?
    Ms. Stewart. Well, let me just start with a couple of 
points, which is I think that it is notable that California has 
had so much success, obviously, and I think the idea of the 
committee that has been formed, the way they have come together 
to look at data, to design interventions, identify where the 
problems are within the state and really design interventions 
that have made a meaningful difference has been important. And 
that is important to say at a high level, but again when it 
comes down to each individual person who still may be affected 
by the gaps in the system like Charles and like his wife Kira, 
then we still have a problem.
    I want to say one thing about diversity in general and the 
importance of how this issue shows up and the disparate 
outcomes that many women of color experience as a result of the 
gaps in the system. And I agree with the chairman we can't 
legislate morality, but what we can do is ensure that we are 
tracking the performance of the system, we are tracking those 
women that are impacted disproportionately by the system, and 
that we are intentional in designing interventions that will 
make a difference.
    The gaps in the system don't just start though when women 
show up in the hospital. They start well before then. We know 
that for example to make sure that we have healthier babies it 
doesn't just happen in the 9 months of pregnancy. And I am not 
a physician. I am not an OB/GYN, but I think I have known that 
in my own experience having had two babies and leading the 
March of Dimes, which is the leading organization in the fight 
for the health of moms and babies.
    The same is true for healthier mothers. We have got to make 
sure that women have access to health care before they are 
pregnant especially if they have chronic diseases, chronic 
health challenges that might risk their health or the health of 
their baby. We have got to make sure they have access to good 
affordable care during pregnancy and what we know now is that 
it is important that women have access to excellent care after.
    And it is especially important and we have had research and 
studies to show that women of color also feel less trust and 
less well-served by the system. They feel less listened to and 
respected in terms of their symptoms when they articulate those 
symptoms. And these are women that are not only low-income 
women of color, these are women that are affluent women of 
color, women that are highly educated who simply have 
reported--and again studies show this--that their needs are not 
being met at the same level at the same rate as white women and 
other women.
    So I just want to say that I think this issue of diversity 
is really important not just in the panels but across the board 
in listening to the issues of disparate outcomes that we see 
across all communities.
    Mr. Cardenas. So best practices are something that we can 
improve and hopefully will become more prolific so we can have 
the outcomes that you just described. My time is limited, but 
hopefully during the testimony some of you can talk about the 
toolkits and how these toolkits are free.
    But a quick, quick question to Mr. Johnson is since you 
have lost Kira, it has been 2 years, how has this affected you 
and your family, if you could describe that for us, so we can 
understand the true responsibility that we have and we can make 
sure that this happens less and less and less. Thank you.
    Mr. Johnson. Well, this has been the most challenging 
experience that I could ever--even more challenging than 
anything that I could ever comprehend. That being said, the 
true blessing in all of this is the two tremendous gifts that 
Kira left us and that is my son Charles and my son Langston. 
They really, truly are what keeps myself, my mother who is 
seated behind me, all of us going.
    And, it is difficult as they mature and as they are, now 2 
and just turned 4 years old, their ability to process and 
understand the absence of their mother evolves. And like I 
said, when you talk to a 2 year old he wants to know why his 
mommy is not coming home. And you explain to him, well, your 
mother is in heaven and she is doing important work with God. 
And he tells you, well, I want to go to heaven too.
    And so there is nothing that I can prepare for, there is 
nothing that I can do to fix that and I hope that over time 
that--the heart is saying to just be completely honest with you 
is I am proud to be here representing these families, but at 
the end of the day I am just a father that whose heart aches 
for his sons and a husband that misses his wife desperately. 
And so while there is every day I search for answers and how to 
support these amazing gifts, what I am clear about is that what 
I have to do is, although there is nothing I can do to bring 
Kira back I have to do everything that I can whenever I can to 
make sure that I send other mothers home with their babies.
    And that if I can prevent another father from going through 
this, if I can prevent another child from having to understand 
why his mother isn't showing up at school--and I will share 
this with the committee. This is something that I have never 
even shared with my family, is when a 3-year-old asks you, 
Daddy, is Mommy mad at me? I want Mommy to come home. Why won't 
she come home? And I have never shared that with anybody 
because it is just too painful for me to articulate.
    But I am clear that the work that we are doing here is 
going to prevent this to continue to happen to other women and 
it is going to make sure that other women get to go home with 
their babies.
    Mr. Cardenas. Mr. Chairman, if you will allow me a few 
seconds to thank Mr. Johnson, my time has expired. Thank you so 
much. Thank you for your courage, your strength, and your 
commitment to community and to others and God bless you and 
your family. And know that your wife is doing good work in 
heaven, but you are doing tremendous work on earth. Thank you. 
I yield back.
    Mr. Burgess. The chair thanks the gentleman. The gentleman 
from California referenced the California Toolkit to Transform 
Maternity Care. I did print off a copy of that and at the 
conclusion of the hearing I will ask unanimous consent to make 
that as part of the record.
    The chair now recognizes the gentleman from Ohio, Mr. 
Latta, 5 minutes for your questions, please.
    Mr. Latta. Thank you very much, Mr. Chairman. And thanks so 
much for our panel of witnesses and for being with us today 
because it is so important for the work that you are doing in 
getting this message out.
    Ms. Stewart, if I could start my questioning, I am also 
concerned for soon-to-be mothers and new moms that live in our 
rural areas of our country. The national data indicates that 
more than half of all rural U.S. counties are without hospital 
obstetric services. With an increase of women dying due to 
pregnancy-related complications, how does access to care and 
hospital services affect pregnancies and postpartum recovery 
and is this issue exacerbated for women in our rural 
communities?
    Ms. Stewart. Thank you very much. It is a very serious 
issue and thank you for the question. And as I mentioned in my 
statement earlier, the March of Dimes is working currently on a 
report that would really show this issue of maternity care 
deserts. The issue of the closing of community hospitals in 
rural areas has been well documented.
    One of the things that we are missing is that it is not 
just the closing of hospitals. It is the closing of hospitals 
compounded by the lack of obstetrical services and OB/GYNs, the 
lack of midwives and doulas in areas, the distance that women 
often have to travel just to receive care, and it is 
particularly acute not just--in rural areas there is a major 
challenge, but one of the things we are looking at is even 
where in urban areas there can be maternity care deserts as 
well.
    I will give you a good example of this. Here in the 
District of Columbia there is no hospital that provides 
obstetrical services east of the river in Wards 7 and 8. So 
east of the Anacostia River, tens of thousands of women who 
live there who have no hospital to go to, who then have to 
travel. If they have no transportation they have to go on the 
Metro often an hour or more to even go to a prenatal visit. If 
you are a high-risk pregnancy or you have a high-risk 
pregnancy, the complications that are then exacerbated or the 
complications that can result because of that distance, because 
that lack of access is increased significantly.
    So one of the things that we really need to talk about in 
the system is the fact that even in the District of Columbia, 
for example, where there may be the number of beds may be 
sufficient for the number of women, that doesn't mean that 
those beds or that care is available to all the women that need 
it when they need it, and that is a very significant problem.
    So I think one of the things that we are doing in the March 
of Dimes is to try to work with our friends in health care, our 
partners--ACOG has been a longtime partner of ours--working 
with hospitals and others to make sure that services are 
available.
    The last thing I will just mention is that because all 
these issues that we are talking about today really just 
disproportionately again impact women of color. Women of color, 
African American women, are three to four times more likely to 
die as a result of childbirth. We also need to look at other 
ways in which services can be provided. We know that African 
American women, for example, are far more likely to want to 
receive services and care from a doula working within the 
formal healthcare system. And we have got to make sure that 
those services are also available so that women have places 
they can go they can trust. They know they go to places that 
will listen to them and that will respond to their needs and 
that will deal with their situation if they have high-risk 
needs as well. And what we are seeing today is that there are 
significant gaps in rural areas as well as in urban areas too.
    Mr. Latta. Dr. Coslett-Charlton, our country is facing an 
opioid epidemic and especially in the State of Ohio we are, 
unfortunately, about the third worst in the country. And while 
Congress and especially this committee has done a lot of work 
and we have passed a lot of bills trying to reverse this 
devastation, I can't help but think of the pregnant women and 
the new mothers who struggle with addiction.
    And how prevalent is opioid abuse in maternal deaths?
    Dr. Coslett-Charlton. Well, I would comment that it is very 
significant and that is why it is so important that these 
maternal mortality review committees include diverse members 
including mental health professionals, substance abuse 
professionals and I know when we established our panel in 
Pennsylvania it was imperative that we had representatives from 
communities where--because that is a very significant issue and 
I know Philadelphia has seen a large increase. That they have 
done a good job of looking at their data, almost a doubling of 
maternal deaths over a short period of time related directly to 
the opioid abuse process.
    And ACOG really appreciates all of the work that government 
is doing to make sure that--pregnant women are a special 
population that sometimes have different needs, so the pregnant 
addicted mother, number one, it is a great population to invest 
in because women that are pregnant that have opioid use 
disorders are often motivated to get better. You have a reason 
to get better. Not that everybody doesn't, but a pregnant woman 
is a special population.
    And the other thing that we have seen is that doing, not 
only paying attention to different prescribing needs as we are 
limiting prescriptions, I see in my state things like that to 
make the special considerations for pregnant women that may 
have difficulties with access and need and to make sure that 
they continue on treatment during pregnancy and postpartum.
    The last thing is that there are special pilot projects 
that are coming out of these committees looking at the special 
population of pregnant women, and like soft landing centers 
where we are not separating moms and babies, and, very 
importantly, not making punitive decisions based on maternal 
care and that because we know that women, the fear of losing 
their child or going into a system are not going to seek 
prenatal care and how imperative that is for the health of the 
woman and the child that she is carrying. So those are all 
things that ACOG is working very passionately on to try to 
improve the health care of women related to opioid use 
disorder.
    Mr. Latta. Well, thank you very much. And, Mr. Chairman, my 
time has expired and I yield back.
    Mr. Burgess. The chair thanks the gentleman. The gentleman 
yields back. The chair recognizes the gentlelady from Colorado, 
Ms. DeGette, 5 minutes for questions, please.
    Ms. DeGette. Thank you so much, Mr. Chairman, and I want to 
thank all of our witnesses, but especially you, Mr. Johnson. I 
just can't even imagine what it must be like raising those two 
boys and I am glad your mom is here to help you. But, I want to 
come over and help myself, but I am not sure what I--and I 
think probably most of us feel that way if there is anything we 
can do.
    I think the first thing we can do is pass this bill. And I 
have been working with my co-sponsor, Representative Herrera 
Beutler, to try to get this bill passed by the end of the year 
and I think your testimony is what will bring us over the line. 
So if people wonder, does it make a difference that answer 
would be yes, so thank you.
    I want to ask you--am I pronouncing it correctly, Crear 
Perry? Crear Perry, OK. I want to ask you, Doctor, according to 
the CDC, the Nation's maternal mortality rate rose by 26 
percent between 2000 and 2014; is that correct?
    Dr. Perry. Yes.
    Ms. DeGette. One of the most striking aspects that I have 
been researching of this uptake is that African American women 
are nearly four times as likely to experience a pregnancy-
related death than other women; is that right?
    Dr. Perry. It is. In some places it is higher.
    Ms. DeGette. It is higher in some places?
    Dr. Perry. Yes. In New York City it was 12 to 1.
    Ms. DeGette. Wow. And can you explain to me why this is? 
But it goes across----
    Dr. Perry. It does.
    Ms. DeGette [continuing]. Socioeconomic lines, which is 
stunning. Can you explain a little bit about that for me?
    Dr. Perry. Well, and I think, for me, Charles' story really 
reflects this idea, right.
    Ms. DeGette. Yes.
    Dr. Perry. Like in general in the United States we have not 
really grasped the idea that women, when they are pregnant, are 
special populations and it is important that we value them. So 
to have someone in the hospital for a long time without 
evaluating them, it means there is a fundamental lack of 
valuing them as a person and wanting to come and check on them. 
And saying she is not a priority right now and what we don't do 
when we just look individually at the doctor, it wasn't just 
the doctor. So a lawsuit, when you have an entire system and a 
structure----
    Ms. DeGette. Just the whole hospital.
    Dr. Perry. And it is the whole structure. So how do we get 
to a space where black women and women in general, right? 
Because the reason that the gap is high in New York and not in 
Texas is because white women in Texas are dying. So it is not 
so much that black women are doing so great in Texas, so in 
general across this country.
    Ms. DeGette. There is just fewer of them.
    Dr. Perry. Right, exactly. So across this country we don't 
value women. We don't have paid leave. We have to go back to 
work really quick, but we don't have child care so all those 
things impact our ability to have a healthy pregnancy. So how 
we then get into the hospital and need to rush out or if 
someone is doing something quickly, it makes it more difficult 
for us to live. So that happens really acutely for women of 
color and so you see that impact of implicit bias.
     So what you can legislate is rules around training on 
implicit bias. What you can legislate is accountability for the 
entire system to look at every death and make sure that all the 
structures that they need to have in place are put there so 
there is not just one individual nurse or doctor but it is the 
entire structure.
    Ms. DeGette. Yes, yes.
    And Ms. Stewart, many nations have actually been able to 
cut the rate of maternal mortality in half. I talked about that 
in my opening statement. I wonder if you can give us some ways 
that they have been able to do that, that we can model our own 
behavior on in the U.S.
    Ms. Stewart. Well, in many of those countries, 
Congresswoman, all of the outcomes relative to moms and babies 
are far better than they are here in the U.S. So one of the 
things about what is going on here in the United States is we 
are focusing on maternal mortality today as we should and 
maternal morbidity as we should. But if you look at all the 
outcomes around moms and babies, whether it is around premature 
birth, infant mortality, our outcomes are far worse than many 
other, most other developed countries in the world.
    Ms. DeGette. And many underdeveloped countries too.
    Ms. Stewart. And some in many underdeveloped, emerging 
countries. I mentioned in my opening statement our maternal 
mortality rates are worse than even countries like Slovenia 
and----
    Ms. DeGette. So what are some of the things these countries 
have done?
    Ms. Stewart. So I think it starts at the highest level of a 
policy environment and an environment that respects and cares 
for and prioritizes women and women's health and women and 
babies. So when you look at certain countries, Scandinavian 
countries for example, there are a range of policies that are 
far more supportive of women having a healthier lifestyle 
before being pregnant, having healthier pregnancies, and then 
having the kind of support even after pregnancy to make sure 
that they recover from their pregnancies well, that they feel 
supported, that they don't feel overwhelmed.
    And we know the issues of stress in this country. Chronic 
stress, for example, can have a devastating impact on the 
health of women and the health of moms that impact not only 
them but their babies as well. So I think it starts with making 
sure that women have the healthcare coverage that they need, 
have access to the care we need. We have talked about that. 
Half of the pregnancies in this country are covered by 
Medicaid. We need to make sure that all women have the kind of 
coverage they need. We need to make sure there are services in 
their communities that are accessible as we mentioned earlier 
around the deserts that exist.
    And then I think we need to make sure that postpartum, 
Medicaid doesn't stop within 60 days of delivering the baby. 
That it extends so that moms have the kind of care and health 
care and support that they need even as they recover from their 
pregnancies.
    Ms. DeGette. Thank you. Thank you so much. I yield back, 
Mr. Chairman. Thanks to all of you.
    Mr. Burgess. The chair thanks the gentlelady. The chair 
recognizes the gentleman from Virginia, Mr. Griffith, 5 minutes 
for your questions, please.
    Mr. Griffith. Thank you very much, Mr. Chairman, and I 
thank our panelists for being here.
    Mr. Johnson, I am just so sorry. Nobody should have to go 
through that. And of course I am sitting there while you are 
testifying thinking about my wife, her C-section with my first 
son. So I am very, very sorry. And as Ms. DeGette said, if 
there is anything that we can do I am sure we would try 
including passing this bill.
    So here is a question for you all. I like the bill, and I 
like the bill because it will have us looking at it from a 
national perspective. If we just do it on a state perspective 
it may not work. Because I represent the corner of Virginia 
that is outside Appalachia and the Allegheny Highlands and so, 
I border four states.
    The Bristol Herald-Courier did a series of articles last 
year on neonatal abstinence syndrome because we have a high 
number at the hospital in Tennessee, but those are my 
constituents even though they are going to a hospital in 
Tennessee. I believe that hospital serves at least three 
states. And so if you are looking at it from a state 
perspective, Virginia is going to look a whole lot better on 
substance abuse and other things than Ohio. But if you compare 
Ohio just with my section of the state, we are probably in 
pretty good similarity. We are in sync along with West Virginia 
because we have similar problems and similar backgrounds. And I 
have got to have some of the deserts on your map because I have 
an area that two of my counties have lost their hospitals.
    And so, I want to see this data from a regional perspective 
not just a state perspective because my part of Virginia is not 
like Arlington or even Virginia Beach or Richmond. It is 
completely different and if you are just looking at it from a 
state perspective you get a skewed picture from my region. So I 
like the bill.
    So then the questions become, do we overload the bill, and 
you don't want to do that. Sometimes you can put too much on 
it. Do we overload it by trying to include prenatal and 
neonatal care into the study? If we don't and if Ms. Beutler is 
in agreement, I would say expand it. If it is going to overload 
it and we might not get it passed by the end of the year, let's 
get this one passed and do something else.
    But how, Ms. Stewart, how do we fix it? I am a big advocate 
of telemedicine. Obviously can't deliver the baby by 
telemedicine, but maybe some prenatal or pre-birth care, some 
neonatal care could be done that way. What do you think of 
that?
    Ms. Stewart. Yes. Actually, we think the prospects of 
telemedicine especially for prenatal care can be very exciting 
and very productive. There have been several studies to show 
that women in rural areas, in urban areas, low-income women are 
very comfortable actually receiving care. And we also know that 
in the postpartum, we have some programs going on right now in 
the postpartum stages where uploading data, checking, taking 
blood pressure at home, uploading that data has actually 
reduced maternal deaths significantly in places like 
Philadelphia and can do the same in rural areas.
    So we think the aspect of telemedicine in this space can be 
extremely helpful to overcome some of the gaps and barriers 
that we have. I will say that we, for sure, believe very 
strongly that this area and the period of time postpartum is 
the most critical period for this bill and for these issues 
that we are talking about. So whatever we can do to make sure 
that women have the care they need during that period.
    We are measuring maternal deaths up to a year, so we need 
to make sure that women have the support they need after the 
baby. We are rightfully so, and we still need to focus 
prenatal, but what we are talking about now is the care 
postpartum that is now so critical and is contributing to so 
many of these deaths. So thank you for raising these issues.
    Mr. Griffith. Thank you all for being here. I think as 
technology moves forward we may have different answers, but I 
do think we have to embrace everything we can for those areas 
that are underserved or have deserts as you call it. And I 
appreciate you all being here. Thank you all so much for what 
you do and I yield back.
    Mr. Burgess. The chair thanks the gentleman. The gentleman 
yields back. The chair recognizes the gentlelady from Florida, 
Ms. Castor, 5 minutes for questions, please.
    Ms. Castor. Well, thank you, Mr. Chairman, for holding this 
very important hearing on maternal mortality. And I really want 
to thank my colleague, Diana DeGette, and Congresswoman Herrera 
Beutler, for their work on the Preventing Maternal Deaths Act. 
And thank you to all of the witnesses who, you all have all 
devoted your careers to this, and Mr. Johnson, I take your 
story to heart especially.
    This is a long overdue hearing and I do hope that this is 
just a start on an important focus on policy regarding maternal 
health because I don't believe that most people in the United 
States of America today understand that we are not doing so 
well. That women in the United States are more likely to die 
from childbirth or pregnancy-related causes than women in other 
parts of the developed world. That is not acceptable and the 
racial disparities are particularly disturbing. In Florida, we 
have our Pregnancy-Associated Mortality Review committee. In 
Tampa we are home to at the University of South Florida, the 
Lawton and Rhea Chiles Center for Healthy Mothers and Babies, 
and I have some wonderful experts there who help me. They have 
shared with me the latest Florida pregnancy-related mortality 
rates.
    Since 1999, Florida's pregnancy-related mortality rate has 
been flat with no significant trend. How can that be that since 
1999 things have not gotten better? I just, I think that is 
outrageous. The committee found that hemorrhage-related deaths 
are the leading cause of pregnancy-related deaths in Florida by 
far. And of course we know that more than half of these deaths 
are preventable. Florida's most recent review committee has the 
statistics for 2016. They have identified 157 pregnancy-
associated deaths, 21 died during the postpartum period. That 
has been the focus of many of your remarks.
    Dr. Coslett-Charlton, I understand in May that ACOG 
released a number of recommendations on ways to optimize 
postpartum care for mothers including that new moms should have 
contact with their OB/GYN or other obstetric care provider 
within 3 weeks postpartum in a comprehensive, postpartum visit 
no later than 12 weeks after birth. Why is focusing on that 
fourth trimester or postpartum period important for the health 
of new moms and what are the barriers? We talked a little bit 
about it, but let's go into greater detail. What are the 
barriers that you and your colleagues see to prioritizing the 
fourth trimester? Transportation, child care--give us a little 
update on that.
    Dr. Coslett-Charlton. So that is a wonderful question and 
that is one of the exciting things that ACOG has developed, 
like you said, over the past several months is reevaluating the 
fourth trimester or postpartum care. And we know that when we 
look at preventable deaths that about half of those preventable 
deaths occur within that year within delivery.
    So it is really important that we continue to engage 
patients on the importance of postpartum care and also reduce 
those barriers that you are discussing. Number one being 
access, number two being, in Pennsylvania I am fortunate to 
practice in a state that I did residency and medical school and 
practice in Pennsylvania, and in Pennsylvania when you are 
pregnant you are covered. And I cannot imagine a woman not 
being covered during pregnancy. But that coverage for Medicaid 
patients ends at 6 weeks postpartum and we know that things can 
happen afterwards.
    And it isn't just the issues with--I have had plenty of 
women have preeclampsia or hypertensive disorders that need 
very close follow up. I have seen women seize 6 weeks after 
delivery in the emergency room related to preeclampsia. So 
those identification of patients that are at risk, number one. 
Number two, having important communications in a manner such as 
telemedicine within the first several weeks after delivery and 
especially in high-risk patients is critical.
    And also, we talk a lot about postpartum depression and 
mental health disorders and how important it is that we screen 
women adequately and continue screening and keeping them within 
that period and also educating patients of the importance of 
the postpartum period. And we think that that might come during 
the prenatal period and that we need to do work to emphasize 
the importance of postpartum to women when they are having 
their babies because, I am a mother of four children.
    I am embarrassed to say it. I don't know if I went back for 
a postpartum visit. I know I am an obstetrician and I know 
that, are privy to knowing the signs, but I was caring for 
children and having important maternal and parental leave, it 
is very important having the transportation. So there are so 
many policy things that are exciting and that, going forward 
hopefully we can look to all of you to make those favorable 
changes a reality.
    Ms. Castor. Yes. One of the major gaps I see in my state 
and other states, Florida is in the minority of states that did 
not expand Medicaid. And I worry about the continuity of care 
for young families, for young women especially if they are not 
taking care of themselves early on and then they reach a gap 
after they have their baby. Has Medicaid been expanded long 
enough for there to be any studies on the differences on 
maternal mortality in states that have expanded Medicaid and 
states that have not, do you all know?
    Dr. Perry. I know for health in general, but not 
specifically maternal mortality and that is why this bill will 
be really helpful for us to be able to drill down on more 
details on maternal mortality.
    Ms. Castor. Thank you very much and I yield back.
    Mr. Griffith [presiding]. The gentlelady yields back. The 
gentleman from Missouri, Mr. Long, is recognized for 5 minutes.
    Mr. Long. Thank you, Mr. Chairman. And I have heard a lot 
of testimony over my years on the committee here and, Mr. 
Johnson, I don't know that I have ever heard any more heartfelt 
or any more important testimony that what we heard from you 
here today. So thank you for being here and I know it is hard 
to do, and but hopefully your voice will add a voice and will 
garner more attention to this, so thank you for being here.
    A quick question for you, your first son, was that--I 
understand that was a C-section also?
    Mr. Johnson. Yes, sir. That was a C-section.
    Mr. Long. Was that a planned C-section like the next one or 
an emergency?
    Mr. Johnson. No, that was not. So that was an emergency C-
section so we went in for, we didn't expect it and so that was 
part of the reason that the C-section was recommended during 
the delivery of Langston, our second son.
    Mr. Long. OK, OK. Because I am curious, but yes, I am a 
little familiar with the emergency part of that situation, so 
yes.
    Ms. Stewart, I just want to thank you for what you do at 
March of Dimes and the big event you hold every year here in 
Washington, D.C. The cook-off I call it. What is the official 
name of it?
    Ms. Stewart. It is called a Gourmet Gala.
    Mr. Long. That is what I was going to say if you hadn't 
interrupted me.
    Ms. Stewart. It is a lot of good food there.
    Mr. Long. Gourmet Gala.
    Ms. Stewart. Gourmet Gala.
    Mr. Long. It is a dandy and it raises a lot of money every 
year for March of Dimes and I appreciate that.
    Ms. Stewart. Absolutely. And we appreciate all of your 
support for that. Thank you.
    Mr. Long. Right. Dr. Coslett-Charlton, as you note, only 33 
states have a maternal mortality review committee, many of 
which are newly created. Could you talk about the important 
role the Centers for Disease Control and Prevention is giving 
technical assistance to states to either help them establish 
MMRCs or ensure that they are operating effectively and getting 
appropriate data?
    Dr. Coslett-Charlton. I would be happy to speak of that. As 
the state that has a very newly formed committee, I mentioned 
earlier that our MMRC is meeting for the first time at the end 
of October and I am very excited to see the outcomes of our 
getting together and being able to collect this data 
effectively. The CDC Foundation has actually reached out to us 
and has been integral in not only determining the makeup of the 
committee and working well with our Department of Health and 
members of the committee, but also ensuring again 
standardization and by knowing best practices from other 
states. So having that cooperation is essential.
    The other thing is that through the CDC there are data 
collecting tools, the MMRIA, collecting tools which will 
standardize the reporting part of the MMRCs so that we would be 
able, if the reports are looking different from every state it 
is a difficult task to try to come to a consensus. So we keep 
talking about the importance of making sure we keep 
standardization and the support through the CDC with the MMRIA 
application is an excellent example of that.
    Mr. Long. OK. In your testimony you discuss Pennsylvania's 
efforts to establish MMRC this year. What has been your 
experience so far in getting it up and running?
    Dr. Coslett-Charlton. Well, fortunately we have an 
extremely supportive Department of Health for this issue and 
some of it has been similar to our efforts here is recognizing 
that there is a problem. And some of the national attention to 
the problem has really given some interest to members that have 
been very interested in participating in this bill.
    Our bill was supported unanimously--House, Senate, and by 
the Governor's Office. So this was an easy ask at this time, 
but it really, it was more momentum initiative and a lot of the 
reports coming out that this truly is a problem that, you know, 
opened the eyes of many and we realized that we need to tackle 
this. And it is not a hard thing to tackle if you do it the 
right way and there are best practices already established.
    Mr. Long. And getting data on why pregnancy-related deaths 
are happening is essential of course, but what can we do to 
improve outcomes once we receive that data and can you talk 
about the role MMRCs have once that data is collected?
    Dr. Coslett-Charlton. So some of collecting the data is 
important so that we can use it to see where it needs not only 
nationally but also in communities. And we talk about these 
perinatal collaboratives that the CDC and the national effort 
to collect data will be the mothership and hopefully we will be 
able to send out the tentacles to go out in the communities and 
find where there is deficiencies and where there is disparities 
and do better to be able to connect patients and meet those 
needs and to hopefully a realization where access really is an 
issue.
    Maternity care is difficult to deliver and, we talk even 
about Philadelphia that has closed half of its maternity 
hospitals in the past decade. The only hospitals that are 
delivering right now are university institutions because a lot 
of hospitals find the reimbursement not adequate for the care 
and liability exposure and a multitude of things which is not 
for the conversation here.
    But it is really important that we are able to identify 
where these deserts are--I think that is wonderful--in care and 
be able to improve upon that.
    Mr. Long. OK, thank you. And once again thank you all very 
much for being here. I appreciate your time in taking time out 
of your day and week to come up here and testify. And, Mr. 
Chairman, I yield back.
    Mr. Burgess. The gentleman yields back. The chair thanks 
the gentleman. The chair recognizes the gentlelady from 
Illinois, Ms. Schakowsky, 5 minutes for questions, please.
    Ms. Schakowsky. Thank you. I want to join my colleagues who 
have thanked you so much for this, all of you. I want to thank 
you, Mr. Johnson, for turning this tragedy into something 
positive. It took a lot of courage and probably a lot of time 
away from being a dad. And so I just want to express my 
appreciation to all of you and just mention that in particular.
    I think that the WHO and the CDC reports, et cetera, were 
really a wake-up call for people. I have been aware of 
communities near me, in Milwaukee for example, where we have 
seen this rise in maternal mortality, infant mortality as well, 
and it has really been unacceptable that we in a country, the 
richest country in the world, would see these kinds of results. 
It is really, it is absolutely shameful.
    So I wanted to--and I think there are a lot of ways that we 
are failing mothers and children, especially African American 
women who are three to four times more likely to die from 
childbirth. We just simply have to do better. But I am 
concerned about the new proposals, the Trump Public Charge Rule 
that puts maternal and infant health in grave danger. By 
targeting legal taxpaying immigrants in this country, this rule 
seeks to discourage immigrants from using the government 
services that pay for--that are paid for with their tax 
dollars--Medicaid, CHIP, SNAP, WIC, and the Earned Income Tax 
Credit, just to name a few.
    So let me ask Dr. Coslett-Charlton and Dr. Crear Perry, 
women who qualify for Medicaid that would cover pregnancy care 
and labor and delivery may face the impossible choice of 
jeopardizing their legal immigration status in this country or 
go without needed care. And let me just add that right now in 
my very diverse district, we are finding that people who 
qualify are not signing up for benefits, right now, because 
they are so fearful. So if women are forced to go without 
needed prenatal care, what could that mean to her health and 
risk of maternal mortality?
    Dr. Perry. So it is an opportunity for us to use the same 
empathy we have when we talked earlier about with the opioid 
addiction moment we are having where we don't want to 
criminalize moms who are addicted to opioids so we ensure that 
they have access to health care. If we criminalize women for 
using SNAP or Medicaid, we are also harming their ability to 
have a healthy pregnancy.
    So we should be able to use that same feeling of empathy 
for all mothers that everyone who is in the United States 
deserves to have a healthy pregnancy and a healthy baby and so 
how do we make sure that they don't miss their prenatal care? 
For example, in Louisiana we didn't for a long time cover 
immigrant mothers and after Katrina it was a big push of new 
immigrants.
    Ms. Schakowsky. This is even legal.
    Dr. Perry. Yes. And so we had to add that to the bill when 
we got more citizens coming because it was important for us to 
ensure that the babies had access and the babies had care. We 
saw an uptick in baby----
    Ms. Schakowsky. But this would prohibit even citizen 
children of those parents from getting the benefits.
    Dr. Perry. Right. So we have to think about what are value 
is, right, so if we don't value citizen children, what do we 
value? If we don't think it is important for them to have 
treatment from a physician then what are we asking for as a 
country. So it is just we have to think about our own values as 
a country.
    Ms. Schakowsky. I agree.
    Yes, Doctor.
    Dr. Coslett-Charlton. And I would just like to add, ACOG 
strongly opposes any efforts to provide any barriers to any 
kind of care for pregnant women and postpartum and prenatal, 
and this rule obviously would do such. So and as a practitioner 
too, the woman is going to deliver the baby no matter what, so 
she is going to deliver. No matter what she is going to 
deliver. And, it is common sense that she needs prenatal care 
or, for fear of having rising morbidities and mortalities 
related to this.
    Ms. Schakowsky. Yes, go ahead.
    Ms. Stewart. I was going to say, Congresswoman, we have 
made a strong statement against that Public Charge Rule as 
well.
    Ms. Schakowsky. Thank you. And I yield back. Thank you so 
much, all of you.
    Mr. Burgess. The chair thanks the gentlelady. The 
gentlelady yields back. The chair recognizes the gentleman from 
Florida, Mr. Bilirakis, 5 minutes for your questions, please.
    Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it. 
Thanks for holding this very important hearing.
    Ms. Stewart, as a parent I remember the birth of my 
children was such a joyful event. The idea that rates of 
maternal mortality are on the rise is horrifying as far as I am 
concerned. In our state it is on the rise. I read that women 
are dying from hemorrhage complications in the State of 
Florida. How does the Preventing Maternal Deaths Act help 
reverse the trend of women who are losing their lives to these 
typical medical complications?
    Ms. Stewart. Well, I will defer to my medical colleagues to 
describe the issues around hemorrhage and how it is 
contributing, but I will say that what this bill is designed to 
do is to establish across the country maternal mortality review 
committees that are designed to collect data on every maternal 
death and to make sure that every state understands the 
underlying causes of death for each woman that dies as a result 
of childbirth.
    But even beyond that what it is designed to do is to not 
just collect the data but to help states and to help the 
participants and the healthcare system design interventions 
that can actually eliminate deaths in the future. And that is 
one of the things that is really important about this bill is 
not only collecting the data, but then designing interventions.
    And of course if we collect data consistently across the 
country and if the sharing of interventions can also be shared 
we can certainly accelerate our ability to reduce and even 
eliminate maternal deaths. I will give you a couple of examples 
of how collecting data in MMRCs has been really helpful.
    In Colorado, for example, data was collected and what was 
found is that women that experienced maternal death had also 
been experiencing suicide and depression and they were, in 
Colorado, able to find and identify where there were gaps in 
mental health services and actually close those gaps and give 
more mental healthcare services to women where they needed it.
    In Ohio, they actually did something, which I think is 
really important, which is do additional training for hospital 
staff beyond just the doctors themselves, hospital staff where 
they went through simulations of training in obstetrical 
emergency situations so that they could actually be more 
responsive in the event of an emergency situation.
    So MMRCs are not only about collecting the data, but 
actually putting into action the things that can actually 
eliminate maternal deaths. And that is why this bill is so 
important and that is why a national bill and a national effort 
is also so important, so the data can be consistent, can be 
collected, we can see the data, we can actually track the 
interventions more successfully.
    Mr. Bilirakis. Thank you very much for that answer.
    Dr. Coslett-Charlton, according to the Centers for Disease 
Control and Prevention, it lists indicators. Severe maternal 
morbidity has steadily been increasing in the years. What are 
the key drivers of this increase and how can it be addressed?
    Dr. Coslett-Charlton. Well, some things are recognizing and 
be able to maintain proper prenatal care and care of women 
throughout their reproductive years and identifying 
comorbidities such as, we talk about obesity and smoking 
cessation and where we see a rise in comorbidities with heart 
disease. So having active interventions before a pregnancy we 
find is critical to having a healthy labor and delivery for all 
women.
    Mr. Bilirakis. So you feel that they are increasing. In 
this day and age with all the technology we have or is it just 
that we are getting more data on this or there definitely are 
increases in maternal deaths?
    Dr. Coslett-Charlton. Well, so far that is part of the 
purpose of this review is so that we were talking earlier about 
the accuracy of the data. So some speculation has been made 
that perhaps because for the past 5 years we were actually 
recording on death certificates whether or not a woman was 
pregnant when she died, or within a year after delivery whether 
or not that has caused a rise in the actual numbers that we are 
seeing. But when comparing to other countries that have had 
similar checkboxes on their certificates where they have seen a 
stabilization or a decrease, we have actually seen an increase.
    So these committees are really imperative to really, 
exactly what you are saying, really know and be able to assess 
and accurately determine if those disease entities as well as 
maternal death if there is a change and make sure that we have 
accurate data so that we can successfully portray appropriate 
interventions.
    Mr. Bilirakis. Yes, exactly. So, whether it is increasing 
or what have you, we have to focus on the issue. There is no 
question.
    And, Dr. Johnson, you have my sympathies. I was in the VA 
Committee so I didn't get a chance to hear your testimony, but 
I know how difficult it must be for you.
    Let's see, Dr. Crear Perry, please, our maternal mortality 
data has been described again as limited, unreliable, and even 
embarrassing by top researchers. Do you agree with these 
characterizations? And I know, let's expand upon this. Are 
there concerns with the research community regarding the 
integrity of the data being collected in states? What are those 
concerns and how might they be addressed federally?
    Dr. Perry. That is me. That is OK. Hi.
    Mr. Bilirakis. Oh, you are over here. I am sorry.
    Dr. Perry. And so it is important, Dave Goodman and the 
folks at CDC are doing a great job of doing the data. They have 
been doing it for a very long time. They have dedicated their 
life to it. And they have looked at if the increase is due to 
error in data versus if it is an increase, that is true, and 
all the studies so far have come back saying no, there is an 
increase and it is from the data.
    And so the robustness with which the CDC is working on to 
look at this issue is something that we should all value. And 
if they are part of this bill, they are not here testifying, 
but CDC is really integral to getting this work done and it is 
important that we understand that they are--that yes, there 
have been researchers that have given us pushback around the 
data over the years, but we have gotten better and better and 
this is just another way to get even more clear about how women 
are dying, because beginning at a granular level and look at 
the hospital level what is happening.
    So yes, there have been a lot of articles about the data, 
but we truly know through the CDC that the rates are increasing 
and that we can do something together to do it better with this 
bill.
    Mr. Bilirakis. Very good. Thank you and I yield back, Mr. 
Chairman.
    Mr. Burgess. The chair thanks the gentleman and the 
gentleman yields back.
    The chair would just make the observation that I believe it 
was Dr. Callaghan from the CDC who came and spoke at one of our 
roundtables about a year ago. And you are correct. They are 
very thorough and they have been at this for a long time. They 
have a lot of good insights.
    The chair recognizes the gentleman from Massachusetts, Mr. 
Kennedy, 5 minutes for your questions, please.
    Mr. Kennedy. Thank you, Mr. Chairman. I want to also thank 
you for your obviously lifelong and personal dedication to this 
issue given your profession before coming to Congress and still 
the work that you do. I want to also thank Representative 
Herrera Beutler who was here earlier and obviously our 
distinguished panel for joining us.
    Mr. Johnson, excuse me. I will apologize. I have been in 
and out. Your words are extremely powerful, sir. Kira sounds 
like quite a woman. I have two kids under 3. I was in a 
delivery room about 9 months ago. Thoughts are with you and 
your family, sir.
    In 2018, the United States of America has the highest rate 
of maternal deaths in the developed world. Every single year we 
mourn roughly 700 mothers who are lost to complications during 
their pregnancy, and at least 350 of those deaths are 
preventable. Most alarmingly, profound racial disparities exist 
in these statistics. Black women today are three to four times 
more likely to die of pregnancy or delivery complications than 
white women.
    Before we try to explain that away on socioeconomic terms, 
just access to care, access to education, and higher income, we 
have to be clear that even when you control for those factors a 
wealthy black woman with an advanced degree is still more 
likely to die or to have a baby die than a poor white woman 
without a high school diploma. In the United States, a black 
woman is 22 percent more likely to die from heart disease than 
a white woman, 71 percent more likely to die from cervical 
cancer. Those are haunting statistics, but they still pale in 
comparison to the one we discussed here today, for black women 
are 243 percent more likely to die from pregnancy or 
childbirth-related causes: 243 percent. So we can't have a 
discussion about how to address a larger crisis in maternal 
mortality without having a discussion about how to confront the 
pervasive, systemic inequities that are buried deep within our 
system of health care in America.
    And the last point I have to make is this, that there are, 
as we speak, 20 Republican Attorneys General that are 
attempting to repeal the Affordable Care Act in our court 
system after most of my Republican colleagues have voted to do 
the very same thing more times than I can count. So let's 
remember 9.5 million. That is the number of previously 
uninsured women that gained healthcare coverage including 
maternity care which is an essential health benefit under the 
Affordable Care Act. Coverage for women of color grew at more 
than twice the rate of women overall in 2013 to 2015. So to 
have a conversation about maternal mortality at a time when my 
Republican colleagues are using every tool in the book to roll 
back access to guaranteed maternal care and maternal coverage 
is a bit much.
    And with that I want to direct my questions to Dr. Crear 
Perry and by the work that you have done, Doctor, in discussing 
how we need to move away from seeing race as a risk factor in 
maternal health and call the real risk factor what it is: 
racism. So can you extrapolate that a bit for the committee 
and, specifically, what do you believe to be the leading cause 
of those racial disparities I mentioned in maternal mortality 
rates?
    Dr. Perry. So we have done quite a bit of focus groups and 
work in hospitals around how patients feel disrespected and not 
heard and not listened to and not valued. And, a great example 
of that is Serena Williams, right. She gives an amazing story 
around how she had symptoms. She knew who she was. She is a 
very wealthy and healthy person as well and she still was not 
heard or valued.
    So what we miss in this country is really being honest 
about when you don't see someone as being fully equal to you, 
you are less likely to think about their care in a very serious 
manner. You are less likely to address their issues in a 
serious manner, and you are less likely to spend the time that 
they need ensuring that they are healthy.
    And so what we have to be able to do is have some truth 
around that conversation first and not act as if that is not a 
true----
    Mr. Kennedy. And so is there data that you would point to 
on this or is this something that is a bit bigger than fits 
into an Excel spreadsheet and a pie chart and how----
    Dr. Perry. This is going to be both a policy fix and a 
cultural shift, right. Like we have had policy shifts. We have 
had the civil rights movement, we have a lot of things of 
policy we can have, but as long as the culture still believes 
that black people are less valuable or inferior, and women, we 
are going to keep having the same conversations over and over 
and over again. So we have to have both a policy conversation 
and a culture shift.
    Mr. Kennedy. Anybody else want to comment on that? Mr. 
Johnson?
    Mr. Johnson. So just talking about this from a personal 
experience and having an African American, extremely vibrant 
woman who was not in good health but in exceptional health at 
one of the top hospitals in the world, and to be quite honest 
with you, when this first happened and I was asked a question, 
do you think that this would have been different if your--do 
you think this is because your wife was black, or do you think 
the outcome would have been different if your wife was 
Caucasian, I was in so much pain I couldn't process that and 
the thought that the color of my wife's skin contributed to her 
death?
    But what I am clear about is that she was not seen or 
valued as human. She wasn't. And the people who were 
responsible for her care that I trusted with her care failed to 
look at her in the same way that they would their daughter or 
their sister or their mother. And the reality of the situation 
is I am asked the question and people sometimes, and, the more 
I have spent with wonderful groups like Black Mamas Matter and 
the more I look at the data, people--and I am very clear about 
this issue of implicit bias and the contributing factors or 
racism. And people say you are making it a racial issue. I 
didn't make it a racial issue, the statistics did.
    So what we have got to do is figure out how these women are 
valued and looked at as human, because what I said at night, 
thinking about my wife and I have to think about that question 
about would she be here today if she was Caucasian? Let me be 
clear that this is an epidemic that affects all families from 
all backgrounds and all walks of life, and unfortunately I know 
that personally because I have talked to these families and I 
have become very close to some of these fathers and some of 
these families and they are from all walks of life.
    But we cannot address this issue without head-on facing the 
way that it is disproportionately and horrifyingly affecting 
African American mothers.
    Mr. Kennedy. Thank you, sir.
    Chairman, thank you for the extra time. Thank you all for 
being here.
    Mr. Burgess. The chair thanks the gentleman. The gentleman 
yields back. The chair recognizes the gentleman from Georgia, 
Mr. Carter, 5 minutes for your questions, please.
    Mr. Carter. Thank you very much, Mr. Chairman, and thank 
all of you for being here. And, Mr. Johnson, thank you for your 
efforts and your work on this especially, and I echo the 
comments of all of my colleagues here today. We appreciate your 
courage.
    Mr. Chairman, I believe this hearing was set for another 
time and I requested and I am sure others did that it be 
delayed so that we could have it. It is important to me and I 
am sorry if it disrupted any of you all or inconvenienced you.
    But I am from the State of Georgia. In 2010, there was an 
Amnesty International report that flagged Georgia as being the 
number one state in maternal mortality. And that is why I 
expressed to the chairman, Mr. Chairman, I want to be at this 
hearing because this is real to me. In fact, when I served in 
the Georgia State Legislature and we passed Senate Bill 273 
that created the MMRC and put it into the Georgia Department of 
Public Health.
    And I wanted to ask you, Dr. Perry, because when we created 
that, you know, we followed the guidelines and we did what we 
were supposed to do. But I believe that your group was involved 
in a study, When the State Fails: Maternal Mortality and Racial 
Disparity in Georgia; so you are familiar with that?
    Dr. Perry. Yes, sir.
    Mr. Carter. I know you are. And I had the chance to look at 
it and study it and one of the things that it pointed out was 
the racial disparity in Georgia was the fact that even though 
the four categories--access to and quality of care, insurance 
access and pricing funding, and accountability around data 
analysis and use, even though we had those in there we are 
still failing on those, particularly access.
    And my question is, what can we do? Tell me what I can take 
back to my state because this is important to me. I served in 
legislature. I was in Health and Human Services, vice chair of 
that committee, and I helped with this legislation. If, and the 
point has been made by my colleagues today, what can we do 
legislatively, but what can I do? What can I take back to the 
State of Georgia?
    Dr. Perry. Thank you so much. And I do work with Dr. 
Lindsay and the folks at Grady around the Georgia work and they 
are specifically trying to look at their mental healthcare 
service structure. So supporting mental healthcare services in 
Georgia is important. Supporting Medicaid expansion in Georgia 
is important. Supporting rural hospital closures in Georgia is 
in support and like supporting support systems that include 
midwives and doulas in Georgia is important.
    All the social structures that we see, all the states where 
we allow for us to disinvest in women honestly have poor 
outcomes. Even though you can look and do the study and see, we 
are working on things inside of hospitals because you have some 
great doctors in Georgia. You have some phenomenal people and 
some nurses and midwives. But until we build a structure that 
holds the entire state together, right, like from rural Georgia 
from--then we are not going to be able to see an improvement 
and we are being separated around ideals that don't allow us to 
come together. And it is important that we know we value all 
the moms in Georgia, rural moms, urban, they all need access to 
insurance.
    Mr. Carter. Well, thank you for mentioning that because as 
you well know, knowing the state we have a disparity between 
rural and urban.
    Dr. Perry. Exactly.
    Mr. Carter. I mean to say Georgia is Atlanta and everywhere 
else. So it really is.
    Dr. Perry. Exactly.
    Mr. Carter. Well, another part of that study that I was 
very interested in, because I am a big advocate of this, is the 
proposition that the state could develop ways to help religious 
organizations in leadership engage and advocate for quality 
health education and services.
    And I am really big with wanting to include the religious 
community. And can you give me examples of how we can do that 
or examples of how that has worked before?
    Dr. Perry. Including, because if you think about mental 
health it is a great example, right, so a lot of religious 
organizations have access to therapy, access to group places 
where women can come to make sure they have grievance 
counseling.
    So there has been a lot of work that religious 
organizations are there to be a safety net and a support for 
women. They can't replace medical care, but they can serve as a 
safety net. They can provide transportation. They can help with 
child care. Like all these other things that we are looking for 
that a community provides, because we know that women who have 
access to a community and to each other, the connectedness, 
have better outcomes.
    So how do we create connectedness and community across this 
country and across Georgia.
    Mr. Carter. Right. And one last question and this could go 
to just about any of you. But the thing that I am wondering 
here is I know we are accumulating the data and we are, and I 
believe you said earlier the data is going to CDC. Are they 
crunching the science of it? Can we tie anything into this 
genetically, regionally?
    Ms. Stewart. I will try and then others. CDC has had a 
surveillance system in place for a number of decades and 
thankfully we are able to collect a lot of data mainly coming 
from death certificates. And just recently now, death 
certificates now include whether or not a woman was pregnant 
within the last year, and so that information has been helpful.
    But what we don't get from all of that--and by the way that 
voluntary system, CDC asks states around the country to 
voluntarily submit the data. There are epidemiologists that 
then review the data and we learn as much as we can from death 
certificates. But what we don't understand is that a death 
certificate does not necessarily tell the full story of how a 
woman may have died and what were the underlying causes and 
what were the potential interventions that could have been in 
place to prevent that.
    And that is what this is about is taking the data we 
collect, improving it, improving the collection, making it 
consistent, having committees that then can design 
interventions and having them well-funded so that they can 
actually see meaningful improvement over time. So that is the 
difference.
    Mr. Carter. Good. Again, thank all of you. And, Mr. 
Johnson, thank you and God bless you.
    Mr. Johnson. And I would just like to say that I am 
actually a native of Georgia and currently----
    Mr. Carter. Did this happen in Georgia?
    Mr. Johnson. It actually happened in California but I am a 
native of Georgia.
    Mr. Carter. OK.
    Mr. Johnson. Kira grew up in Decatur, Georgia and I grew up 
in East Point and we are back living in Georgia.
    Mr. Carter. Right.
    Mr. Johnson. So we look forward to working together with 
you----
    Mr. Carter. Absolutely.
    Mr. Johnson [continuing]. To see how we can help out too.
    Mr. Carter. Can I ask you, was your wife originally from 
Georgia?
    Mr. Johnson. Absolutely. Decatur, Georgia. Born and raised.
    Mr. Carter. OK, see this is the point I am getting at here. 
We are the Cardiac Belt. Has anybody looked at any of this to 
kind of try to tie this into it?
    Ms. Stewart. There is a lot of work being done on what is 
going on that is that are sort of the underlying causes to why 
so many women of color especially are dying, and there are a 
bunch of issues. I will mention one of them. By the way I am 
from Atlanta too. Don't hold that against me.
    Mr. Carter. I see a pattern here.
    Ms. Stewart. We have known each other a long time.
    Look, there is a very important study and we could go 
through a laundry list of things, but there is a very important 
study that has really helped all of us understand what are some 
of the underlying causes to why we see so many disparities 
among African American women in particular.
    A study that was done by a researcher who is now at the 
University of Michigan but she started this study in New 
Jersey, I believe, where she started to look at this as your 
weathering. The fact that African American women's health tends 
to, and African American women tend to have more challenges the 
older they get, challenges in pregnancy, challenges in 
childbirth, challenges maybe post childbirth may be due to this 
issue of weathering, which is that the impact of chronic stress 
that may be coming from racism and discrimination over a long 
period of time.
    This issue of weathering which tends to deteriorate one's 
health may be a big contributor why we see so many disparities. 
The fact that women are getting, are older as they are getting 
pregnant and the fact that if black women are older having 
babies and they are experiencing this impact from this 
weathering effect that that could explain in part why we are 
seeing so many outcomes.
    Having said that, we still need to address the fact that we 
don't specifically have to accept that that is the case, we can 
actually do something about it. We can actually address those 
issues. We can actually deal with the underlying stress that 
exists. We can actually deal with the systems that may be 
creating the stress in the first place, and we can make sure 
that we understand when interventions are really effective 
across all communities.
    Mr. Carter. Thank you, Mr. Chairman. I yield back.
    Mr. Burgess. As the gentleman's time has expired, the chair 
recognizes the long-suffering Mr. Engel from New York, 5 
minutes for your questions, please.
    Mr. Engel. Thank you, Mr. Chairman. I appreciate those 
words, thank you.
    Thank you, Mr. Chairman, for holding today's hearing. Just 
in listening, it is just shocking that right here in the United 
States women are dying from preventable pregnancy-related 
complications. That alone is shocking, but that women are more 
likely to die from those complications here than in other parts 
of the developed world, that is shocking. And the fact that 
this risk is three to four times higher for black women than 
white women, that is shocking.
    So it is a tragedy and it is an emergency, and thank you, 
Mr. Johnson, for sharing your story with us.
    I want to thank my colleagues, Congresswoman Herrera 
Beutler and Congresswoman DeGette, for introducing the 
Preventing Maternal Death Act legislation which I am a proud 
co-sponsor of. And I hope that after today our committee can 
move forward on solutions to this problem that we really need 
to move more quickly. It is long past time we acted to reverse 
this horrible trend once and for all.
    So let me ask this question. I have long supported 
investments in family planning and reproductive health and I am 
particularly interested in the impact that such investments can 
have on maternal mortality. As the ranking member of a House 
Foreign Affairs Committee, I have seen that impact on a global 
scale. In fiscal year 2016 alone, U.S. investments in family 
planning worldwide provided contraceptive services and supplies 
to 27 million women and couples, which in turn helped to 
prevent 11,000 maternal deaths.
    So let me ask Drs. Crear Perry and Coslett-Charlton, would 
you each explain why meeting unmet need for contraception helps 
to prevent maternal deaths?
    Dr. Perry. So there has been some data that shows that the 
safety and security you get from having access to family 
planning and not having to worry about if you are going to get 
pregnant again because you are not planning to be pregnant at 
that moment really decreases your stress and your weathering 
and ensures that you have a healthier pregnancy.
    We know that we have looked at the states that have more 
supportive policies around family planning also have better 
infant mortality rates and better maternal mortality rates. So 
it is not a coincidence that when you invest in family planning 
and when you invest in infrastructure for moms and babies, you 
actually create a safety net where people can live longer and 
be healthier. So it is important that these policies that are 
created in this House improve the ability for moms and babies 
to live.
    Dr. Coslett-Charlton. And I would certainly echo that 
response. But also it has been shown that women that are able 
to plan their pregnancies by spacing intervals between 
pregnancies and having access to adequate contraception that it 
improves the safety. There is very clear data to show that it 
improves outcomes in pregnancy and delivery also.
    Mr. Engel. So thank you. But along those lines, let me ask 
you if either of one of you would explain why women in the 
United States specifically have unmet need for contraception. 
By that I mean they want to use modern contraception but are 
not currently.
    Dr. Perry. Well, it is a state and local issue, usually, 
around access to family planning and reproduction and because 
when we allow that to be made state-based wide people's 
personal, you get gaps in what states pay for, things like sex 
education, what states allow for, things like having birth 
control inside of high schools.
    Once again I will say for my great State of Louisiana, we 
struggle with getting sex education in the schools. We struggle 
with getting access to family planning for the people who 
actually need it very desperately. So I think in an attempt to 
make for a safe environment for our state sometimes we mislabel 
what safety looks like. Safety looks like having access to 
choice when it comes to your reproduction. And when you have 
that access to choice and information, you can have a safer 
pregnancy and a safer outcome.
    Mr. Engel. Well, thank you. Obviously there is a lot more 
work to do on this front. Let me mention this. A December 
report from the Guttmacher Institute estimated that globally, 
``fully meeting the unmet need for modern contraception would 
result in an estimated 76,000 fewer maternal deaths each 
year.'' That is 76,000.
    So I want to ask either one of you doctors to please, if 
you agree is it fair to say that improving access to 
contraception for American women could help address the rates 
of maternal death in the United States?
    Dr. Perry. Yes.
    Dr. Coslett-Charlton. Yes.
    Mr. Engel. That is a loaded question, but I wanted to put 
it out on the record. I want to also take this opportunity to 
briefly talk about legislation. I have introduced with 
Congressman Stivers, the Quality Care for Moms and Babies Act. 
The legislation would bring together diverse stakeholders to 
identify care quality benchmarks for women and children in 
Medicaid and CHIP as well as fund new and existing maternity 
and infant care quality collaboratives.
    These collaboratives bring together local stakeholders such 
as doctors and nurse midwives to best share the best practices 
in improved care for patients, and I am grateful to both the 
ACOG and March of Dimes for supporting this legislation.
    And let me ask you, finally, both--let me ask perhaps Ms. 
Stewart. I will ask you this. Wouldn't you agree that we should 
be measuring and evaluating performances of Medicaid and CHIP 
caring for America's moms and babies as well as investing in 
perinatal quality collaboratives which work to implement 
maternal mortality review committee recommendations at the 
state level?
    Ms. Stewart. Congressman, we are very involved across the 
country in perinatal collaboratives and they are very effective 
and we would very much support them. And I would just add at 
this point which is that 60 percent of all births are covered 
by Medicaid and that is a lot of women and a lot of babies.
    And whatever we can do to make sure that the quality of 
care exists for those women as it does for women in the private 
insurance market to make sure we are collecting the kind of 
data to understand what is effective and what is not and that 
we are sharing that data across states, we would firmly support 
that.
    Mr. Engel. Thank you. Thank you very much. Thanks, Mr. 
Chairman.
    Mr. Burgess. And the gentleman's time has expired.
    Seeing no additional members wishing to ask questions, I 
want to thank all of our witnesses again for being here today. 
I have some documents I need to read into the record, a 
statement for the record from Sean Blackwell, M.D.; 
momsrising.org; and Alexis Joy Foundation. I also have the 
September report for the Maternal Mortality and Morbidity Task 
Force from the state of Texas \1\; a letter from Dr. Gary 
Hankins who participated in one of our roundtables--Dr. Hankins 
is from the University of Texas Medical Branch in Galveston; 
and Dr. Cardenas had mentioned the Obstetric Hemorrhage Toolkit 
in California \2\ and I do have a copy of that I am going to 
submit for the record.
---------------------------------------------------------------------------
    \1\ The information has been retained in committee files and can be 
found at: https://docs.house.gov/meetings/IF/IF14/20180927/108724/HHRG-
115-IF14-20180927-SD022.pdf.
    \2\ The information has been retained in committee files and can be 
found at: https://docs.house.gov/meetings/IF/IF14/20180927/108724/HHRG-
115-IF14-20180927-SD023.pdf.
---------------------------------------------------------------------------
    Also, documents from the March for Moms; Postpartum Support 
Virginia; Association of Maternal & Child Health Programs; 
Heart Safe Motherhood; Massachusetts Child Psychiatry Access 
Program; a letter signed by 1,000 Days and other patient 
groups; Americans United for Life; Alexis Joy Foundation; 
Nurse-Family Partnership; Preeclampsia Foundation; Society for 
Maternal and Fetal Medicine; a letter from Timoria McQueen 
Saba; American College of Surgeons; KSM Consulting \3\; more 
California PPH; SAP America; and Forbes Insight Study.
---------------------------------------------------------------------------
    \3\ The information has been retained in committee files and can be 
found at: https://docs.house.gov/meetings/IF/IF14/20180927/108724/HHRG-
115-IF14-20180927-SD004.pdf.
---------------------------------------------------------------------------
    [The information appears at the conclusion of the hearing.]
    And just to end on a somewhat positive note, my grandfather 
was an OB/GYN, an academic OB/GYN at McGill University in 
Montreal and practiced obstetrics during the decade of the 
1930s when the maternal mortality fell from all-time highs to 
all-time lows, certainly indicative that if we put our minds to 
it, it has happened before, it can happen again.
    Pursuant to committee rules, I remind members they have 10 
business days to submit additional questions for the record. I 
ask the witnesses to submit their responses within 10 business 
days upon receipt of the questions. Without objection, the 
subcommittee is adjourned.
    [Whereupon, at 12:23 p.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
 

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