[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
energycommerce.house.gov
__________
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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
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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.
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\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.]
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