    [House Hearing, 116 Congress]
    [From the U.S. Government Publishing Office]

                      EXPECTING MORE: ADDRESSING AMERICA'S
                       MATERNAL AND INFANT HEALTH CRISIS

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

                                 JOINT HEARING

                                   BEFORE THE

                      SUBCOMMITTEE ON HEALTH, EMPLOYMENT, LABOR,
                                   AND PENSIONS

                                    AND THE

                     SUBCOMMITTEE ON WORKFORCE PROTECTIONS

                                     OF THE

                             COMMITTEE ON EDUCATION
                                   AND LABOR
                         U.S. HOUSE OF REPRESENTATIVES

                         ONE HUNDRED SIXTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                HEARING HELD IN WASHINGTON, DC, JANUARY 28, 2020

                                   __________

                               Serial No. 116-50

                                   __________

          Printed for the use of the Committee on Education and Labor

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

               Available via the World Wide Web: www.govinfo.gov
                                       or
                  Committee address: https://edlabor.house.gov

                                    __________

                        U.S. GOVERNMENT PUBLISHING OFFICE
    39-730 PDF                 WASHINGTON : 2022

    -----------------------------------------------------------------------------------

                        COMMITTEE ON EDUCATION AND LABOR

                 ROBERT C. ``BOBBY'' Scott, Virginia, Chairman

    Susan A. Davis, California           Virginia Foxx, North Carolina,
    Raul M. Grijalva, Arizona            Ranking Member
    Joe Courtney, Connecticut            David P. Roe, Tennessee
    Marcia L. Fudge, Ohio                Glenn Thompson, Pennsylvania
    Gregorio Kilili Camacho Sablan,      Tim Walberg, Michigan
      Northern Mariana Islands           Brett Guthrie, Kentucky
    Frederica S. Wilson, Florida         Bradley Byrne, Alabama
    Suzanne Bonamici, Oregon             Glenn Grothman, Wisconsin
    Mark Takano, California              Elise M. Stefanik, New York
    Alma S. Adams, North Carolina        Rick W. Allen, Georgia
    Mark DeSaulnier, California          Lloyd Smucker, Pennsylvania
    Donald Norcross, New Jersey          Jim Banks, Indiana
    Pramila Jayapal, Washington          Mark Walker, North Carolina
    Joseph D. Morelle, New York          James Comer, Kentucky
    Susan Wild, Pennsylvania             Ben Cline, Virginia
    Josh Harder, California              Russ Fulcher, Idaho
    Lucy McBath, Georgia                 Steve Watkins, Kansas
    Kim Schrier, Washington              Ron Wright, Texas
    Lauren Underwood, Illinois           Daniel Meuser, Pennsylvania
    Jahana Hayes, Connecticut            Dusty Johnson, South Dakota
    Donna E. Shalala, Florida            Fred Keller, Pennsylvania
    Andy Levin, Michigan*                Gregory F. Murphy, North Carolina
    Ilhan Omar, Minnesota                Van Drew, New Jersey
    David J. Trone, Maryland
    Haley M. Stevens, Michigan
    Susie Lee, Nevada
    Lori Trahan, Massachusetts
    Joaquin Castro, Texas
    * Vice-Chair

                       Veronique Pluviose, Staff Director
                     Brandon Renz, Minority Staff Director
                                     ------

            SUBCOMMITTEE ON HEALTH, EMPLOYMENT, LABOR, AND PENSIONS

                    FREDERICA S. Wilson, Florida, Chairwoman

    Donald Norcross, New Jersey          Tim Walberg, Michigan
    Joseph D. Morelle, New York            Ranking Member
    Susan Wild, Pennsylvania             David P. Roe, Tennessee
    Lucy McBath, Georgia                 Rick W. Allen, Georgia
    Lauren Underwood, Illinois           Jim Banks, Indiana
    Haley M. Stevens, Michigan           Russ Fulcher, Idaho
    Joe Courtney, Connecticut            Steve C. Watkins, Jr., Kansas
    Marcia L. Fudge, Ohio                Ron Wright, Texas
    Josh Harder, California              Dan Meuser, Pennsylvania
    Donna E. Shalala, Florida            Dusty Johnson, South Dakota
    Andy Levin, Michigan                 Fred Keller, Pennsylvania
    Lori Trahan, Massachusetts
    Vacancy
                     SUBCOMMITTEE ON WORKFORCE PROTECTIONS

                   ALMA S. Adams, North Carolina, Chairwoman

    Mark DeSaulnier, California          Bradley Byrne, Alabama,
    Mark Takano, California                Ranking Member
    Pramila Jayapal, Washington          Mark Walker, North Carolina
    Susan Wild, Pennsylvania             Ben Cline, Virginia
    Lucy McBath, Georgia                 Ron Wright, Texas
    Ilhan Omar, Minnesota                Gregory F. Murphy, North Carolina
    Haley M. Stevens, Michigan

                                C O N T E N T S

                                  ----------
                                                                       Page

    Hearing held on October 23, 2019.................................     1

    Statement of Members:
        Adams, Hon. Alma S., Chairwoman, Subcommittee on Workforce
          Protections................................................     6
            Prepared statement of....................................     7
        Walberg, Hon. Tim, Ranking Member, Subcommittee on Health,
          Employment, Labor, and Pensions............................     4
            Prepared statement of....................................     5
        Walker, Hon. Mark, Ranking Member a Representative in
          Congress from the State of North Carolina..................     7
            Prepared statement of....................................     8
        Wilson, Hon. Frederica S., Chairwoman, Subcommittee on
          Health, Employment, Labor, and Pensions....................     1
            Prepared statement of....................................     3

    Statement of Witnesses:
        Crear-Perry, Dr. Joia, MD, President, National Birth Equity
          Collaborative..............................................    36
            Prepared statement of....................................    39
        Sankofa, Ms. Nikia, Executive Director, United States
          Breastfeeding Committee....................................    24
            Prepared statement of....................................    27
        Stewart, Ms. Stacey D., President and CEO, March of Dimes....     9
            Prepared statement of....................................    12

    Additional Submissions:
        Chairwoman Adams:
            Prepared statement from A Better Balance.................    90
        Courtney, Hon. Joe, a Representative in Congress from the
          State of Connecticut:
            Letter dated January 27, 2020 from Locke, Mr. Caleb
              Andrew.................................................    94
        Jayapal, Hon. Pramila, a Representative in Congress from the
          State of Washington:
            Letter dated July 10, 2019...............................    95
        Johnson, Hon. Dusty, a Representative in Congress from the
          State of South Dakota:
            Article: Effort Begins To Reduce Risk of Death of S.D.
              Mothers During Childbirth..............................    98
        Morelle, Hon. Joseph D., a Representative in Congress from
          the State of New York:
            Letter dated January 28, 2020 from Johnson and Johnson...   110
        Scott, Hon. Robert C. ``Bobby'', a Representative in Congress
          from the State of Virginia:
            Letter dated January 27, 2020 from National Association
              of County and City Health Officials (NACCHO)...........   111
            Letter dated January 27, 2020 from undersigned
              orgranizations.........................................   113
            Prepared statement from Abbott, Mrs. Becky M.............   115
            Link: Sexual Abuse To Maternal Mortality Pipeline........   127
        Stevens, Hon. Haley M., a Representative in Congress from the
          State of Michigan:
            Letter dated January 27, 2020 from National Foundation
              for Ectodermal Dysplisias (NFED).......................   128
        Takano, Hon. Mark, a Representative in Congress from the
          State of California:
            Article: Medicaid Expansion Fills Gaps In Maternal Health
              Coverage Leading to Healthier Mothers and Babies.......   130
        Underwood, Hon. Lauren, a Representative in Congress from the
          State of Illinois:
            Prepared statement from Mom Congress.....................   142
            Prepared statement from The American College of
              Obstetricians Gynecologists............................   144
            Prepared statement from 2020 Mom.........................   151
            Link: Eliminating Racial Disparities In Maternal and
              Infant Mortality.......................................   153
        Chairwoman Wilson:
            Prepared statement from American Dental Association (ADA)   154
            Prepared statement from American Society of Plastic
              Surgeons...............................................
        Questions submitted for the record by:
            Schrier, Hon. Kim, a Representative in Congress from the
              State of Washington

            Ms. Underwood............................................   163
        Responses submitted for the record by:
            Dr. Crear-Perry..........................................   166
            Ms. Sankofa..............................................   171
            Ms. Stewart..............................................   177

     EXPECTING MORE: ADDRESSING AMERICA'S MATERNAL AND INFANT HEALTH CRISIS

                                  ----------

                           Tuesday, January 28, 2020

                            House of Representatives

             Subcommittee on Health, Education, Labor, and Pensions

                                   Joint with

                     Subcommittee on Workforce Protections

                        Committee on Education and Labor

                                Washington, D.C.

                                  ----------

        The subcommittees met, pursuant to call, at 10:19 a.m., in
    Room 2175, Rayburn House Office Building. Hon. Frederica S.
    Wilson (Chairwoman of the Subcommittee on Health, Education,
    Labor, and Pensions) presiding.
        Present: Representatives Wilson, Adams, Courtney, Fudge,
    Takano, DeSaulnier, Norcross, Jayapal, Scott, Morelle, Wild,
    Harder, McBath, Underwood, Shalala, Levin, Omar, Stevens,
    Trahan, Walberg, Roe, Walker, Fulcher, Mueser, Johnson, Keller,
    and Foxx.
        Also Present: Representatives Bonamici and Schrier.
        Staff Present: Ilana Brunner, General Counsel; Sharon
    Crowder, Health Policy Fellow; Emma Eatman, Press Assistant;
    Daniel Foster, Health and Labor Counsel; Alison Hard,
    Professional Staff; Carrie Hughes, Director of Health and Human
    Services; Ariel Jona, Staff Assistant; Stephanie Lalle, Deputy
    Communications Director; Andre Lindsay, Staff Assistant; Jaria
    Martin, Clerk/Special Assistant to the Staff Director; Kevin
    McDermott, Senior Labor Policy Advisor; Max Moore, Office Aid;
    Udochi Onwubiko, Labor Policy Counsel; Veronique Pluviose,
    Staff Director; Ivorie Stanley, Labor and Health Policy Fellow;
    Banyon Vassar, Deputy Director of Information Technology;
    Joshua Weisz, Communications Director; Cyrus Artz, Minority
    Parliamentarian; Courtney Butcher, Minority Director of Member
    Services and Coalitions; Akash Chougule, Minority Professional
    Staff Member; Cate Dillon, Minority Staff Assistant; Rob Green,
    Minority Director of Workforce Policy; Jeanne Kuehl, Minority
    Legislative Assistant; John Martin, Minority Workforce Policy
    Counsel; Audra McGeorge, Minority Communications Director;
    Alexis Murray, Minority Professional Staff Member; Carlton
    Norwood, Minority Press Secretary; Ben Ridder, Minority
    Professional Staff Member; and Kelly Tyroler.
        Chairwoman Wilson. The Subcommittees on Health, Employment,
    Labor, and Pensions and Workforce Protections will come to
    order.
        Welcome, everyone.
        I note that quorum is present, I note for the subcommittee
    that Congresswoman Bonamici of Oregon and Congresswoman Schrier
    of Washington are permitted to participate in today's hearing
    with the understanding that their questions will come only
    after all members of the HELP and Workforce Protections
    Subcommittees on both sides of the aisle who are present have
    had an opportunity to question the witnesses.
        The subcommittees are meeting today in a hearing to receive
    testimony on addressing our Nation's maternal and infant health
    crisis.
        Pursuant to Committee Rule 7(c), opening statements are
    limited to the Chairs and the Ranking Members. This allows us
    to hear from our witnesses sooner and provides all members with
    adequate time to ask questions.
        I recognize myself now for the purpose of making an opening
    statement.
        Today we are gathered for a bipartisan hearing to discuss
    our responsibility to address America's maternal and infant
    health crisis. During this hearing we will confront the
    troubling reality that the United States has the worst maternal
    mortality rate among developed countries. Each year 700 women
    die from pregnancy-related complications and 50,000 women
    suffer from life-threatening pregnancy-related complications.
    Even as our peer nations across the world make significant
    improvements in maternal and infant health, outcomes in the
    United States are moving in the opposite direction. In fact,
    the U.S. maternal mortality rate in 2016 was nearly 17 per
    100,000 live births, more than double the rate in 1987.
        This impacts communities across the Nation, including my
    own. In Florida, the situation is even more severe. The
    maternal mortality rate is 22.3 deaths per 100,000 live births,
    well above the national average. Miami-Dade County had a
    maternal mortality rate for Black women of 34.3 in 2018, more
    than double the national average for all mothers. These numbers
    are unacceptably high.
        Improving maternal and infant health requires us to focus
    not just on the health of mothers during pregnancy, but on
    their overall health. That means providing consistent quality
    and affordable health insurance to the roughly 11 percent of
    reproductive age people, 10.6 million Americans who went
    without health insurance in 2017.
        Fourteen states still have not expanded Medicaid
    eligibility, which pays for 43 percent of births, to cover more
    low-income people. In those states, women may lose their
    insurance just two months after giving birth. It means
    supporting the Special Supplemental Nutrition Program for
    Women, Infants, and Children, or WIC, which has proven to help
    protect the health of both mothers and infants by providing
    breastfeeding support and helping mothers avoid preterm births.
        A recent study found that infants born to WIC participants
    are 33 percent less likely to die than non-participants.
    Despite this track record, WIC saw the lowest number of
    participants in over a decade in 2016. Instead of restricting
    access to quality health care, Congress must pass legislation
    to expand access to programs, like WIC, that have helped
    mothers navigate healthy pregnancies for decades.
        Finally, and most importantly, addressing the maternal and
    infant health crisis means undoing structural racism that
    affects every facet of American life, from health care to
    housing to education and transportation.
        Black mothers are three to four times more likely to die
    from pregnancy-related complications than White mothers,
    regardless of their education and income. Native American
    mothers are two to three times more likely to experience
    maternal mortality than White mothers. Simply put, if we are to
    stop this crisis we must all work together and address the
    complex issues in maternal and infant health.
        That is why I am pleased we have an opportunity today, with
    the help of our witnesses, to discuss how we can make
    meaningful and immediate steps to improve maternal and infant
    health for all people. I look forward to today's bipartisan
    discussions and thank our witnesses again for joining us.
        [The statement of Ms. Wilson follows:]

          Prepared Statement of Hon. Frederica S. Wilson, Chairwoman,
            Subcommittee on Health, Employment, Labor, and Pensions

        Today, we are gathered for a bipartisan hearing to discuss our
    responsibility to address America's maternal and infant health crisis.
        During this hearing, we will confront the troubling reality that
    the United States has the worst maternal mortality rate among developed
    countries. Each year, 700 women die from pregnancy-related
    complications and 50,000 women suffer from life-threatening pregnancy-
    related complications.
        Even as our peer nations across the world make significant
    improvements in maternal and infant health, outcomes in the United
    States are moving in the opposite direction. In fact, the U.S. maternal
    mortality rate in 2016 was nearly 17 per 100,000 live births--more than
    double the rate in 1987.
        This impacts communities across the nation, including my own. In
    Florida the situation is even more dire. The maternal mortality rate is
    22.3 deaths per 100,000 live births - well above the national average.
    Miami-Dade County had a maternal mortality rate for black women of 34.3
    in 2018 - more than double the national average for all mothers. These
    numbers are unacceptably high.
        Improving maternal and infant health requires us to focus not just
    on the health of mothers during pregnancy, but on their overall health.
        That means providing consistent, quality, and affordable health
    insurance to the roughly 11 percent of reproductive age people--10.6
    million Americans--who went without health insurance in 2017. Fourteen
    states still have not expanded Medicaid eligibility, which pays for 43
    percent of births, to cover more low-income people. In those states,
    women may lose their insurance just two months after giving birth.
        It means supporting the Special Supplemental Nutrition Program for
    Women, Infants, and Children, or WIC, which is proven to help protect
    the health of both mothers and infants by providing breastfeeding
    support and helping mothers avoid preterm births. A recent study found
    that infants born to WIC participants are 33 percent less likely to die
    than non-participants.
        Despite this track record, WIC saw the lowest number of
    participants in over a decade in 2016. Instead of restricting access to
    quality health care, Congress must pass legislation to expand access to
    programs, like WIC, that have helped mothers navigate healthy
    pregnancies for decades.
        Finally--and most importantly--addressing the maternal and infant
    health crisis means undoing structural racism that affects every facet
    of American life, from health care, to housing, to education, and
    transportation.
        Black mothers are three to four times more likely to die from
    pregnancy-related complications than white mothers, regardless of
    education and income. Native mothers are two to three times more likely
    to experience maternal mortality than white mothers.
        Simply put, if we are to stop this crisis, we must all work
    together and address the complex issues in maternal and infant health.
    That is why I am pleased we have an opportunity today, with the help of
    our witnesses, to discuss how we can take meaningful and immediate
    steps to improve maternal and infant health for all people.
        I look forward to today's bipartisan discussions and thank our
    witnesses, again, for joining us.
                                     ______

        Chairwoman Wilson. I now recognize HELP Ranking Member, Mr.
    Walberg, for an opening statement.
        Mr. Walberg. Thank you, Madam Chairwoman.
        Today we are here to discuss the critical issue of infant
    and maternal health, and in fact to I would hope to exalt
    motherhood and birth itself.
        While women around the globe are dying less from
    childbirth, here in the United States the rates have been
    climbing. Other countries with rising maternal mortality rates,
    Afghanistan, Lesotho, and Swaziland. For black women, the
    statistics are even more troubling. According to the World
    Health Organization, the maternal mortality for black women in
    the United States are the same for women in Mexico, Uzbekistan,
    and this is unacceptable.
        This issue, a matter of literal life and death for women
    and babies, demands a serious and thoughtful response. The
    exact causes of the United States' high maternal and infant
    mortality rates are unclear and varied, but they can be known.
        The HELP subcommittee has jurisdiction over employment-
    related health benefits and the Employee Retirement Income
    security Act, otherwise known as ERISA. So as we study the
    important issue before us today, and before this committee
    considers the imposition of additional government mandates that
    could have unintended consequences on employers and employees
    alike, we should closely examine this problem through separate
    hearings about the larger issue and propose legislative
    solutions.
        As we have learned from experience, one size fits all
    government requirements more often than not compound the
    problem. That is why specific policies from this committee and
    Congress must involve a thorough review of the current problem
    and a recognition that community, individual, and family
    engagement are also key components which need to be recognized
    and addressed.
        Let us not forget the important role employers are playing
    in providing health insurance to mothers and babies. Because of
    our strong economy more workers have access to high quality
    affordable health insurance at work. The most recent
    Congressional Budget Office numbers indicate that 159 million
    Americans are covered by employer-sponsored coverage. In
    addition, maternity benefits are often the largest type of
    health care expenditures for employers. Because of this,
    employers proactively offer a number of programs aimed at
    increasing quality and lowering cost for employees, and another
    reason for an encouraging economic growth and employment.
        Many employers offer programs for fertility, prenatal care,
    neonatal and premature birth medical care, lactation
    consulting, and transparency tools to view provider and
    hospital quality metrics as well. Employers also rely on
    payment and delivery model reforms to reduce scheduled preterm
    births, direct high-risk patients to high-quality providers and
    hospitals, or lower costs by offering bundled payments to
    providers for childbirth services. Milk delivery services have
    also gained popularity with employers by offering convenient
    shipping services for employees who travel for business.
        While employers, communities, and families are play a
    pivotal role in decreasing maternal and infant mortality rates,
    we must also ensure that Congress is taking the necessary steps
    to guarantee the safety and wellbeing of women and newborn and
    unborn infants. We should promote policies in Washington that
    encourage a strong family, allow families to flourish, and
    protect life at all stages, from conception to natural death.
        I know that both sides can agree that maternal and infant
    health is an issue worthy of attention. And it is my hope that
    we can hold additional legislative hearings on any proposed
    solutions and that any subsequent legislation can be considered
    in a bipartisan manner. I certainly commit myself to that.
        Bottom line, bringing a child into the world should be an
    exciting and joyful time for women and their families. In light
    of the eternal truth that ``children are a gift, the fruit of
    the womb is a reward''. Mothers should feel secure and
    confident in their new role and not have to fear for their own
    life or their baby's life.
        I thank the Chairwoman for scheduling today's hearing and I
    look forward to hearing from our witnesses.
        I yield back.
        [The statement of Mr. Walberg follows:]

    Prepared Statement of Hon. Tim Walberg, Ranking Member, Subcommittee on
                    Health, Employment, Labor, and Pensions

        Today, we are here to discuss the critical issue of infant and
    maternal health. While women around the globe are dying less from
    childbirth, here, in the U.S., the rates have been climbing. Other
    countries with rising maternal mortality rates? Afghanistan, Lesotho,
    and Swaziland. For black women, the statistics are even more troubling.
    According to the World Health Organization, the maternal mortality
    rates for black women in the U.S. are the same for women in Mexico and
    Uzbekistan. This is unacceptable.
        This issue, a matter of literal life and death for women, demands a
    serious and thoughtful response.
        The exact causes of the United States' high maternal and infant
    mortality rates are unclear and varied. The HELP Subcommittee has
    jurisdiction over employment-related health benefits and the Employee
    Retirement Income Security Act, also known as ERISA. So, as we study
    the important issue before us today, and before this Committee
    considers the imposition of additional government mandates that could
    have unintended consequences on employers and employees alike, we
    should closely examine this problem through separate hearings about the
    larger issue and proposed legislative solutions. As we have learned
    from experience, one-size-fits-all government requirements, more often
    than not, compound the problem. That is why specific policies from this
    Committee and Congress must involve a thorough review of the current
    problem and a recognition that community, individual, and family
    engagement are also key components which need to be recognized and
    addressed.
        Let's not forget the important role employers are playing in
    providing health insurance to mothers and babies. Because of our strong
    economy, more workers have access to high-quality, affordable health
    insurance at work. The most recent Congressional Budget Office numbers
    indicate that 159 million Americans are covered by employer-sponsored
    coverage. In addition, maternity benefits are often the largest type of
    health care expenditures for employers. Because of this, employers
    proactively offer a number of programs aimed at increasing quality and
    lowering costs for employees.
        Many employers offer programs for fertility, prenatal care,
    neonatal and premature birth medical care, lactation consulting, and
    transparency tools to view provider and hospital quality metrics.
    Employers also rely on payment and delivery-model reforms to reduce
    scheduled pre-term births; direct high-risk patients to high-quality
    providers and hospitals; or lower costs by offering bundled payments to
    providers for childbirth services. Milk-delivery services have also
    gained popularity with employers by offering convenient shipping
    services for employees who travel for business.
        While employers, communities, and families all play a pivotal role
    in decreasing maternal and infant mortality rates, we must also ensure
    that Congress is taking the necessary steps to guarantee the safety and
    wellbeing of women and newborn and unborn infants. We should promote
    policies in Washington that encourage a strong family, allow families
    to flourish, and protect life at all stages, from conception to natural
    death.
        I know that both sides can agree that maternal and infant health is
    an issue worthy of attention, and it is my hope that we can hold
    additional legislative hearings on any proposed solutions and that any
    subsequent legislation can be considered in a bipartisan manner.
        Bottom line, bringing a child into the world should be an exciting
    and joyful time for women and their families, in light of the eternal
    truth that `children are a gift . . . the fruit of the womb is a
    reward.' Mothers should feel secure and confident in their new role,
    and not have to fear for their own life or their baby's life.
        I thank the Chairwoman for scheduling today's hearing, and I look
    forward to hearing from our witnesses.
                                     ______

        Chairwoman Wilson. Thank you so much, Mr. Walberg.
        I now recognize Workforce Protection Subcommittee Chair
    Adams for an opening statement.
        Ms. Adams. Thank you, Madam Chairwoman, and thank you to
    our witnesses for being here today.
        As Co-Chair of the Black Maternal Health Caucus alongside
    Ms. Underwood, I am grateful for today's bipartisan opportunity
    to focus on our role in addressing America's maternal and
    infant health crisis. This crisis is devastating communities
    across the country, particularly Black and Native communities
    that experience far worse outcomes than their White
    counterparts. However, in some places in the country, such as
    in my home state of North Carolina, there are strategies in
    place that have been proven to work in reducing these
    disparities. It is up to us as lawmakers to make it easier for
    our caregivers to take what works and expand upon it.
        Today our witnesses will help us understand and address the
    causes behind pregnancy--related mortality and morbidity that
    hit our communities every day.
        As Chairwoman Wilson noted, expanding access to affordable
    health care and nutrition services is an important part of the
    solution. However, as women increasingly work later into their
    pregnancies and return to work shortly after the baby is born,
    we must also ensure that our workplaces support the health of
    mothers and infants. In this area Federal law falls woefully
    short.
        For example, Federal law currently does not guarantee all
    new mothers the right to express breast milk. Workplace
    breastfeeding supports such as designated pumping breaks and
    private space are particularly critical for both maternal and
    infant health. Unfortunately, while employers are required to
    provide pumping breaks and break time for some workers, a gap
    in the law has caused millions of overtime-exempt employees to
    fall through the cracks. Further, even covered workers have
    limited avenues to ensure their employers provide pumping
    breaks and a private space. I think we can all agree that this
    is unacceptable. There is no question that our country is
    facing a maternal and infant health crisis. There is no
    question that our mothers and infants are suffering preventable
    tragedies that rarely occur in other developed nations. The
    only question is whether we will come together and fulfill our
    responsibility to find solutions and to take action.
        Again, I want to thank all of the witnesses for joining us
    today and, Madam Chair, I yield back.
        [The statement of Ms. Adams follows:]

     Prepared Statement of Hon. Alma S. Adams, Chairwoman, Subcommittee on
                             Workforce Protections

        Thank you, Chairwoman Wilson. As the co-chair of the Black Maternal
    Health Caucus alongside Ms. Underwood, I am grateful for today's
    bipartisan opportunity to focus on our role in addressing America's
    maternal and infant health crisis.
        This crisis is devastating communities across the country,
    particularly Black and Native communities that experience far worse
    outcomes than their white counterparts. However, in some places in the
    country, such as in my home state of North Carolina, there are
    strategies in place that have been proven to work in reducing these
    disparities. It's up to us as lawmakers to make it easier for our
    caregivers to take what works and expand upon it.
        Today, our witnesses will help us understand and address the causes
    behind pregnancy-related mortality and morbidity that hit our
    communities every day.
        As Chairwoman Wilson noted, expanding access to affordable health
    care and nutrition services is an important part of the solution.
    However, as women increasingly work later into their pregnancies and
    return to work shortly after the baby is born, we must also ensure that
    our workplaces support the health of mothers and infants. In this area,
    federal law falls woefully short.
        For example, federal law currently does not guarantee all new
    mothers the right to express breast milk. Workplace breastfeeding
    supports, such as designated pumping breaks and private space, are
    particularly critical for both maternal and infant health.
    Unfortunately, while employers are required to provide pumping breaks
    and break time for some workers, a gap in the law has caused millions
    of overtime exempt employees to fall through the cracks. Furthermore,
    even covered workers have limited avenues to ensure their employers
    provide pumping breaks and a private space.
        I think we can all agree that this is unacceptable. There is no
    question that our country is facing a maternal and infant health
    crisis. There is no question that our mothers and infants are suffering
    preventable tragedies that rarely occur in other developed nations. The
    only question is whether we will come together and fulfill our
    responsibility to find solutions and take action.
        Thank you, again, to our witnesses for joining us today.
                                     ______

        Chairwoman Wilson. I now recognize Workforce Protection's
    Ranking Member Walker for an opening statement.
        Mr. Walker. Thank you, Madam Chair.
        Bringing a child into the world should be an exciting and
    joyful time for women and their families, not one clouded by
    fear and by worry. Unfortunately, infant and maternal mortality
    rates in the United States paint an abysmal picture. From 1990-
    2015 the U.S. mortality rate increased by 34 percent. To put
    that number into proper perspective, the global rate for
    maternal mortality decreased by 44 percent over that same time
    period. As for the United States infant mortality rates, they
    are declining, but remain 71 percent higher than the comparable
    country average.
        Considering that the cause of these worsening and
    troublesome trends aren't clear, we must be cautious of
    implementing government mandates on employers that could end up
    potentially doing more harm than good. With that said, though,
    public policy has an important role to play in this issue,
    which is why there are protections under Federal law that
    safeguard mothers and their newborn babies' health.
        For example, the Fair Labor Standards Act, the FLSA,
    requires employers to provide reasonable workplace
    accommodations and break time for nursing mothers for 1 year
    after their child's birth. Women with children are the fastest
    growing segment of the workforce. According to the Department
    of Health and Human Services, 6 in every 10 new mothers are in
    the workforce. So the types of accommodations included in the
    FMLSA help our nation's workers and job creators succeed.
        We agree that maternal and infant mortality trends are an
    important concern which deserves our attention. In the past
    Congress has been able to come together in a bipartisan manner
    to tackle serious policy challenges. For example, last year
    Congress passed H.R. 6, the SUPPORT for Patients and
    Communities Act, bipartisan legislation to address the opioid
    crisis, including mothers and infants affected by this terrible
    epidemic. Our hope is that we can continue this bipartisan work
    as we discuss solutions to address maternal and infant health
    here today.
        In closing, hundreds of maternal deaths occur every year.
    These statistics are heartbreaking. As a Nation with some of
    the most advanced obstetrics and emergency care, we can and we
    should do better. But it is important that we legislate with a
    reasoned approach backed by a careful examination of the issue,
    which is why this hearing is a good starting point.
        Again, thank you, Madam Chairwoman, for scheduling today's
    hearing. I look forward to a thoughtful discussion and hearing
    from all of our witnesses on how we can improve maternal and
    infant health conditions.
        I yield back.
        [The statement of Mr. Walker follows:]

     Prepared Statement of Hon. Mark Walker, a Representative in Congress
                        from the State of North Carolina

        Thank you, Madame Chairwoman. Bringing a child into the world
    should be an exciting and joyful time for women and their families, not
    one clouded by fear and worry.
        Unfortunately, infant and maternal mortality rates in the U.S.
    paint an abysmal picture. From 1990 to 2015, the U.S. maternal
    mortality rate increased by 34 percent. To put that number into
    perspective, the global rate for maternal mortality decreased by 44
    percent over the same time. As for U.S. infant mortality rates, they
    are declining, but remain 71 percent higher than the comparable country
    average.
        Considering that the cause of these worsening and troublesome
    trends is unclear, we must be cautious of implementing government
    mandates on employers that could end up doing more harm than good.
        With that said, public policy has an important role to play in this
    issue, which is why there are protections under federal law that
    safeguard mothers and their newborn babies' health.
        For example, the Fair Labor Standards Act (FLSA) requires employers
    to provide reasonable workplace accommodations and break time for
    nursing mothers for one year after their child's birth.
        Women with children are the fastest-growing segment of the
    workforce. According to the Department of Health and Human Services,
    six in every 10 new mothers are in the workforce. So, the types of
    accommodations included in the FLSA help our nation's workers and job
    creators succeed.
        We agree that maternal and infant mortality trends are an important
    concern which deserves our attention. In the past, Congress has been
    able to come together in a bipartisan manner to tackle serious policy
    challenges. Last year, Congress passed H.R. 6, the SUPPORT Patients and
    Communities Act, bipartisan legislation to address the opioid crisis,
    including mothers and infants affected by this terrible epidemic. Our
    hope is that we can continue this bipartisan work as we discuss
    solutions to address maternal and infant health here today.
        In closing, hundreds of maternal deaths occur every year. These
    statistics are heartbreaking. As a nation with some of the most
    advanced obstetric and emergency care, we can and should do better. But
    it is important that we legislate with a reasoned approach backed by a
    careful examination of the issue, which is why this hearing is a good
    starting point.
        Again, thank you, Madame Chairwoman for scheduling today's hearing.
    I look forward to a thoughtful discussion and hearing from our
    witnesses on how we can improve maternal and infant health outcomes.
                                     ______

        Chairwoman Wilson. Thank you.
        Without objection, all other members who wish to insert
    written statements into the record may do so by submitting them
    to the Committee Clerk electronically in Microsoft Word format
    by 5:00 p.m. on February 10, 2020.
        I will now introduce our witnesses.
        Stacey Stewart is the President and CEO of the March of
    Dimes. In this role Stewart heads the organization leading the
    fight for the health of all moms and babies.
        Nikia Sankofa is the Executive Director of the United
    States Breastfeeding Committee, an independent nonprofit
    coalition of more than 100 influential professional,
    educational, and governmental organizations that share a common
    mission to drive collaborative efforts for policy and practices
    that create a landscape of breastfeeding support across the
    United States.
        Dr. Joia Crear-Perry is the Founder and President of the
    National Birth Equity Collaborative and a board member of the
    Black Mamas Matter Alliance. She is a thought leader around
    racism as a root cause of health inequities.
        Welcome to each of you powerful Black women.
        We appreciate all of you for being here today and we look
    forward to your testimony.
        Let me remind the witnesses, we have read your written
    statements and they will appear in full in the hearing record.
    Pursuant to Committee Cule 7(d) and committee practice, each of
    you is asked to limit your oral presentation to a 5-minute
    summary of your written statement.
        Let me also remind the witnesses that pursuant to Title 18
    of the U.S. Code, Section 1001, it is illegal to knowingly and
    willfully falsify any statement, representation, writing,
    document, or material fact presented to Congress, or otherwise
    conceal or cover up a material fact.
        Before you begin your testimony please remember to press
    the button on the microphone in front of you so that it will
    turn on and the members can hear you. As you begin to speak the
    light in front of you will turn green. After 4 minutes the
    light will turn yellow to signal that you have 1 minute
    remaining. When the light turns red, your 5 minutes have
    expired and we ask that you please wrap it up.
        We will let the entire panel make their presentations
    before we move to member questions. When answering a question,
    please remember to once again turn your microphone on.
        I will now recognize Ms. Stacey Stewart. Welcome, Ms.
    Stewart.

      TESTIMONY OF STACEY D. STEWART, PRESIDENT AND CEO, MARCH OF
                                 DIMES

        Ms. Stewart. Thank you and good morning, Chairwoman Wilson
    and Chairwoman Adams, also Ranking Member Walberg and Ranking
    Member Byrne, and members of the subcommittees. It is a
    pleasure for me to be here today, and thank you for inviting me
    to testify.
        My name is Stacey Stewart. I am President and CEO of the
    March of Dimes. Every day at March of Dimes we lead the fight
    for the health of all moms and all babies. We began that fight
    more than 80 years ago as an organization dedicated to
    eradicating Polio in the United States, a goal that we
    achieved. We continue that fight today as we work to address
    some of the biggest threats to moms and babies, such as
    premature birth and maternal mortality, through research,
    through education, programs, and advocacy.
        March of Dimes' mission is more important than ever before
    as our Nation, as many of you all have mentioned, is in the
    midst of a maternal and infant health crisis. Two babies die
    every hour in the United States and one woman dies every 12
    hours as the result of complications from pregnancy and
    childbirth.
        The most recent March of Dimes report card shows that the
    Nation's preterm birth rate rose for the fourth year in a row
    in 2018 and it revealed unacceptable disparities in outcomes
    for babies born in certain communities. Infants of color and
    those born in the southeastern United States are much more
    likely to be born too soon. In fact, the preterm birth rate
    among Black women is 49 percent higher than the rate among all
    other women.
        The state of maternal health mirrors that of infants born
    too soon. Outcomes are getting worse and those worsening
    outcomes are driven by disparities. Each year approximately 700
    women die from pregnancy complications, and for every maternal
    death another 70 women suffer life threatening health
    challenges. That is 50,000 women every year. These startling
    statistics make the U.S. one of the most dangerous developed
    places in the developed world in which to give birth.
        The threat is especially acute for women of color. Black
    mothers of all ages are three times more likely to die from
    pregnancy-related causes and complications than their White
    peers. For Black and American Indian and Alaska Native women
    over the age of 30 rates of maternal death are 4 to 5 times
    higher.
        We need your help to address this crisis by focusing on
    policies that will improve both maternal and infant health.
        March of Dimes was pleased by the passage of the Preventing
    Maternal Deaths Act and the PREEMIE Reauthorization Act in late
    2018. Both of these bills continue vital programs to collect
    enhanced data on the causes of maternal mortality and premature
    birth.
        Fortunately, we don't have to wait for new data to take
    additional action. We know that the causes of this crisis are
    diverse. They can be traced issues in our health care system,
    including quality of care and implicit bias. They stem from
    factors in our homes, on our workplaces, in our communities.
        There are additional steps you can take today to address
    this crisis. A full description of those steps can be found in
    my written testimony, but I will address policies most relevant
    to the subcommittees' jurisdictions now.
        First, Congress should take all necessary steps to ensure
    that women have access to comprehensive and affordable health
    care before, during, and after pregnancy and guaranteeing her
    newborn has the same from birth. The Patient Protection and
    Affordable Care Act codified a number of vital provisions,
    including protecting individuals with pre-existing conditions,
    guaranteeing coverage for maternity care, and ending annual and
    lifetime caps on coverage. Lawmakers must protect and build
    upon these protections.
        The March of Dimes supports creating a new special
    enrollment period for pregnancy, as outlined in the Healthy MOM
    Act, to ensure all pregnant women have access to prenatal care.
    We also support efforts to protect families from surprise bills
    by simplifying the process for enrolling newborns in a family's
    health plan.
        Congress can guarantee women and infants have access to
    both preventive care and treatment by strengthening the ACA's
    requirement that health plans cover preventive services for
    women and infants without cost sharing. Further, lawmakers
    should require health plans to cover a minimum number of free
    health care provider visits each year, as outlined in the
    Primary and Behavioral Health Care Access Act.
        While health insurance and health care services are
    essential to healthy moms and babies, we cannot address this
    public health crisis by focusing exclusively on doctors'
    offices and hospitals. We have to address the barriers in our
    communities as well. We also applaud efforts to improve the WIC
    program. We strongly support reforms to ensure that every mom,
    no matter where she works, can continue to breastfeed if she
    chooses.
        I look forward to expounding upon some of the proposals
    that we are talking about today, and thank you for having me.
        [The statement of Ms. Stewart follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Chairwoman Wilson. Thank you, Ms. Stewart.
        We will now recognize Ms. Nikia Sankofa.
        Welcome.

     TESTIMONY OF NIKIA SANKOFA, EXECUTIVE DIRECTOR, UNITED STATES
                        BREASTFEEDING COMMITTEE

        Ms. Sankofa. Good morning, Chairwoman Wilson and Chairwoman
    Adams and Ranking Members Walberg and Walker.
        Thank you for this opportunity to participate in today's
    hearing to discuss American's maternal and infant health
    crisis. It is an honor to share the insights I have gained from
    2 decades of public health work at the community and national
    levels.
        I am the Executive Director of the United States
    Breastfeeding Committee, an independent nonprofit coalition of
    more than 100 national, tribal, regional, state, and community
    organizations working together to drive policies and practices
    that create a landscape of breastfeeding support throughout the
    country.
        Breastfeeding is a proven primary prevention strategy,
    building a foundation for lifelong health and wellness.
    Compared with formula fed children breastfed infants have a
    reduced risk of illness, infection, and infant death. Women who
    breastfeed their children have a reduced long-term risk of
    diabetes, cardiovascular disease, and certain cancers.
        The evidence for the value of breastfeeding to children and
    women's health is scientific, robust, and continuously being
    reaffirmed by new research. Leading health organizations
    recommend exclusive breastfeeding for about 6 months followed
    by continued breastfeeding as complementary foods are
    introduced for at least the first year of life.
        You might think that infant feeding decisions are a
    personal family matter, but we are all shaped by our
    circumstances. Lack of education in the prenatal period,
    maternity care practices that do not prioritize breastfeeding,
    returning home after birth unsure of where to go for support,
    and having lack of access to counseling and supplies, such as
    breast pumps, can compromise the early establishment of
    breastfeeding. And lack of support in the community and
    employment settings can stand in the way of continued
    breastfeeding.
        Recent data show that 84 percent of infants were ever
    breastfeed, meaning that they initiated breastfeeding,
    indicating that most mothers in the United States want to
    breastfeed and start out doing so. But only a quarter are still
    breastfeeding exclusively at 6 months and 60 percent of mothers
    report that they did not breastfeed for as long as they
    intended.
        Some of these barriers to breastfeeding exist outside of
    the mother's sphere of power or control and they
    disproportionately impact young women, those with low income,
    and women of color. This is reflected in significantly lower
    breastfeeding rates across all tracked indicators for these
    populations.
        The key to supporting families and alleviating
    breastfeeding disparities is investing in upstream policy
    systems and environmental change solutions that deconstruct
    barriers and build environments where healthy choices, like
    sustained breastfeeding, can be the easy default option for
    most families.
        Some well-known breastfeeding policy systems and
    environment change solutions include the Baby-Friendly Hospital
    Initiative, WIC's Breastfeeding Peer Counselor Program, and the
    2010 Break Time for Nursing Mothers law, which was unanimously
    passed out of a bipartisan committee in recognition of the role
    that breastfeeding plays in infant and maternal health.
        Even with these systemic solutions in place, we know more
    must be done. A simple and commonsense policy solution to
    addressing ongoing workplace barriers is within reach of this
    committee. The Providing Urgent Maternal Protections for
    Nursing Mothers Act, the PUMP Act, was introduced with
    bipartisan support for breastfeeding employees and it helps
    breastfeeding employees while clarifying implementation
    processes for employers across the Nation.
        Nearly one in four women of childbearing age, that is 9
    million employees, are excluded from coverage under the current
    Break Time law, and as such they have no clear right to break
    time and a private space to pump breast milk. Although state
    legislation covers more than half of these employees, creating
    Federal laws ensures that employers from all sectors are
    considered and employees from all communities are supported
    under a national law that recognizes the important of breast
    milk in human and population health.
        Without protections breastfeeding employees face serious
    health consequences, including risk of painful illness and
    infection, diminished milk supply, or inability to continue
    breastfeeding. According to a recent report from the University
    of California's Center for WorkLife Law, the consequences of
    this coverage gap also include harassment at work, reduced
    wages, and job loss, putting some new mothers in the position
    of risking their family's economic security by attempting to
    continue breastfeeding and working.
        The PUMP for Nursing Mothers Act would strengthen the 2010
    Break Time law by closing the coverage gap for women who are
    not currently covered, providing employers clarity on when
    pumping time must be paid and when it may be unpaid, and
    providing remedies for nursing mothers.
        We know that the vast majority of people become parents
    during their lifetime and their needs and the needs of their
    infants are neither surprising nor difficult to meet if we plan
    appropriately.
        Thank you for this opportunity.
        [The statement of Ms. Sankofa follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Chairwoman Wilson. Thank you, Ms. Sankofa.
        We now recognize Dr. Joia Crear-Perry.
        Welcome.

     TESTIMONY OF JOIA CREAR-PERRY, MD, PRESIDENT, NATIONAL BIRTH
                          EQUITY COLLABORATIVE

        Dr. Crear-Perry. Thank you so much. Thank you, Chairwoman
    Wilson, Chairwoman Adams, Ranking Members Walberg and Byrne, as
    well as members of the House Committee on Education and Labor,
    for allowing me, Dr. Joia Crear-Perry, to provide testimony for
    this Expecting More: Addressing America's Maternal and Infant
    Health Crisis hearing representing the National Birth Equity
    Collaborative and the Black Mama's Matter Alliance.
        We can support improvements for all workers of reproductive
    age to grow their families with the appropriate wages, dignity,
    and protections they deserve. Women are integral to every
    industry in the U.S. Can they trust this body to support them
    through their pregnancy and return to the workforce? We can
    begin by shoring up the existing state investments for new
    mothers that are based upon evidence, like diversifying our
    workforce, scaling and deepening the ACOG Alliance for
    Innovation on Maternal Health, and building a community for
    respectful care, increasing our investment in the CDC-supported
    Perinatal Quality Collaboratives, mandating implicit bias and
    anti--racism training, and uplifting the leadership influence
    of the National Institutes of Health, Office of Research on
    Women's Health, Federal Divisions.
        We can solidify these investments by heeding the
    recommendations of entities like us at the Black Mamas Matter
    Alliance.
        As has been mentioned, the CDC defines pregnancy-related
    death as a death of a woman while pregnant or within 1 year of
    the end of pregnancy, regardless of outcome, duration, or site
    of the pregnancy, from any cause related to or aggravated by
    pregnancy and its management. Based on that definition, the CDC
    found in their surveillance 2,726 women died in the United
    States between 2011 and 2014, and of those 1,010, or 38 percent
    were Black. Based on that data and estimates of maternal
    mortality data from the CDC, a modest estimate of loss of
    preventable causes is about 1,000-1,500 Black mothers in the
    last decade. That is a caravan of coach buses each year. This
    is unacceptable.
        Furthermore, over 60 percent of these deaths were
    preventable. As a Black woman from the Deep South who is an
    obstetrician and a mother, my strong desire to end this
    inequity is amplified every time I look into the faces of my
    daughter and my patients. The legacy of a hierarchy of human
    value based upon the color of our skin continues to cause
    differences in health outcomes, including maternal mortality.
    Racism is the risk factor, not my Black skin. There is not
    Black gene. Race is a social and political construct. Maternity
    mortality extends beyond the period of pregnancy and birth.
    Nine months of prenatal care cannot counter underlying social
    determinants of health inequities, in housing, political
    participation, transportation. Currently we do not have access
    to maternity care that is culturally congruent. Lack of
    workforce diversity and provider shortages are a direct
    consequence of policies created in halls like this that date
    back to the 1921 Sheppard-Towner Act, among others.
        I am the founder of the National Birth Equity Collaborative
    and on the founding board of the Black Mamas Matter Alliance.
    The National Birth Equity Collaborative creates solutions that
    optimize Black maternal and infant health through training,
    policy and advocacy, research, and community centered
    collaboration. When working with large hospital systems as we
    currently do, health departments, and large legacy
    organizations to build a culture of reproductive justice, we
    have learned that Federal policy and investment is critical. As
    Black birthing people we have been devalued for generations,
    and that devaluation shows up in your policy choices that you
    pick today.
        The Black Mamas Matter Alliance serves as a national voice
    and coordinating entity for stakeholders advancing maternal
    health, rights, and justice and intentionally centers Black
    women's leadership. BMMA has a network of organizations with
    reach and relationships and capacity that you could support for
    an intergenerational movement.
        Ultimately, what Black women in the United States need is
    accountability. We need to know that our lives are valued. This
    accountability may be complicated, by government still has an
    obligation to act. Racism, classism, and gender oppression are
    killing us from rural to urban America. This is not about
    intentions. Lack of action is unintentionally killing us and it
    is a human rights imperative.
        This hearing that calls for us to expect more is an
    opportunity for esteemed members of this Education and Labor
    Committee to look deeply at all the ways policies around our
    social determinants of health are causing maternal morbidity
    and mortality. We must be willing to continue to name this
    problem directly.
        Yes, Black Mamas Matter.
        [The statement of Dr. Crear-Perry follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Chairwoman Wilson. Thank you, Dr. Crear-Perry.
        Under Committee Rule 8(a) we will now question witnesses
    under the 5-minute rule.
        I will now yield myself 5 minutes.
        Dr. Crear-Perry, in your testimony you discuss the history
    of the Sheppard-Towner Act of 1921 and the impact it had on
    midwifery, and Black midwifery in particular. How many Black
    midwives are in practice and what policies do you think
    Congress could pursue to increase the number of Black midwives?
        Dr. Crear-Perry. Well, we currently know that less than 5
    percent of midwives in practice are Black and we also know that
    there is a shortage of midwifery in general in this country.
    When that Act was enacted we were still operating in a belief
    that people of color and Black people were not fully capable of
    providing the care that everyone needs. And so we did things
    like that were harmful and didn't value the women who had been
    birthing America for generations.
        So there is an opportunity for us to say well what is it
    that people and patients want. When we interview women, they
    really want less intervention, they want a midwife, they want
    someone who looks like them, who understands them. So an
    opportunity through Congress is to increase the workforce
    development, have nursing programs at HBCUs, like my own
    hometown of Grambling, to ensure that we have access to
    midwifery programs, because that is a direct pipeline. There
    are nursing schools at a lot of the HBCUs that do not have
    access to midwifery programs as well.
        Chairwoman Wilson. Thank you.
        In your testimony you discuss some of the history of racism
    within the field of obstetrics and gynecology. Today, we know
    that when Black women seek medical treatment they receive a
    lower quality of care than their White counterparts. Can you
    say more about the role of Dr. J. Marion Sims in this history
    of OB/GYN?
        Dr. Crear-Perry. Yes, thank you so much.
        So as you may know, Dr. J. Marion Sims traveled across the
    United States with three Black women who were enslaved. Their
    names were Lucy, Betsey, and Anarcha. I would like to uplift
    their names because they are human beings who existed, who we
    don't even honor and they don't have statues. We have statues
    and honors for J. Marion Sims. We name--if you are an OB/GYN
    and you reach for a retractor, you are asking for a Sims
    retractor. That name comes from a man who traveled around the
    country doing experiments on women without any anesthesia and
    then he wrote, based upon the fact that these Black women could
    handle these surgeries with anesthesia, that we clearly did not
    feel pain the same way that White women did. And that believe
    still pervades today. There are studies that show, from
    prestigious universities in the United States, that medical
    students still believe that Black people do not feel pain the
    same way. As if melanin has something to do with your pain
    receptors.
        So it is important for us to really think about all the
    ways that racism is embedded in how we created obstetrics and
    gynecology, how we decimated midwifery, and how we still
    provide care today and how we do not acknowledge those truths.
    We are not taught even about J. Marion Sims when you are
    training in medical school or residency. So you don't even have
    an understanding of the retractor that you are asking for and
    how it was used and created on the bodies of people who were
    not valued.
        Chairwoman Wilson. Okay, thank you.
        About 1 in 33 children in the United States is born with a
    congenital anomaly. Some of these conditions, such as a cleft
    palate, can have serious impact on a child's ability to breathe
    and to speak.
        Ms. Stewart, does March of Dimes support legislation such
    as Ensuring Lasting Smiles Act that would close this gap in
    coverage for these children?
        Ms. Stewart. Thank you, Chairwoman.
        Yes, the Ensuring Lasting Smiles Act is Federal legislation
    that would do some very important things.
        First of all, it would ensure that all private group and
    individual health plans cover medically necessary services,
    including needed dental procedures as a result of congenital
    anomalies. And, as you mentioned, about 4 percent of children
    in the U.S. are born with these kinds of anomalies or birth
    defects. And of course the March of Dimes in our history has
    been very dedicated to addressing the issues of birth defects
    among children.
        But the issue is that while most private health plans do
    provide coverage for surgical treatment of many of these
    anomalies and there are many states that actually require
    insurers to provide coverage for health services related to
    some of these birth defects, we still hear that there are too
    many health plans that often deny claims and appeals for oral
    or dental related procedures, like orthodontia or dental
    implants and other procedures. And what this means for these
    families is that they are often left to have to figure out how
    to pay for these services on their own. And some of those
    expenses can be extraordinary and often devastating financially
    to many of these families.
        So we support the Ensuring Lasting Smiles Act along with
    over 30 other organizations because we think that when babies
    are born, due to no fault of their own or their families, with
    these kind of birth defects, they deserve and need the
    treatment, often these dental surgeries to make sure that not
    only can they really thrive as kids, but they can actually
    function as normal human beings, because some of these kinds of
    birth defects affect their ability to breathe, their ability to
    eat. They are more than just cosmetic surgeries, they are
    actually medically necessary, and medically indicated
    surgeries. So we are in strong support of the Ensuring Lasting
    Smiles Act because we believe that it will provide the support
    that is needed to so many of these families.
        Some of these families are even here today, like the Abbott
    family from Wisconsin I just got a chance to meet, and families
    that have been really impacted by some of these issues. And
    without some of the support from the Ensuring Lasting Smiles
    Act we would leave too many families too vulnerable--
        Chairwoman Wilson. Thank you.
        Ms. Stewart.--and without the care that the need.
        Chairwoman Wilson. Thank you very much.
        I ask unanimous consent to enter into the record letters of
    support for this legislation.
        I now recognize member Walberg, my Ranking Member for his
    round of questions.
        Mr. Walberg. Thank you, Madam Chairwoman, and thanks to the
    panel for being here today and taking the effort to join us
    this morning.
        Ms. Stewart, last Congress I was proud to serve as member
    of the Energy and Commerce Committee as we passed a bipartisan
    bill, H.R. 1318, the Preventing Maternal Deaths Act, which
    reauthorized funding for the Centers for Disease Control and
    Prevention programs that support state and local maternal
    mortality surveillance and prevention programs, added
    additional funding for state governments to establish maternal
    mortality review commissions. H.R. 1318 was signed into law by
    President Trump in December 2018. These state commissions
    worked to collect, to track, analyze, and report data on
    maternal and infant outcomes in states that have established
    these commissions.
        How has the increased availability of data impacted
    maternal safety and quality improvement initiatives?
        Ms. Stewart. Thank you.
        Well, one of the things that is really important as we
    address the maternal and infant health crisis is being able to
    collect good data, good, reliable data across the country. And
    thank you for your support for the Preventing Maternal Deaths
    Act, because it did provide the impetus for every state to be
    able to establish what we call a maternal mortality review
    committee. We now have every state, with the exception of
    three, that have established these MMRCs. And what they are
    doing is actually going collecting the data. The underlying
    data is really important to understand the cause of death, why
    a mother may have died as a result, and tie it back to
    obviously the fact that she may have just had a baby or any of
    the causes due to pregnancy and childbirth.
        These state-based committees are full of experts who really
    analyze this data and then help design recommendations or
    interventions to prevent further deaths from happening. So
    before this, we didn't have this kind of data collection
    effort. Now that we do, we are able to look more deeply at the
    underlying causes of maternal mortality and morbidity and
    design at a federal level or at a state level the kinds of
    interventions that will hopefully prevent these kinds of deaths
    from happening in the future. We would not be able to do this
    work and accelerate our interventions and our successes with
    this crisis if we didn't have more robust data collection.
        Mr. Walberg. It will certainly take some time for that to
    work in, but we are seeing benefits already?
        Ms. Stewart. We are starting to see benefits. We still have
    three states that need to establish MMRCs and then we need to
    start collecting the data and reporting it up.
        Mr. Walberg. What are those states?
        Ms. Stewart. South Dakota, North Dakota, and Wyoming, as I
    understand it.
        Mr. Walberg. Okay. Dr. Crear-Perry, high-risk pregnancies
    can pose significant challenges to all women and to health
    providers. I am a grandfather and when I am asked how many
    grandkids I have, I say one in heaven and five on the ground.
    My first two were twin boys born at 24 weeks, 1.12 ounces, 12
    inches long. John Timothy is in heaven waiting, but thanks to
    the wonderful care that they received in Northwestern
    University Hospital on the north side of Chicago, Mike is now
    13 and almost 6 feet tall, healthy, and going strong. But my
    daughter-in-law also was part of that process, and thank god
    she was given great care and pulled through.
        So it is an important issue that we are talking about
    today. Some hospitals have successfully implemented standard
    protocols to address common high-risk scenarios. In looking at
    labor and delivery issues, hemorrhaging, high blood pressure,
    et cetera, how can these protocols help increase quality and
    decrease maternal mortality rates?
        Dr. Crear-Perry. I had a one pounder myself. He is now 23
    years old. He was supposed to come with me this morning, but he
    played video games too late last night, so he is not here with
    me. So I appreciate that.
        Mr. Walberg. So he is normal?
        Dr. Crear-Perry. Exactly. So I am making him watch it on
    YouTube.
        No, so it is important of course that the way that those
    tools work is we can have standards for hospitals. So, for
    example, the Joint Commission just passed--who accredits
    hospitals--asked the hospitals--they have about a year to get
    it together to report on hemorrhage and how they are using the
    bundles. And so we have seen improvements. In fact, the State
    of California saw a large decrease in the number of deaths
    after really implementing the use of those hemorrhage bundles
    and hypertension. And what they found, though, is that there
    still was bias around who was implementing the bundles. So now
    we are going back and we are saying how can we do this in a
    more equitable way and how can we do things like work on our
    implicit biases.
        But it is important to have those tools so that you have a
    standard of how you are supposed to take care of patients.
        Mr. Walberg. Okay. I appreciate that.
        In the very limited time here, Ms. Stewart, we talked about
    the United States and its problem. As U.S. maternal mortality
    rates continue to increase, are other countries experiencing
    similar increases and are we learning something from that as
    well?
        Ms. Stewart. Well, we are sort of unique in that we are one
    of the few, if any, of the largest industrialized countries in
    the world with increasing maternal mortality rates. I think it
    was mentioned earlier that we kind of stand alone in that
    respect.
        I do think there are things that we learned from other
    countries where the rates have been declining, where you see a
    range of other supportive policies to make sure that women are
    provided the support that they need. In the UK, for example,
    there are lots of supports that women are given through
    midwifery care and through other kinds of home visiting
    programs that actually are providing a lot of support to women
    during pregnancy and even postpartum. Our country lacks in
    terms of the ability to expand these kinds of policies to many
    women and that leaves many women falling through the cracks.
        We also know a couple of things. One is that we will not
    solve this issue just by looking at the 9 months of pregnancy.
    We have to look at women before they are pregnant, during
    pregnancy, and after pregnancy. We also have to make sure that
    we look at health care and health and wellness for women. It is
    not just something that happens in the doctor's office because
    so many of the issues that impact a woman and her health and
    the baby's health have to do so much with their environment and
    what we call the social determinants of health, how they live
    their day to day lives. And until we get a full handle on
    policies that address the totality of how women live in this
    country, we won't be able to address this issue in the way we
    need.
        Mr. Walberg. Thank you. I yield back.
        Chairwoman Wilson. Thank you. Thank you, Ranking Member
    Walberg.
        I remind my colleagues that pursuant to committee practice
    materials for submission for the hearing record must be
    submitted to the Committee Clerk within 14 days following the
    last day of the hearing, preferably in Microsoft.
        And now we will hear from our members. Dr. Adams, who has
    been on the forefront of this issue here in Congress, along
    with Nurse Underwood. I commend them.
        Now, Dr. Adams.
        Ms. Adams. Thank you, Madam Chair.
        Dr. Crear-Perry, thank you for highlighting the importance
    of training providers as a strategy to reduce the racial
    disparities that we are seeing in maternal and infant health
    outcomes. And that is why I introduced the Maternal CARE Act,
    which would create implicit bias training grants.
        In your experience working with physicians and other health
    care providers, how common is implicit bias training and what
    kind of gaps do you see in the training of health care
    providers?
        Dr. Crear-Perry. So right now it keeps me very busy doing
    implicit bias training, and we just did one in Kaiser in
    Atlanta. We trained their entire maternal and child health
    division. So that is everybody from the people who answer the
    phone to the actual high-risk OB/GYNs.
        So there is an opportunity we have right now to really
    build up on these trainings. My organization is one of several
    that do these trainings. I know the March of Dimes has created
    some work around that as well.
        And the importance is that we need to understand our own
    biases in health care and how we were taught those things. And
    biases are not--they are coded in us, we can change it. We
    don't have to believe that Black people are broken, we don't
    have to believe that women can't do things. Those are things
    that we have been taught, and so they are part of our implicit
    biases now. But we can change that.
        Ms. Adams. Thank you.
        My home state of North Carolina has a program called
    Pregnancy Care Management and provides needs assessments,
    coordination of care, and other supports for eligible women
    with at-risk pregnancies. The program has been cited as a
    factor in--in halving the Black maternal death rate in North
    Carolina. Why is coordination of care and supportive services
    particularly effective for Black mothers? And what can Congress
    do to support these types of programs?
        Dr. Crear-Perry. I have the honor of working with Dr.
    Menard and others at UNC around that work, the Pregnancy
    Medical Home work, and this idea that you can have
    coordination. Because as was mentioned by Ms. Stewart, we are
    losing people in the gaps. They don't have access to the
    coordination around breastfeeding or if they need
    transportation or housing. So this coordinated care model,
    which was I think spun out through Medicaid, allows for you to
    then also have coordination with other services in North
    Carolina and they have seen a decrease in their Black maternal
    health mortality, they also saw the gap close in the disparity
    in North Carolina. So you should be really proud of your home
    state for putting that forward.
        Ms. Adams. Well, I am, you know, of some things. So do you
    agree that WIC has an opportunity to play a greater role in
    this conversation?
        Dr. Crear-Perry. I love our WIC partners. We did a training
    of implicit bias at the WIC conference last year as well. And
    so because they touch more moms than most anybody--I mean
    people go to WIC when they don't go to their pediatrician, when
    they don't go--they definitely don't go to their postpartum
    visit to see us, and so WIC is an important partner. They
    already have boots on the ground and they know the mothers.
        Ms. Adams. Thank you.
        Ms. Sankofa, recently the Department of Labor finalized
    regulations narrowing its interpretation of joint employment
    status under the Fair Labor Standards Act, which contains the
    nursing mother's protections that you discussed. Although the
    rule does not have the force and effect of law, it tells us how
    the Department will be enforcing joint employment standards for
    determining if an employer must comply with these requirements.
        What is the impact of this, and especially where the
    nursing mother has limited ability to take legal action against
    the employer?
        Ms. Sankofa. I think that is an excellent question and I
    appreciate it because I really think that it makes it more
    difficult for the lactating mother to really enforce their
    right to have a clean and private place to pump and store their
    milk while they are at work.
        As I said at the end of my oral testimony, when employees
    don't have a clean and adequate safe space, private space in
    order to pump their milk, they have to make these difficult
    tradeoffs, and this tradeoff is do you want to stay employed
    and have economic viability for your family, or do you want to
    provide the nutritional biological standard for your infant.
    And I think it is important--we often say that breast is best,
    while it is true, breast is the nutritional standard, it is
    what everybody is supposed to have, it is how people are fed,
    and everything else is actually something that is inferior to
    breast milk.
        Ms. Adams. All right. Okay. So protections that entitle
    nursing workers to break time and private space to express milk
    are only available to those who are eligible for overtime pay,
    so who are we leaving out by only protecting who is eligible
    for overtime pay, and is there a policy reason why these women
    should not have the right to break time and a private space to
    express milk?
        Ms. Sankofa. We are leaving out, as I said, up to 9 million
    workers in the United States. And those are typically salaried
    employees. That includes people who you know, like if you all
    have children, you have teachers in your life. So it includes
    teachers, it includes nurses, it includes software engineers,
    it includes many of the people who you encounter every day. And
    I don't know that there is actually a policy reason that these
    families are not covered by the Break Time for Nursing Mothers
    law. I think that placement in statute made that gap present.
    And I think that the PUMP Act gives us the opportunity to kind
    of right size. We have 10 years of recognized defects within
    the system to be able to really see where we can take the next
    step to kind of close that gap.
        Ms. Adams. Great. Thank you very much, Madam Chair. I yield
    back.
        Thank you for your responses.
        Chairwoman Wilson. Thank you, Dr. Adams.
        Mr. Walker?
        Mr. Walker. Thank you, Madam Chair.
        As I listen today I appreciated the passion of all the
    witnesses here today. It makes me think of my wife, who is a
    family nurse practitioner, and her boss, Dr. Lisa David, is the
    chair there at Wake Forest Baptist Medical Center, and they
    work with infants and children with cleft palates and do great
    work. So a quick shout out to them and their work.
        Ms. Stewart, you mentioned the increase in the Nation's
    preterm birth rate to 10 percent. And I am sad to say maybe
    this picks up with Dr. Adams there, that our home state of
    North Carolina even has a higher rate, a 10.4 percent, I
    believe a D rating.
        The March of Dimes report card I believe is where that was
    listed. What would you say attributed to this shift in the
    preterm birth rate after a decade of decline?
        Ms. Stewart. So unfortunately we don't know all the answers
    of why the preterm birth rate has increased. What we know is
    that in general health outcomes for moms and babies have
    generally declined in this country over the past many years.
    And there are a various number of reasons for it.
        First of all, I will just let you know the March of Dimes
    has six prematurity research centers, five in this country, one
    in the UK, all working together to try to look at some of the
    underlying causes, biological reasons why some of this is
    happening. But we also know that the impact of the way women
    and families--women especially--live in this country could also
    have a serious impact. So the degree of stress on women,
    especially before pregnancy and after, during pregnancy and
    even after.
        We also know that--a lack of access to care. We have too
    many women living in places where even if they have coverage
    they may not have care, and those are two different things. So
    we have, even in a state like North Carolina, places, counties
    that are considered maternal care deserts where women are not
    able to access the kind of prenatal care that they need in
    order to have successful pregnancies.
        So there are a variety of reasons for it.
        Mr. Walker. Gotcha. Yeah. You and certainly my wife would
    know more than I, but I believe preterm or premature birth is
    defined as before 37 weeks, is that correct?
        Ms. Stewart. Before 37.
        Mr. Walker. It is the number one cause of infant death in
    the United States, with an average of 275 babies being born
    preterm per week. I know it is in North Carolina.
        What challenges or complications can infants face who are
    born preterm, and what challenges do their mothers face as
    well?
        Ms. Stewart. Well, either I can talk about it or Dr. Joia
    Crear-Perry can because she has personal experience with it.
        Mr. Walker. Sure.
        Ms. Stewart. But we work on this issue as a primary issue
    for the March of Dimes. As I mentioned, 380,000 babies born
    every year prematurely, again, before 37 weeks of gestation.
    What we know is a lot of those preterm births are happening in
    the period between 34 and 36 weeks, so very late preterm, but
    some of the most devastating effects happen for a baby like Dr.
    Crear-Perry's baby, born at a very early preterm stage, so at
    21 weeks or 23 weeks of gestation.
        And for those babies, the effects can be devastating.
    Babies can have developmental delays, cognitive delays,
    physical disabilities, and a whole range of lifelong health
    complications that are very expensive to address.
        One of the things that the March of Dimes did is we updated
    a study on the cost of preterm birth. About over a decade ago
    we looked at it at a cost of $26 billion in this country, it is
    now well over $30 billion. So it has a significant cost of the
    country from a productivity standpoint, as well as families and
    those children individually.
        Mr. Walker. Thank you.
        Certainly I am someone that believes that life is precious,
    whatever term that it might be in. I know that is not our
    discussion today, but any kind of biases before or after
    something is important to me. And I know, Dr. Crear-Perry, that
    is kind of your kind of specialty area, if it is; and someone
    who tries to advocate for all people, I would be concerned
    about that. So you are telling me that you see biases in there.
    I want to take that at face value, but I also want to ask you
    on those biases, do you believe they are intended? Is it out of
    ignorance? Is it out of an intentional--can you break that--I
    have got a minute left. I am going to skip my final question
    because I want to hear from you on that as well, because that
    is important to me.
        Thank you.
        Dr. Crear-Perry. They are definitely not intended. They are
    definitely things that we all kind of grew up believing. I
    believed--I was taught in medical school by my professors that
    there were three races, mongoloid, caucasoid, and negroid. That
    was what I was taught. So I believed that the reason that I had
    a baby preterm is because I was Black, because there was
    something inately--so that is a bias that we have been teaching
    that we have to undo, that we have to retrain. As my
    grandmother would say, we have to unlearn us, right. We have
    learned some things that are incorrect. So it is an opportunity
    for us to really--we are all the same. There is no difference
    between you and I. Our biology is the same. And so how do we
    then think about what are we doing as a country to ensure that
    we both have a good outcome?
        Mr. Walker. Thank you, Dr. Crear-Perry. I appreciate your
    passion in that area.
        With that, I yield back to Madam Chair.
        Chairwoman Wilson. Thank you so much.
        And now Mr. Courtney from Connecticut.
        Mr. Courtney. Thank you, Madam Chairwoman, and to both
    Chairs and Ranking Members for holding this hearing.
        The topic here today should shock the conscience of every
    American. And what I want is to just thank all the witnesses.
    Just that, you know, you have put forth some really, you know,
    manageable, doable solutions that, again based on your
    testimony, I think should encourage us all that we actually
    have the tools to address this. So, again, thank you all for
    being here today.
        And also that, you know, these two subcommittees I think
    really, you know, also are positioned to move forward on these
    issues.
        Ms. Stewart, you mentioned--and I think Dr. Perry also in
    your testimony alluded to the fact that the ACA when it passed
    obviously moved the ball forward in terms of maternity care,
    Medicaid coverage, and also the essential health benefits. But
    I do think, as Ms. Stewart's testimony indicated, I think it
    would surprise people to know that the age 26 coverage, which
    is hands down probably one of the most popular, if not the most
    popular provision of the law, does not extend to dependent
    adult children in terms of maternity benefits. The number we
    have is that it is about 4.2 million women, ages 19-25 that are
    covered under their parents' health insurance plans, again have
    that gap. And Mercer, which is a pretty credible think tank
    study, found that approximately 70 percent of employers don't
    cover maternity care for dependents.
        So, again, this is the subcommittee that actually wrote the
    age 26 provision, because we have ERISA jurisdiction. Again, I
    wonder, Ms. Stewart, if you could just sort of talk a little
    bit about how that is maybe contributing to this issue, that
    gap.
        Ms. Stewart. No, I really appreciate it. And I think you
    are right in that it is certainly one of the most popular
    provisions in the ACA, that health plans offer dependent
    coverage for children up to the age of 26. And the inclusion of
    an essential health benefit--so it is a part of ACA--has also
    been a huge benefit to pregnant women for maternity coverage.
    What we know though is the essential health benefits only apply
    in the individual and small group markets. So these health
    plans for these large employers who are not required to provide
    coverage for maternity care for dependents leaves this large
    gap and this large loophole, about 4 million young women who
    are covered as dependents but don't have access to this kind of
    coverage.
        So we think that it is very important to deal with this
    loophole that potentially puts a lot of women at risk, it
    subjects them potentially to a lot of out of pocket costs if
    they become pregnant. And certainly this gap in coverage is
    actually threatening their own health and potentially the
    health of their baby if they are not able to receive the proper
    prenatal coverage and the kind of care that they may need. So
    addressing this loophole will be very important. And it is,
    again, millions of women that are left in this gap.
        Mr. Courtney. Dr. Perry, I don't know if you would like to
    comment as well.
        Dr. Crear-Perry. As a person who has a 26 year old
    daughter, I was super depressed when she had to get off my
    insurance. So I appreciate that exists and that it is popular.
        And you think about who gets pregnant, it is 21-26 year
    olds, and we are leaving off millions by not having this
    loophole addressed. So it is important for us to recognize if
    mortality is something we care about and morbidity and
    parenting and mothering, then we would not leave a space where
    people don't have access to care.
        Mr. Courtney. Thank you. I have a 25-year-old, so we are
    holding on by our fingernails.
        And, again, Ms. Wilson, I want to just to again thank you
    for bringing up the issue of the Ensuring Lasting Smiles Act
    and the impact of that sort of fragile coverage for congenital
    birth defects.
        I have a letter which I ask to be admitted to the record
    from Caleb Andrew Lock, who is a 10-year-old just passionate
    advocate who represents Rhode Island and Connecticut and
    describes his own situation, which as he points out, if it was
    caused by a car accident it would be covered, but the fact that
    it is a congenital defect runs into this obstacle, which is
    just completely unacceptable.
        So, again, thank you for addressing that issue and
    hopefully that bill will move forward because of the spotlight
    you are putting on it here today.
        And with that, I yield back.
        Chairwoman Wilson. So ordered.
        Dr. Roe, you know all about this.
        Dr. Roe. Thank you, Madam Chair.
        And, Ms. Stewart, this has nothing to do with this hearing,
    but we are working on your pension issue at the March of Dimes,
    okay?
        Ms. Stewart. It only helps us deal with our other issues
    too. Thank you so much.
        Dr. Roe. And I want to congratulate this entire committee.
    Every one of you finished in exactly 5 minutes, so
    congratulations.
        A few things I want to go over very quickly. And, Ms.
    Sankofa, I want to get this on the record thanking you for
    advocating breastfeeding and I think that is a huge thing that
    you have done. And also to encourage women out there that may
    be watching this to use the WIC program.
        My background, I am an obstetrician. And I have got a
    little head start on your, Dr. Perry. I have delivered almost
    5,000 babies. And one of the things I noticed in my practice, a
    couple of things that have not been mentioned at all, is
    obesity and drug addiction.
        In our state of Tennessee, in 1998 we had 50 opioid-
    addicted babies in the entire State of Tennessee. It would have
    been a rarity to ever see in our--now we have a NICU, of which
    the surgeon general will be there this Thursday visiting our
    children's hospital, specifically for opioid addicted babies.
    And I know absolutely it is depressing to me to see maternal
    mortality rate in the late '70s being lower than it is today
    with all the enormous amount of resources and money we have
    spent.
        And would you, Dr. Perry, go--I think it is very important,
    the definition of maternal mortality and is it described that
    way, defined that way in other countries?
        Dr. Crear-Perry. I don't want to mess up the real
    definition so I could read it again, but how we define it is a
    global definition. So up to 42 days it is a standard and no
    matter the site or the--within 42 days of delivery. What we
    also are starting to do in the United States though is
    recognize women are dying up to a year later. So although the
    international standard is 42 days, we really don't have--we
    know that people die from opioid and substance abuse 3 months
    later, right. And it is still tied to the pregnancy. So we are
    now tracking deaths up to a year and really pushing the
    international community to start thinking about doing the same
    thing.
        Dr. Roe. Just to give you an example, in our state this
    year we are trying to take our Medicaid-covered patients, whose
    coverage in maternal would be out at 6-8 weeks postpartum, and
    extend that for a year.
        Dr. Crear-Perry. Yes, yes. Exactly.
        Dr. Roe. Because what we are finding is some of these women
    who are opioid addicted will go overdose later.
        Dr. Crear-Perry. Yes. Yes.
        Dr. Roe. And I think that is important for every state to
    do that.
        Dr. Crear-Perry. It is critical. And if you think about us
    as OB/GYNs, we believed 6 weeks was the magical thing, and so
    we had insurance end at 6 weeks, but that doesn't match
    actually the science. The science shows us that women have
    cardiomyopathy within 6 months to a year later and can die. So
    all these other things around childbirth are still impacting
    your body, and there is nothing magical about 42 days.
        Dr. Roe. I totally agree with that. And the risk factors
    that you see for maternal mortality would be age, obviously.
    Women are older when they have their children. Ethnicity, which
    you mentioned, obesity, lifestyle, which could be opioids, drug
    addiction, other things, preeclampsia. We know those things.
    But why do you see--because to me to have it almost double--
        Dr. Crear-Perry. Right.
        Dr. Roe.--is one of the most distressing things with the
    amount of money that we put into maternal health in this
    country.
        Dr. Crear-Perry. Right. And so it would be a few things.
    One of them is our lack of investment in community-based
    organizations and hospitals are--when you practiced, you knew
    everybody around you, I am sure, and we just don't have that
    kind of system anymore. So how do we have a system that values
    the community members who are close and understand the moms,
    and so really getting back to being close to that.
        We also increased our c-section rate, you know that.
        Dr. Roe. Yeah.
        Dr. Crear-Perry. And so a lot of women are dying from
    hemorrhage and other things after having a c-section. We have
    one of the highest c-section rates in the world, and we then
    export that to other countries. India starts following us and
    having high c-sections too. So we need to really think about
    why we are doing some of the choices we are doing. And this
    body has a greater capacity to hold systems accountable for
    making choices.
        Dr. Roe. That was one of the other thing I was going to
    bring up. I have looked at--when I stopped delivering babies I
    looked at my primary cesarean section rate.
        Dr. Crear-Perry. Yeah.
        Dr. Roe. And I was trained in Memphis, very similar to
    where you are in New Orleans.
        Dr. Crear-Perry. Mm-hmm, yeah, exactly.
        Dr. Roe. And it was 8 percent.
        Dr. Crear-Perry. Yup.
        Dr. Roe. Primary cesarean section rate.
        Dr. Crear-Perry. Yup.
        Dr. Roe. Now it is probably 30-35 percent.
        Dr. Crear-Perry. Exactly, exactly.
        Dr. Roe. And the mortality rate is much higher, as we
    know--
        Dr. Crear-Perry. Exactly.
        Dr. Roe.--in cesarean births as opposed to a natural birth.
    I would like some firm things. We did this in Memphis many,
    many years ago. We had neighborhood clinics--
        Dr. Crear-Perry. Yup.
        Dr. Roe.--for women who had a hard time getting--this is
    urban areas.
        Dr. Crear-Perry. Exactly.
        Dr. Roe. I live in a rural area. And someone mentioned an
    OB/GYN desert.
        Dr. Crear-Perry. Yup.
        Dr. Roe. I represent four counties and four, almost five,
    of them have zero obstetrical care in those counties, which
    means they have to drive long distances.
        Dr. Crear-Perry. Right.
        Dr. Roe. In Memphis we had neighborhood clinics and we had
    nurses that took care of those. If there was a certain issue,
    then they were sent to the hospital clinic--
        Dr. Crear-Perry. Right.
        Dr. Roe.--to get evaluated. If their blood pressure was
    above a certain amount. That seemed to work pretty well when we
    took the care to--and this was 50 years ago.
        Dr. Crear-Perry. Exactly. We stopped investing in those
    kind of things and we stopped in perinatal birth workers. We
    know community health workers work, we know that investments in
    people who are closer to the community work, and then you don't
    have to make people come all the way downtown for a visit. We
    can now use technology. Telehealth is an opportunity for us to
    really increase the access. I mean we have so many
    opportunities. Sometimes we just have to allow for the room for
    people to build up some of the things that they have learned
    and that we have been doing on the ground.
        Dr. Roe. Dr. Perry, do you think that malpractice--
        Dr. Crear-Perry. Yup.
        Dr. Roe.--has--we haven't mentioned that at all.
        Dr. Crear-Perry. I know.
        Dr. Roe. A lot of young doctors--
        Dr. Crear-Perry. You and I could talk about this all day.
        Dr. Roe. Yeah, exactly. We won't say anything bad about
    lawyers too much. But anyway, I think that didn't affect me
    much. I trained in a different time.
        Dr. Crear-Perry. Yup.
        Dr. Roe. But I see our younger physicians--
        Dr. Crear-Perry. Yes.
        Dr. Roe.--that are really impacted I think by that.
        Dr. Crear-Perry. For sure. People quit practice because--my
    malpractice insurance was $80,000 a year, and that was--you
    know, and I had to pay that first before I could pay rent or
    pay employees. So the cost of how much you pay for malpractice
    is so prohibitive. And then we are not going to fix maternal
    health through lawsuits. So that is our current structure in
    the United States, if we are going to fix this we just sue our
    way out of it. And that is just not working. This is an
    imperative that we really come up with policies that are bigger
    than lawsuits to fix health.
        Dr. Roe. Madam Chair, I want to thank you for having this.
    We can go on, Dr. Perry and I all day.
        Dr. Crear-Perry. Exactly.
        Dr. Roe. I want to thank you for having this. I think we
    should continue this, because this is a travesty in the United
    States to have these kinds of mortality rates. And I do hope we
    continue this conversation.
        Dr. Crear-Perry. Thank you.
        Chairwoman Wilson. Thank you, thank you. I knew you would
    be interested, Dr. Roe.
        Ms. Fudge from Ohio.
        Ms. Fudge. Thank you very much, Madam Chair. Thank you all
    so much for being here. It is good to see my friend, Ms.
    Stewart. Thank you as well.
        It is interesting to me that we talk about the number--many
    of the reasons. Now, let me just say that I am from Cuyahoga
    County, Ohio and you don't need to go much further than
    Cuyahoga County and Summit County in my district to see the
    tragic disparities in infant mortality. There are as many White
    addicted people as there are Black addicted people, but
    according to MomsFirst, which is a home visitation program in
    the City of Cleveland, of the 13,872 births in 2018, 120
    infants died within the first year of life. Black babies make
    up a little over one-third of all of those births, but
    accounted for more than two-thirds of the infant deaths. And in
    Summit County, the infant mortality rate among non-Hispanic
    Black families are more than three times that of non-Hispanic
    White families. So there is just more than just what we are
    hearing.
        And I am really glad that Dr. Roe likes the whole concept
    of community health centers, we just need to fund them.
        Ms. Sankofa, how can we remove barriers to breastfeeding
    for Black mothers?
        Ms. Sankofa. The reality is that I think that most of the
    solutions exist within the communities that are having the
    problem. And the most important thing that I think that anybody
    can do is listen to the communities that you intend to serve.
        I used to run a breastfeeding project at a different
    organization and we did implementations of community-level
    breastfeeding support interventions at 72 community-based
    organizations and local health departments across the country.
    And the thing that really made sense was to have a community
    specific understanding, meaning you have to do some level of
    community assessment to evaluate what are the systemic and
    structural barriers that exist for that community. The problem
    in Cuyahoga County is not going to be the same exact problem in
    Memphis, and so you have to have different solutions. And I
    think that those solutions have to be policy systems and
    environmental change solutions that really look at creating
    spaces of continuity of care. Breastfeeding happens at the
    hospital. It needs to be educated prenatally. It happens in the
    community. And all of those different spheres and spaces where
    women go, they need to be interacting and speaking to one
    another in a way that make sure that people don't fall through
    the gaps.
        Ms. Fudge. Thank you very much.
        Dr. Crear-Perry, can you speak to the phenomenon of
    weathering and its impact on maternal health outcomes for Black
    women?
        Dr. Crear-Perry. So although we look fabulous, you know,
    Black don't crack as we say, on the inside the impact of racism
    is really bothering our bodies. And Dr. Geronimus for about 20
    years has been doing studies that show that we have--work out
    of UCSF, out of UNC, that shows that the biological impact of
    racism on our bodies causes us to have higher rates of
    hypertension, higher rates of preterm birth. And so instead of
    looking for a pill or a shot to fix weathering, what we can
    begin to do is hold people accountable, hold systems
    accountable for things that are harming our bodies, like
    racism, classism, and gender oppression.
        Ms. Fudge. Pregnant women just don't feel, I feel it here
    every day.
        Let me, before I go any further, thank the organizations in
    my district that work to help eliminate these disparities. I
    think it is important for us to say thank you. They are First
    Year Cleveland, MomsFirst, Birthing Beautiful Communities, and
    Full Term First Birthday, Greater Akron.
        It is important to know that there is help. And so often we
    don't know where to get help. Because these kinds of agencies
    and organizations, they just get by, so it is difficult for
    them sometimes to let people know that they are even there.
        You talked, I think, Ms. Stewart, about having coverage but
    not access. I represent some of the best health care in the
    world--in the world. Cleveland Clinic, University Hospitals,
    Rainbow Babies, and I could go on and on and on, yet my people
    don't have the kind of access they need. You talked about how
    we get people to a place of health, but it starts way before
    pregnancy. And so I just appreciate the work that you all do. I
    thank you and I think the Chairs for having this hearing,
    because it is an epidemic that nobody is dealing with in any
    big way. So I hope that I can be helpful in some way going
    forward, especially because there are so many of my babies that
    we are losing.
        I thank you and I yield back.
        Chairwoman Wilson. Thank you, Ms. Fudge. Thank you very
    much.
        Mr. Fulcher.
        Mr. Fulcher. Thank you, Madam Chairman.
        And I have got a question for Dr. Perry, but I have to
    share my bias first. I love babies. I like all of them. And I
    like the name of your group, the Black Mamas Matter Alliance,
    and I am sure that probably extends to the Black Babies Matter
    Alliance too, so it is great.
        We know that women of color have about a three times more
    likelihood of having an abortion than not. And that is kind
    of--I wanted to just talk to you about that because we are
    confronted with a situation where in this case Planned
    Parenthood is the number one provider in that, and just
    historically they have targeted that community, the women of
    color community, and they provide many more abortions there
    than elsewhere. And that is just wrong to me. And it is just--
    the data is so obvious. And why women of color? And why do they
    target there? And it just seems unconscionable to me that
    people are making money off that and somehow we tolerate it.
    And I just wanted to get your thoughts.
        Dr. Crear-Perry. I am not a representative of Planned
    Parenthood, although I work with them extensively. So I am
    speaking on behalf of Joia and not the organization.
        So how black women interact with health care is a lot based
    upon the history, historical injustices and oppressions. And so
    perhaps instead of thinking it as they are being preyed upon by
    Planned Parenthood, that we are being provided a service
    because we don't have access to Medicaid expansion in some
    states, we don't have access to all the other services, we
    don't have hourly wage jobs that we can leave, so we don't have
    all the social things that people need to be able to make
    different choices around birth options.
        Mr. Fulcher. The result of that is that we are losing
    babies.
        Dr. Crear-Perry. Exactly. So the result of us not making
    choices in this building to support Black women means that
    Black women have to make a lot of different choices around
    their bodies.
        So if we decided that we believe that we should have access
    to paid leave, maybe that would impact who chooses to have an
    abortion or not. Like there are choices that you all make here
    as policy makers that impact how we can live our lives. That is
    much more impactful upon our lives than any one organization
    like Planned Parenthood. They are one small organization, you
    are the government. So how you decide to support women and how
    you decide to support Black women and listen to Black women,
    really matters way more than what Planned Parenthood does.
        Mr. Fulcher. Thank you.
        Madam Chair, if I might just follow up.
        And I hear what you are saying and that makes sense. At the
    same time, I don't think that crosses their mind one little
    bit. I don't think they care. I think that their whole deal is
    looking at the bottom line, because that is--when we get
    approached for funding and we get that kind of pressure, all
    right, I understand the point you are making, but I am just
    trying to communicate a point. I don't think they care one bit.
        Dr. Crear-Perry. So I am going to give you a counterpoint.
    Our wonderful congresswoman from Cleveland mentioned Cleveland
    Clinic. They choose not to open labor and delivery in the part
    of the city where they had--their big hospital is because they
    don't make money there. They have a labor and delivery in the
    suburbs, right, so they have their hospital that is in the
    neighborhood that needs the most care for pregnant moms. They
    make a choice to say we are not going to do any labor and
    delivery here, we are not going to provide services for the
    people in this community.
        So I would say that most organizations, big health care
    systems, make choices based upon money and that is a choice
    that the United States has made in general around how we
    provide care. If we took that conversation outside of where you
    can make money--because I could go back and forth with you
    about all the systems and where they choose to put clinics,
    where they choose to put hospitals. Those are choices based
    upon money, based upon choices around Medicare and private
    insurance that are made here; that we could make very different
    choices.
        Mr. Fulcher. Thank you, Madam Chair.
        And I will close my comments. And thank you, Dr. Perry. I
    will just say this. Let us agree on this.
        Dr. Crear-Perry. Okay.
        Mr. Fulcher. Maybe that is a two-pronged approach, because
    I think you bring up some good points and to the extent I and
    colleagues can be supportive of that, then I am happy to try to
    do that.
        And at the same time, for those who I am convinced are
    preying on our community of color, I am not supporting that.
    And so please know you are appreciated, your work is
    appreciated.
        Dr. Crear-Perry. Thank you.
        Mr. Fulcher. And hopefully we can work together on a two-
    pronged approach to try and make things better, okay?
        Dr. Crear-Perry. Sound great. Thank you.
        Mr. Fulcher. I yield back. Thank you.
        Chairwoman Wilson. Mm-hmm. Thank you.
        Mr. Takano of California.
        Mr. Takano. Thank you, Madam Chair, Chairwoman Wilson and
    Chairwoman Adams for this critical hearing on maternal health
    and infant health.
        The United States has some of the best physicians,
    hospitals, and groundbreaking medicine in the world, and yet it
    is also the most dangerous and worst place to give birth among
    any of the developed countries. A 2019 report from the Centers
    for Disease Control and Prevention found that three in five
    pregnancy related deaths could have been prevented. And
    unfortunately, the number of infant and maternal deaths are
    increasing every year. We know there is a link between having
    access to health coverage and the decrease in maternal
    mortality and severe maternal morbidity. A report by Georgetown
    University's Health Policy Institute found that in Medicaid
    expansion states like California, they have seen decreasing
    maternal and infant mortality rates.
        Madam Chair, at this moment I would like to ask unanimous
    consent to enter into the record the report from Georgetown
    University.
        Chairwoman Wilson. Without objection.
        Mr. Takano. Thank you, Madam Chair.
        My first question is for Ms. Stewart. Ms. Stewart, what
    benefits do you believe extending Medicaid coverage for mothers
    beyond 60 days will have?
        Ms. Stewart. Well, thank you for that. And I appreciate you
    raising that issue of the CDC study that said that three out of
    five of the cases of maternal death could have been avoided,
    and it could have been avoided with improved care, not having
    delayed or misdiagnoses, and a whole range of other issues. So
    we know that this issue is completely within our ability to
    control.
        We also know that the issue of maternal deaths is spread
    across the period of time from pregnancy, right at the time of
    the childbirth, and then from the period of time from one week
    out from having the baby out to 1 year.
        When we look at the issue of Medicaid coverage, we know
    that for many women who actually were able to receive Medicaid
    coverage for the birth of their child, after several months
    over 50 percent of them are often dropped from Medicaid
    coverage, which means that they have had chronic health
    challenges, even some that were exacerbated, or any health
    challenges exacerbated because of pregnancy or childbirth, they
    are often left without coverage.
        And so the idea of expanding Medicaid coverage for all
    women, and for not only during the period of the childbirth,
    but for women to make sure that they have the care that they
    need, both in terms of their physical conditions, but also
    their mental health conditions as well, because a lot of the
    challenges that women may face often are not just as a result
    of issues that affect their health, maybe related to obesity or
    hypertension, but also due to mental health concerns as well.
        So we think that the ability and the need to have to extend
    Medicaid coverage to make sure that women have the coverage
    they need out to 1 year is essential in terms of dealing with
    the kinds of postpartum challenges that many women experience
    after having birth.
        Mr. Takano. So, again, the reasonable length of time that
    coverage should be extended is?
        Ms. Stewart. We propose, and I think there is a lot of
    agreement that out to a year is really important.
        Mr. Takano. To a year? To a year?
        Ms. Stewart. A year.
        Mr. Takano. What can we learn from other developed
    countries that have lower mortality rates? What do we know?
        Ms. Stewart. So I think--and I mentioned it earlier--I mean
    think there are a lot of things that we can look at. One is
    that, you know, a lot of countries actually have far more
    supportive policies for families. So issues like paid family
    leave, more supportive policies within the workplace, really
    more extended care for women, access to other alternative forms
    of care, like midwives have been really important and really
    productive effective ways to help women have more successful
    pregnancies.
        Mr. Takano. Thank you.
        As Chairwoman Adams has stated, nursing workers that are
    eligible for overtime pay under the Fair Labor Standards Act
    are entitled to break time and a private space to express
    mother's milk. This is an important workplace right that helps
    promote the health of both the baby and the mother.
        Ms. Sankofa, when an employer violates a nursing mother's
    right to break time and private space to express milk, how can
    the nursing mother hold her employer accountable?
        Ms. Sankofa. Thank you. That is actually a really difficult
    thing for the actual employee to do. There is a significant gap
    that has surfaced in terms of remedial measures related to the
    break time law. The employee has to reach out to the Department
    of Labor, Wage and Hours for the Department of Labor to express
    that they are--to file a claim and then the Department of Labor
    has to investigate whether or not there was an actual
    violation. And before anything extra can happen, the Department
    of Labor actually has to take the step to take it to court or
    not.
        And so when it goes to court there is nothing that mothers
    actually get from that process typically because it is for--the
    break time law is not necessarily a paid aspect of that
    process. And so there is no actual thing that you get back even
    if it goes to court via the Department of Labor.
        And so I think that--
        Mr. Takano. Thank you.
        Mr. Takano. So I think that movement to the PUMP Act is a
    very efficient way of trying to create a space where the
    traditional spaces of the FLSA can be implemented so that the
    same type of remedial actions that exist for other violations
    of employee accommodations--employers already know how to work
    with this and this puts it within that same level of statue
    within the law.
        Mr. Takano. Thank you, Ms. Sankofa.
        I am sorry I went over. Madam Chair, I am yielding back. I
    just want to acknowledge the work of Barbara Anderson, a
    constituent of mine who has done tremendous work on this topic
    as a nurse midwife who has been a scholar and researcher.
        So I apologize for going over. I yield back.
        Thank you. And thank you for the answer, Ms. Sankofa. Very
    helpful
        Chairwoman Wilson. Thank you. Thank you very much.
        Dr. Foxx.
        Ms. Foxx. Thank you, Madam Chairman.
        I have great respect for my colleague from Tennessee and I
    yield him 30 seconds.
        Dr. Roe. Just very quickly, we don't have enough people
    breastfeeding, we have a maternal mortality rate that is too
    high. Why don't we take a public health approach? Remember only
    you could prevent forest fires? We all remember that. If you
    are old enough you do. Why don't we have a public health
    approach to educate the public and the country? I will bet you
    that most Americans have no idea that the mortality rate is
    that high. So why don't we look at the surgeon general, March
    of Dimes, and so forth and do a public health education
    approach to our people in the country?
        I yield back.
        Ms. Foxx. Thank you, Dr. Roe.
        Ms. Stewart, as we like to say in this committee, states
    are the laboratories of innovation, most often for the better,
    but sometimes not so. We can learn a lot from what states are
    doing to address infant and maternal mortality and find out
    what works and what does not.
        What state initiatives are underway to address infant and
    maternal mortality? What are the preliminary results of these
    initiatives and programs?
        Ms. Stewart. Well, I actually think one of the states that
    has probably had the most success on the issue of maternal
    mortality for sure has been one that was mentioned earlier, in
    California. California was one of the early states to actually
    create what essentially is now one of our maternal mortality
    review committees and actually use data to actually drive
    decisions on where maternal deaths were happening and what
    interventions--working with health care providers, working with
    hospitals, and others to make real progress. They have made
    measurable progress over many years. They still are working on
    some of the inequity issues that they experience. In other
    words, they saw large decreases in terms of maternal deaths,
    but they were still seeing unacceptable--and they are still
    seeing unacceptably high rates--not to speak for them--
    unacceptably high rates among those women of color.
        So I think there still are--I think one of the most
    important things that we have not done as a country and in
    states is have the appropriate data, which is why I go back to
    the action that you all took to create maternal mortality
    review committees. It has been a huge step forward. But now
    that we are learning more, we can do more to actually prevent
    some of the causes and the underlying causes of death.
        Ms. Foxx. Well, thank you. And I think there has been a
    huge emphasis in this Congress in the last 3 or 4 years on
    evidence-based decision making. We have talked about it in all
    areas. We want to be able to do what works instead of just
    throwing money at programs for the sake of throwing money at
    programs or thinking our district deserves a certain amount of
    money. We really do need to be using our scarce resources very,
    very wisely.
        Let me ask you another question, Ms. Stewart. As we
    consider this important issue from the perspective of this
    committee and examine potential solutions which are in the
    jurisdiction of this committee, how can employers and health
    plans work with providers to support decreased maternal and
    infant mortality? We have heard from employers about
    partnerships with other organizations, including the March of
    Dimes, to promote value-based care, reduce unnecessary
    interventions, increase transparency around provider quality.
    Are you aware of any partnerships among providers, employer-
    sponsored health plans, and organizations that are working to
    improve the quality of maternal health?
        Ms. Stewart. Well, I think there are a lot of employers
    that are becoming much more aware of some of these issues. And
    I think one of the things that I mean you all have the ability
    to impact, and one of the policies that I think is most
    effective in terms of providing the support that often families
    need, is around paid family leave. It is not the only thing,
    but it certainly is one thing that can make a big difference.
    If a woman has had a problematic pregnancy, if she is having to
    stay at home to take care of a child, she should not have to be
    forced between having to return back to work or stay at home to
    take care of her baby and then face income interruption that
    could be devastating to her family.
        So I think the kinds of accommodations that would be
    provided by making sure that there is sufficient paid family
    leave for a woman to have to deal with maybe her own health
    issues or the health issues of a baby are incredibly important.
        I also think that a lot of employers are now much more
    aware of some of these issues than ever before and are open to
    making sure that there is more information and more awareness,
    as was mentioned earlier, around some of these challenges. And
    I think the more and more that we can pursue building the
    awareness and expanding public education--we have had at the
    March of Dimes an incredible relationship with the CDC to
    provide broad information to the public around a lot of health
    challenges as it relates to maternal and infant death. We think
    we need to do more of that.
        And then the last thing I would just say is I think a lot
    of employers have a vested interest in this. When a baby is
    born prematurely it has a significant cost to that employer.
    And so a lot of employers are very--and even when a mother has
    her own health challenges, if that employer is left without a
    productive worker or if that mother dies and is no longer
    there, there are significant costs to the employer. So I think
    there are tremendous opportunities to go to employers and look
    for partnerships to expand the kind of information and access
    to care that women need and the families need.
        Chairwoman Wilson. Thank you very much.
        Ms. Foxx. As I have said before, I think that employers
    understand what you are talking about and that any time an
    employee is out there is a significant loss to everyone. And so
    I do think there is a great deal of concern on the part of
    employers for their employees and they would like to do things
    that make it better for everyone concerned.
        Thank you, Madam Chairman. I yield back.
        Chairwoman Wilson. Thank you.
        Ms. Jayapal.
        Ms. Jayapal. Thank you, Madam Chair.
        Thank you all so much for your excellent testimony. Very,
    very powerful. And I can tell you, as a mom myself who
    delivered my kid at 26 1/2 weeks, 1.14 ounces, serious threat
    to my own mortality and certainly to theirs, and morbidity,
    this is an issue that I have worked on myself and followed for
    a long time.
        I think we are, you know, the richest country in the
    history of the world and we spend by far the greatest amount of
    money on health care, and yet we have such abysmal health
    outcomes, as you have gone through.
        And I completely agree with you, Dr. Crear-Perry, when you
    said that we should expect more, that we should demand more,
    and that we must address the maternal mortality crisis in this
    country, and that we have to do so by clearly calling out the
    racism and discrimination within our existing health care
    system that makes it so much more dire for communities of color
    and especially for Black mothers. So thank you for that.
        Let me start with you, Dr. Crear-Perry. Your testimony
    illustrates how for-profit insurance and payment systems have a
    significant impact on maternal health outcomes. Can you talk to
    us about how high out of pocket costs, like private insurance
    premiums, co-pays, and deductibles, exacerbate racial
    inequalities in our health care system?
        Dr. Crear-Perry. Well, you know, the data shows us that
    Black women, despite income or education, are more likely to
    die in childbirth. So that means that most of the Black women
    who are receiving care are not on Medicaid, they are the
    private insurance payers that you all have legislative power
    and authority over. So when you allow for those institutions to
    charge huge deductibles, when you allow for those institutions
    to say that we are not going to cover your child when your
    child is pregnant, you are allowing those organizations to then
    harm women, specifically Black women, because we are also so
    exposed to having morbidity and mortality in childbirth.
        So it is important for us to not only think about
    governmental insurance when we talk about this maternal
    mortality crisis, because we, all three of us sitting up here,
    just as well as you, have education and access and we still
    have poor outcomes, right. So it is important for us to really
    think about our private insurers and the choices that they make
    that harm our bodies.
        Ms. Jayapal. And can you also talk to us about the huge
    gaps in coverage for prenatal services, doulas, patient support
    for after birth, and home care if we had a plan--as my Medicaid
    for All plan does--
        Dr. Crear-Perry. Exactly.
        Ms. Jayapal.--provide comprehensive services of this
    nature? How would that benefit maternal health outcomes?
        Dr. Crear-Perry. Because we talk a lot right now about
    improving doula care. And I usually hear that conversation in
    the Medicaid population. And once again, it leaves off that we
    don't cover any of these things for folks on insurance. I, as a
    city employee who ran a city health department, had to
    negotiate with the insurance company around coverage for my
    staff. People don't realize there is an individual who is
    making choices for your care at your job. They are negotiating
    with the insurance company and they are deciding what they are
    covering. We could make a rule that they have to cover doulas
    and they have to cover midwifery and they have to cover them at
    parity. Those are choices that one individual at your job
    should not be making for you.
        Ms. Jayapal. And if every person had guaranteed coverage of
    comprehensive services under a universal health care system,
    like Medicare for All, with no cost barriers, what do you think
    would happen to the impact on reducing or even eliminating
    disparities in health care access and outcomes?
        Dr. Crear-Perry. We see a little bit of a glimpse of what
    that would look like in places that did expand Medicaid. We see
    an improvement in outcomes just with that one small ask. Even
    in a program that is chronically underfunded, that people don't
    have a lot of access with, we still see improvements in
    outcomes. So if everybody had access to insurance and coverage,
    then we would see an even bigger uptick of what we could look
    like as a country to the rest of the world to show that we are
    really all that we dream to be.
        Ms. Jayapal. I really thank you for your testimony. I
    think, as people know, I have been pushing for a universal
    health care system because I believe it is not out of reach, it
    is what other countries do. We certainly spend enough money
    that we should be able to do it here. And that would mean that
    we are all guaranteed the same level of high-quality
    comprehensive coverage with no premiums, co-pays, and
    deductibles or out-of-network doctors.
        And also, by the way, a more efficient system for our
    safety net and rural hospitals as well.
        Madam Chair, I seek unanimous consent to enter into the
    record a letter from a coalition of racial justice
    organizations, including the NAACP, LULAC, and the Black
    Women's Health Imperative, making the case for why Medicare for
    All is a racial justice issue.
        Chairwoman Wilson. So ordered.
        Ms. Jayapal. Thank you, Madam Chair.
        And I just want to thank you all again for your excellent
    testimony and for lifting up the issues that particularly Black
    women and women of color face and this critically important
    issue that we all need to push for immediate action on.
        Thank you. I yield back.
        Chairwoman Wilson. Thank you. Thank you.
        Mr. Johnson.
        Mr. Johnson. Thank you, Madam Chair. I would start by
    noting that yesterday, as I was eating my Wheaties, I read an
    excellent article by the South Dakota News Watch that printed
    in my local newspaper, the Mitchell Daily Republic, and it
    dealt with this very issue. And I thought it was an in depth
    and insightful piece, and so I would ask unanimous consent to
    introduce into the record, ``Effort Begins to Reduce Risk of
    Death of South Dakota Mothers During Childbirth'' into the
    record.
        Chairwoman Wilson. Without objection.
        Mr. Johnson. Thank you very much.
        This is probably for your, Doctor, but if any of the
    panelists want to weigh in, I would be interested to get their
    take as well. I was intrigued by some of the best practices
    that this article brought out, things that seemed to me to be
    relatively low hanging fruit. I will give a couple of examples.
    Weighing blood absorbing pads so that we can better ascertain
    how much blood loss a mother has had during childbirth. That
    doesn't seem very difficult to implement.
        Dr. Crear-Perry. Exactly.
        Mr. Johnson. Blood pressure cuffs, so that medical
    professionals can have real time information. So if they
    forget, if the Ms. a measurement time, they are still alerted
    to when that mother--when we have got a blood pressure problem.
        Again, I view this as relatively low hanging fruit. When
    you look at the implementation of these practices across the
    country, on a scale from 1, being we are not doing any of them,
    and 10, we have perfect implementation of these best practices,
    where do you think we are as a country?
        Dr. Crear-Perry. Yeah. Oh, man, 3 1/2 maybe. The good news
    is because--
        Ms. Stewart. Two.
        Dr. Crear-Perry. Two? Yeah. I mean you bring up the blood
    loss one. So as an OB/GYN we weren't measuring blood loss that
    way. You might be surprised to know that we would do things
    like look and say, ah, looks about like 1,000 milliliters. Like
    that is how we estimated blood loss. So it is a big shift in
    practice to actually weigh and measure the pads. So what you
    then have to do is say to the people who feel like, well I have
    always done really great care, that you--actually women are
    dying because we are not doing this correctly as a field. This
    is a systems change, this is not about you as an individual and
    the care you provide, but a systems change. So that system
    shift has been difficult because people still believe in their
    own individual, that they as an individual provider are doing
    great things. So having legislation, having standards by
    governing bodies then makes for room for implementation to
    occur. As long as it is optional--and I will even go back to
    the--it was exciting to have the CDC give money to states
    around maternal mortality, but we don't require it, so that is
    why you still have three states who haven't done it.
        So there are times that we need government to act, to put
    together policies that require things, like you need to count
    the blood loss.
        Mr. Johnson. Yes.
        Ms. Stewart. Can I add to that too? Because I think those
    are practices, like measuring, monitoring whether or not women
    are hemorrhaging and how much they are hemorrhaging, so that we
    actually know how at risk they are. After they have had the
    baby they go home and they are experiencing problems that were
    not dealt with when they were in the hospital.
        But the real issue is that we have to--we are not going to
    deal with the issue at the point of a woman almost at the point
    of death, right. I mean if she is hemorrhaging to the extent,
    she is so close to potentially losing her life. The issue is
    how do we move more upstream, how do we address these issues of
    women's health before they are pregnant? What we find is that
    increasingly more women that are pregnant have chronic health
    conditions, they are obese, hypertension. One of the leading
    causes of death for women as a result of pregnancy and
    childbirth are heart-related challenges. So how do we make sure
    that women are able to manage their health before they are
    pregnant so that they don't have these problems exacerbated as
    a result of pregnancy and childbirth?
        Mr. Johnson. So maybe a follow up, Dr. Crear-Perry. You
    know, we mentioned standards and national bodies. You know,
    this article talks about the joint commission, which I think
    has some oversight or engagement with they said about 80
    percent of hospitals in the country. I mean if I am looking to
    some repository of best practices, if I am looking to a source
    that really has it right, is the joint commission a good place
    for me to pay attention to?
        Dr. Crear-Perry. So I was on the Joint Commission task
    force to create those measures. And so I think there are people
    in that room--the American College of OB/GYN has the AIM
    bundles. It is a great place where you can look to find a
    repository of best practices. And that is really who through
    HRSA has been funded to build the policies out. The CDC has the
    Perinatal Quality Collaboratives, and they really need more
    funding to uplift those collaboratives. In South Carolina they
    are doing--I just spoke at your annual meeting around maternal
    mortality in South Carolina--and really having more investment
    in the Perinatal Quality Collaboratives would be so important.
    Because you get the numbers and the data and someone has to
    implement it. So who is going to say to the people in South
    Carolina, are you measuring your blood loss? It is going to
    come from that Perinatal Quality Collaborative who needs
    support from legislation.
        Mr. Johnson. Well, thank you very much.
        And, Madam Chair, what an important topic and what a
    meaningful conversation we have had.
        Thank you.
        Chairwoman Wilson. Mr. Morelle from New York.
        Mr. Morelle. Thank you. I find it completely unacceptable
    that 1 in 700 American women dying of pregnancy-related causes
    each year and tens of thousands facing severe health
    implications. So I appreciate very much, Madam Chair, you and
    the Ranking Members for convening this hearing today to talk
    about what we need to do to protect mothers and children.
        There has been a lot of conversation about what goes on in
    other states, so I just want to just share a little bit about
    what we are doing in New York if I can get a little equal time
    for the Empire State.
        We have actually made I think significant improvements. We
    were just a decade ago I think about 46th in the Nation, which
    is really obviously just a horrendous number, but we have now
    moved up to 23rd, at least as it relates to maternal health
    outcomes. We have made significant investments in the last
    decade. Today we have 86 hospitals participating in the New
    York State Perinatal Quality Collaborative, which better
    assesses and manages obstetric hemorrhage. Last year we took
    steps to create our own maternal mortality review board,
    building on the success of collaborations in many other states
    that have been mentioned here today. But we still have a long
    way to go.
        And I note that my son and daughter-in-law are expecting a
    grandchild very soon, so I am really paying attention to a lot
    of what you are talking about today, more than perhaps I knew
    about when I was an expectant father. But I do, after the
    testimony, and I do want to get to a couple of different
    questions if I might.
        First, Ms. Stewart, obviously it has been talked about, the
    estimated 60 percent of all maternal deaths could have been
    prevented. I am interested, I understand in the state of
    California and elsewhere hospitals have found success using
    simple innovations, hemorrhage carts, quantitative blood loss,
    elective c-section reductions, all methods that resulted in
    lower rates of death as I understand it among pregnant women in
    hospitals. And I am just trying to understand what are some of
    the changes that can be made among the medical community that
    relates to providing care during pregnancy and delivery first
    and foremost. I know that there is the post, but I am just
    curious, during delivery and immediately after--during
    pregnancy, delivery, and then immediately after. If you could
    talk about some of those impediments or barriers.
        Ms. Stewart. So I think one of the things that we have to
    realize is that women have been having babies for a long time
    before hospitals existed.
        Mr. Morelle. Now that may be the truest statement ever said
    in a congressional hearing.
        Ms. Stewart. This has actually been going on for a while,
    and even before hospitals were even around. And what existed--
    now, there were some not great outcomes before and hopefully
    our medical community has really sought to look at ways it can
    improve those outcomes over time, but one of the things that we
    found are some unintended consequences. One of the things that
    Dr. Crear-Perry mentioned is dramatic increase in c-sections,
    right. So 1 out of 3 deliveries now is by c-section. And we
    know that puts that mom's health at risk, right.
        Mr. Morelle. I am sorry to interrupt, but in recent years
    has that number gone up or down?
        Ms. Stewart. It has been going up.
        Mr. Morelle. Still, continuous?
        Ms. Stewart. It has been going up. We actually at the March
    of Dimes had a big influence on the number of elective c-
    sections, which we actually were able to see a decline in
    elective c-sections. Especially during the period of time
    before this last 4 year period of an increase in preterm birth
    rates we were actually seeing a decline. And we think a big
    contributor to that may have been a reduction in elective c-
    sections.
        Mr. Morelle. I see.
        Ms. Stewart. But we are seeing overall c-sections increase
    and it is not often, you know, fully elected by the mom, right.
        One of the things I think that we can really look at is the
    fact that we can go back to some practices that actually did
    work for us in the past before we had a very medicalized
    process of delivering babies, right. So in New York, you all
    are doing a whole experiment on doulas as a part of the
    Medicaid program. We think and we encourage health care
    professionals, medical professionals, doctors, to have better
    relationships with midwives and with doulas. Studies have shown
    that doula care can often reduce the level of c-sections, can
    increase and improve health outcomes for moms and babies. We
    think that if these kinds of services were more available,
    maybe in addition to their traditional medical care, we could
    probably see some outcomes improve over time.
        Those are just some of the things that--
        Mr. Morelle. Right. Thank you.
        And I only have a few seconds left, but I did want to hear
    Dr. Crear-Perry, the issues of unconscious bias related to both
    gender and race affecting pregnancy-related care, could you
    just talk a little bit more about that?
        Dr. Crear-Perry. Yeah. I mean I have the pleasure of
    working with your staff there in New York around this work. And
    they are doing some trainings with their staff because what we
    are recognizing is unconscious bias makes us do things like if
    we believe it is a Black woman and their blood pressure is 160/
    90, the hospital will say, oh, but they all kind of run high,
    so they won't treat it. And then the next thing you know, that
    woman is seizing and in the ICU. So the bias around believing
    that we all kind of have hypertension when we don't is killing
    people.
        So those are kind of the important things for us to be able
    to unpack.
        Mr. Morelle. Great. Thank you.
        Thank you, Madam Chair. I do ask unanimous consent to
    submit into the record a letter from Johnson & Johnson
    applauding this subcommittee's leadership in addressing the
    urgent health crisis that affects families around the country
    and expressing their commitment to the goal of eliminating
    preventable maternal deaths globally.
        Chairwoman Wilson. Without objection.
        Ms. Wild from Pennsylvania.
        Ms. Wild. Thank you, Madam Chairwoman.
        First, I just want to thank this panel for not only the
    content of your written testimony, but the passion that you
    bring to this subject, very easy to listen and absorb what you
    have said. And it is just such an important subject. I feel as
    though in a country where we say that we value family values so
    much, that we often miss the boat when it comes to policies and
    accommodations and efforts that need to be made to truly
    promote family values, and of course maternal health is key to
    that.
        And I appreciate the systemic approach that all of you seem
    to have adopted to the problem of America's maternal and infant
    health crisis, because it seems to me, both in my own thinking
    but also you have fleshed it out for me in your testimony, that
    it really has to be a holistic approach, it has to start very
    early in life, it has to start with education, it has to start
    with making sure that young women and men are able to get a
    good education so that they can go on to get good jobs where
    they have more flexibility and hopefully better health care
    benefits and that kind of thing. We have to make sure that our
    workplaces are safer and that workplace accommodations for
    pregnant women and new moms are made. We need improved health
    care from all perspectives, not just pre and postnatal care,
    but overall preventive health, whether it be blood pressure
    checks, routine mammograms, immunizations, gynecologic care,
    and that kind of thing.
        So with all of that said--none of that was a question--but
    I want to ask--and I could ask any of you these questions
    because you are all very well qualified--but let me just start
    with Dr. Perry.
        I won't ask it ask it as a leading question. Do you believe
    that better access to contraception is an important component
    of women's health?
        Dr. Crear-Perry. For sure. We know for sure that if you
    don't have access to be able to make choices around your body
    that you can enter care later, you can enter care sicker, that
    you are not making fully informed choices for yourself. And so
    I love that you used family value. So the value of valuing what
    the woman wants and valuing what her needs are and meeting her
    wherever that is. And you can have your own beliefs in your own
    house, but our job really is to support what people believe for
    themselves and what they want for themselves.
        Ms. Wild. And before we even get to the issue of
    contraception, I assume you feel the same way about sex
    education--
        Dr. Crear-Perry. Yes.
        Ms. Wild.--both in the schools and outside the schools--
        Dr. Crear-Perry. Exactly, exactly.
        Ms. Wild.--throughout our communities?
        Dr. Crear-Perry. Yeah. And it is important as a person
    who--you know, as a mother and as an OB/GYN, so many patients
    don't know basic information about their bodies and we are
    expecting them to navigate a world where we haven't given them
    the tools to be able to do that.
        Ms. Wild. Right. And same thing with the protection against
    intimate partner violence.
        Dr. Crear-Perry. Yes, for sure.
        Ms. Wild. And, Ms. Stewart, I will address my comments to
    you, just because I see you nodding. That is a similarly
    important component of this, am I right?
        Ms. Stewart. It is important. And I just want to mention
    one thing on contraception too. Science tells us that one of
    the most effective ways to reduce preterm birth if a woman has
    had a preterm birth already is to ensure that there is
    appropriate birth spacing. And that means that a woman has to
    be given the ability to make the choice as to when she has a
    baby. And certainly ensuring that there is an 18 month gap at
    least between the time when she has had a baby and the time
    that she becomes pregnant again has been proven to actually
    reduce the risk of a subsequent preterm birth.
        But we also know that protections around intimate partner
    violence are really important. I mean we have seen an
    increase--I live in Maryland and we saw a dramatic increase in
    the kind of violent activity targeted towards pregnant women
    and our state took action there. And I think it is important
    that at a Federal level we address the fact that too many
    pregnant women are subject to the kind of violent treatment by
    their partners or significant others that really put them at
    risk and then also put their babies at risk too.
        Ms. Wild. So Dr. Perry--I am switching back--am I correct
    that not all health plans, even under the ACA, cover the
    services that we have just talked about?
        Dr. Crear-Perry. For sure. And, you know, it is just really
    frightening to think that we have made so many steps forward,
    but we keep getting steps back. So really making a commitment
    for people to have access to all the services would be
    important.
        Ms. Wild. So my colleague, Mr. Fulcher, across the aisle
    commented on Planned Parenthood.
        Dr. Crear-Perry. Yes.
        Ms. Wild. And my question to you is what is the role of
    community health centers and places like Planned Parenthood to
    fill these gaps in services?
        Dr. Crear-Perry. Right. So because we do not have a
    universal health care system we need players like Planned
    Parenthood and others, we need organizations like Federally
    Qualified Health Centers. Here in DC there is an FQHC that has
    a birthing center inside of a Federally Qualified Health Center
    with a Black midwife, Ebony Marcelle, who is running this
    center, to have a full range of reproductive options. Also in
    Memphis there is an option.
        So we need the Planned Parenthoods, we need the clinics, we
    need quality care provided for people in their neighborhoods
    who--and all their needs met across the reproductive spectrum.
        Ms. Wild. Thank you very much.
        My time is up. I yield back.
        Chairwoman Wilson. Thank you.
        Ms. McBath from Georgia.
        Ms. McBath. Thank you, Chairwoman Adams and Chairwoman
    Wilson. I appreciate you both for being so instrumental in
    highlighting the need for transformative maternal health in
    this country. And I also want to thank the panel for coming to
    address Congress on this very, very pressing issue.
        And we all know the statistics, so we don't have to go over
    them again. We have all seen the failure to make progress on
    this problem. That is the reason why you are here today. This
    problem runs far deeper than many want to even acknowledge and
    we have a responsibility to these families to make sure that
    their safety and the health is the number one priority.
        Research is clear, access to care and other socioeconomic
    factors play a significant role in maternal mortality rates in
    Georgia and throughout this country. And actually Georgia has
    the second highest maternal mortality rate in the country.
        Dr. Crear-Perry, what should we be doing to ensure that
    women have access to not only the health care, but also the
    other supports that they need to be healthy during pregnancy,
    childbirth, and postpartum?
        Dr. Crear-Perry. Well, it is exciting to see--thank you--
    that there is a move to extend Medicaid for a year. I think
    Georgia is one of the states that could really benefit from
    that. Having not done Medicaid expansion, really letting the
    science show us that you need to have insurance for at least a
    year after you have a baby, so that would be an important move.
        I think also in Georgia and other states, looking at our
    policies around access to work leave, it is not even just when
    you have the baby. If you are a high-risk pregnant person, you
    need to go to the doctor more often. If you are choosing
    between your hourly job and being able to make twice a week
    appointments at a doctor's office where you sit for four and
    five hours at the waiting room, right. You don't have time for
    that, you have to go to work. And so when do we make room for
    paid leave and structures that allow for people to be healthy,
    not just when the baby comes home, but caring about mom while
    she is pregnant?
        Ms. McBath. Thank you for that, because I was a high-risk
    pregnancy myself and actually had to take short-term
    disability--
        Dr. Crear-Perry. Exactly.
        Ms. McBath.--because when I was working as a flight
    attendant there were no particular considerations that were
    made for us as pregnant women.
        Dr. Crear-Perry. Exactly, exactly.
        Ms. McBath. So I had to go on short-term disability just to
    be able to make sure that I brought my son into the world.
        Dr. Crear-Perry. Exactly.
        Ms. McBath. A few months ago I worked with Representative
    Gwen Moore, Tom Cole, and John Katko to introduce the Family
    Violence Prevention and Services Improvement Act. As you know,
    FVPSA provides necessary funding to help survivors of domestic
    violence, and it should not go unaddressed today that there
    truly is a correlation between intimate partner violence and
    maternal health.
        Dr. Crear-Perry. Yup.
        Ms. McBath. Dr. Crear-Perry, can you share more about why
    pregnancy puts women at a higher risk of experiencing intimate
    partner violence?
        Dr. Crear-Perry. Yeah. So we know that the stressors that
    are impacting mom are also impacting dad. So we want to move to
    a space of restorative justice, right. How do we think about
    intimate partner violence in a lens of if we don't provide
    supports for families for people of color across the United
    States, when a mom gets pregnant, you are going to see dad act
    out, you are going to see the partner act out and become more
    violent because they don't have the resources they need and
    they feel very--that they can't meet the needs of what they are
    supposed to have done. If we really want to improve intimate
    partner violence, if we really understand why it happens, that
    people are not just mad and sad and acting out, but they are a
    part of a larger system, then important for us to invest in
    both moms and making sure they are safe, and really thinking
    through how are we educating our sons. I have two. What are we
    doing around people and their access to how they think about
    pregnancy and birthing in their communities.
        Ms. McBath. So let me go on and ask you what are some of
    the health consequences of intimate partner violence for
    pregnant women and their infants?
        Dr. Crear-Perry. Yes. We know in some states it is one of
    the top leading causes of maternal mortality, right. In our own
    state of Louisiana, my home state. So we could look and see a
    policy choice. If you say if I call the police, if I live in
    HUD housing or in Section 8 housing, because of intimate
    partner violence I can get kicked out, when I am pregnant that
    rule makes me at higher risk of actually dying, right. Because
    I am afraid to lose my place I am not going to call anybody to
    come. And so that is a policy change that improves it. So we
    lobbied or we advocated for getting rid of that rule, that
    people cannot be kicked out of Section 8 housing because they
    are calling the police for domestic violence. That improved the
    outcomes for Black women who were pregnant in the State of
    Louisiana.
        So those are the kind of policy choices that are not around
    individual choices, but you are putting people at risk of harm
    when you create solutions that don't think through what will
    happen to someone who is impacted.
        So morbidity and mortality, having risk of death is the
    highest risk that you can have, and it is really high during
    pregnancy.
        Ms. McBath. Thank you so much.
        I yield back the balance of my time.
        Chairwoman Wilson. Thank you.
        Ms. Underwood of Illinois.
        Ms. Underwood. Thank you, Madam Chair.
        On January 28, 2017, 3 years ago from today, I lost a
    friend. Dr. Shalon Irving was a classmate of mine at the MPH
    program at Johns Hopkins University. She went on to become a
    CDC epidemiologist, a lieutenant commander at the U.S. Public
    Health Service Commissioned Corps. She was highly educated,
    financially secure, surrounded by a strong network of family
    and friends. She was covered by quality health insurance. She
    is a Black woman and she lost her life 3 weeks after giving
    birth to her baby girl, Soleil, her first child.
        Three years after that tragedy we are here to address a
    crisis that cuts across education levels, income brackets,
    geographic regions, and type of insurance. Moms and babies are
    losing their lives at unacceptably high rates in the United
    States. And families like Shalon's are left picking up the
    pieces.
        The name of today's hearing is Expecting More. And when it
    comes to America's maternal and infant health crisis, we need
    to expect more. We need to pay more attention, take more
    action, and make more progress.
        Ms. Stewart, through your work leading the March of Dimes
    you have heard too many stories like Shalon's in America. Why
    are protective factors, like education and wealth, failing to
    insulate American moms from elevated risk of maternal mortality
    and severe morbidity?
        Ms. Stewart. So, first of all, I am very grateful that you
    tell that story and that you celebrate the life of your friend
    who unexpectedly and wrongfully has passed away and
    unfortunately is no longer with us. And I think the point you
    are raising around the maternal mortality rate for Black women
    as it relates to no other issue other than the racism that they
    probably experience as a result of their health care
    experience, is really one of the most critical issues that we
    have to talk about in this country.
        The fact that we can look at an educated Black woman and
    she dies at a rate that is five times more than her White
    counterpart, is just simply unacceptable. And if it is not due
    to their income level, it is not due to education level, it is
    not due to medical coverage or health care coverage or
    insurance, or all these things, then what else is it? It has
    simply to do with how they are being received and treated by
    the system where they are expecting to receive quality care and
    the system is failing them.
        And so I think part of what we are doing at the March of
    Dimes is acknowledging and working with many partners to say
    what can we do as one participant in the system to change these
    kinds of outcomes and to help the system realize that there is
    implicit bias in the system that medical providers, though they
    don't intend to, are making judgments about Black women and are
    then therefore causing Black women to receive inadequate care,
    often putting their lives at risk.
        And so part of what we are doing, just one of the things
    that we are doing is, in addition to have entire health equity
    approach to our work, is looking at certain programs like
    introducing an implicit bias program. Dr. Crear-Perry talked
    about the work she is doing in that space. We have worked with
    an organization to create a whole new implicit bias program for
    many of our hospital and other health care provider partners to
    make sure that they are aware of the implicit bias that they
    may be experiencing on a daily basis, that it is actually
    influencing the lives of the patients that are attempting to
    serve.
        Ms. Underwood. Yeah, putting their lives at risk.
        Ms. Stewart. Absolutely.
        Ms. Underwood. Earlier this month the Commonwealth Fund
    published a report showing that the Affordable Care Act
    narrowed racial and ethnic disparities in insurance coverage.
    And we know that in the context of today's hearing, coverage
    leads to better outcomes for moms and babies, and yet as we
    speak the Affordable Care Act is being threatened by a
    Republican repeal lawsuit.
        Ms. Stewart, what is at stake with this reckless attack on
    health care and how could it exacerbate existing racial and
    ethnic disparities and maternal and infant health outcomes?
        Ms. Stewart. So we know that the ACA has been an incredible
    support to expanding coverage for so many women. And it is
    especially true for women of color, where their rate of women
    that have qualified under ACA has grown at more than twice the
    rate of women overall between the period of 2013 and 2015. And
    what this has been doing is allowing women to access the care
    they need.
        Again, to talk about this issue is really to underscore the
    importance of women getting the kind of preventive care they
    need before pregnancy and during pregnancy. The fact that they
    now--many of these women, women of color, have more access to
    the kinds of coverage that is available to the ACA, especially
    because of essential health benefits being involved.
        Ms. Underwood. Yes.
        Ms. Stewart. So no cost sharing applied to all kinds of
    well women visits, all kinds of prenatal care visits that are
    really essential and incredibly important. You know, we still
    look at prenatal care visits and still know that too many women
    are not able to access the kind of prenatal care that they
    need. If ACA is removed, if they don't have access to being
    able to get the kind of health coverage that the ACA provides
    for women, especially women of color, we are likely to see a
    worsening of outcomes for those women and a worsening of
    outcomes for their babies. It simply would be devastating to so
    many of the families that we are trying to serve.
        Ms. Underwood. Thank you.
        Madam Chair, my time is expired. I could sit here all day
    and talk about this issue. It is so important. Thank you for
    your leadership and for convening us here today. Thank you to
    the witnesses, and thank you for being a member of the Black
    Maternal Health Caucus.
        Chairwoman Wilson. Thank you.
        Dr. Shalala.
        Ms. Shalala. Thank you very much, Madam Chair. Let me
    congratulate Representative Adams and Underwood for their
    leadership of the Black Maternal Health Caucus. Those of us
    that joined it, we have a simple goal, save Black women's lives
    and tackle racial disparities in health care.
        My colleague from Florida has already indicated the
    statistics in our own Miami-Dade County, which the racial
    disparities are simply criminal and not acceptable. But the
    root cause of the statistics for maternal death are often
    misunderstood. The public image of maternal death is a woman
    who has a medical emergency, like a hemorrhage, while in labor,
    rather than four out of five of these deaths happen in the
    weeks and months before or after birth. And ensuring women have
    access to comprehensive and affordable care during and after
    pregnancy is absolutely critical.
        I do want to put on the record that over 96 percent of
    Planned Parenthood services are really in women's health. It is
    to help women be and stay health before, after, and between
    pregnancies. And Planned Parenthood does not, unlike the myths,
    make money on abortions. Planned Parenthood is supported by
    charity and by contributions from millions of Americans.
        I want to ask a very specific question, because what I am
    interested in is in Federal programs. We have talked a bit
    about Federal programs and about filling in the gaps. We know
    that chronic medical conditions, including obesity,
    cardiovascular disease, hypertension are chief contributors to
    maternal mortality, yet we have also heard that Federal
    programs are not designed to support women's overall health
    before and in between pregnancies. Medicaid's pregnancy
    coverage only extends to 60 days of postpartum, WIC's
    postpartum coverage only covers 1 year for breastfeeding women,
    and the ACA has real limitations, including those that were
    pointed out on women under 26. If we are going to write a
    comprehensive bill here, it is really going to be a bill that
    fills the gaps while we are waiting for universal seamless
    health coverage that would make a difference for all Americans.
        So I would like to ask each of you what your top two or
    three recommendations would be, specifically on program
    supports and program improvements, because what we might do is
    simply go through all the programs and do a comprehensive bill
    that fills in the gaps on the programs. That would be I think a
    lifesaving step for all of us.
        Let us start with Ms. Stewart.
        Ms. Stewart. So I guess a couple of things I will mention.
    I think one of the most important things that can be done is
    the extension and expansion of Medicaid up to 1 year. I think
    the fact that we have too many women that are being dropped
    from coverage within 60 days to several months after childbirth
    is a real challenge. And it is inhibiting their ability to seek
    the kind of continued medical care that they need.
        A couple of other things that I will mention though. I
    think it is really important to look at what Medicaid covers
    beyond just the medical care for the health care provider. We
    know that access to Medicaid reimbursement for doulas, for
    midwifes, and I would even say--we are involved in a program
    that is involving group prenatal care. That is an evidence-
    based program and it is shown to reduce the rate of preterm
    birth by up to 30 percent. But in many states we are not able
    to receive Medicaid reimbursement. But we know that is the kind
    of care that women often need beyond just their traditional
    health care. So there are things like that.
        And the last thing I will just mention is we do have some
    gaps and some barriers, for example, around newborns being
    added to health plans. We find that they are too many families
    who have a 30-day window to add their newborn to a health plan
    and often miss that window. And then as a result, especially if
    their baby is in the NICU, they may be subject to exorbitant
    health care costs because they missed that window. And so
    closing that gap would be also very important.
        Dr. Crear-Perry. So I will go by agency. So HRSA, you could
    improve how we do National Healthy Start. It is a great
    program, it is community led, community driven. CDC, we can
    bolster up the PQC, the Perinatal Quality Collaboratives. They
    are the driving force of how we are going to get policy done.
    We have not invested in those. And then in the NIH, you can
    uplift the Office of Women's Health. It is just an office, so
    it has no budget. So we think women are more than half of the
    population and yet we don't have any dedicated institute or
    center for women's health. So it would be exciting to see you
    all look at these big larger institutions and how you could
    change them.
        I mean really investing in community birth workers on the
    ground, lay folks who have been doing the work for the
    community for a long time. I mean the education policy, we
    wanted an education plan. Black maternal health week is coming
    up, so there will be a lot of investment--April 11-17--looking
    all the folks on the ground who are doing work.
        Ms. Shalala. Thank you.
        Chairwoman Wilson. Thank you very much.
        Mr. Levin from Michigan.
        Mr. Levin. Thank you very much, Madam Chairwoman.
        It is an honor to be here with the Chairwomen of these
    subcommittees, with Congresswoman Underwood. I thank her for
    her leadership. And with all three of you to talk about this
    incredibly important issue.
        It is simply outrageous and unacceptable that so many women
    and babies of color die at disproportionate rates in this
    country. And we need to be able to talk about racism in this
    country. I want all of my White siblings in spirit who may be
    freaked out if I can just speak plainly about being called a
    racist, or worried that they might be whenever we talk about
    racism. Look at this situation. This is structural racism. In
    our society, when people like Congresswoman Underwood's friend
    die, who have every advantage in life, there is no explanation
    but structural racism. So let us all take a deep breath, relax
    our shoulders, and get on with the conversation. Because we
    just commemorated Holocaust Remembrance Day and we say never
    again, and what does it mean. It means we must not be silent in
    the face of injustice. This is clear injustice in our society
    and we all have a role to play and none of us can be silent.
        Now, Dr. Crear-Perry, I am worried I am going to get in
    trouble with you. I was not planning on raising this, but I
    think your very first answer to a question was about midwives.
    So I have four kids and we had home births with midwives, but
    it was not legal in Maryland. So we had illegal home births
    with the lay midwife. So here I am confessing. Koby was born 26
    years ago.
        Mr. Scott. Statute of limitations.
        Mr. Levin. Yeah, I hope so, Mr. Chairman. And at the same
    time I am I think the only member of this body who has run a
    state workforce system. So I feel personally responsible for--
    so talk to me about the training at, you know, HBCUs, at other
    institutions. What do we need to do to train more midwives?
    Because it is certainly a crucial part of the answer here.
        Dr. Crear-Perry. Thank you. In the same way that you want
    our colleagues to not have their shoulders raised when we talk
    about racism, which is what I have to do a lot with folks, I
    have to have my colleagues in OB/GYN not have their shoulders
    raised when we talk about midwifery.
        Mr. Levin. That is why I thought I might get in trouble.
        Dr. Crear-Perry. No, no, actually my shoulders are relaxed,
    I am good. Because I don't feel threatened. We need this. Every
    country that has better outcomes than us has a much more robust
    midwifery workforce. They have invested in training women
    across the country who actually are doing the births. We
    provide care in an ICU that could be done, like you did, at
    home. And that is just a fact. And we are afraid of change, but
    that fear is harming Black women. And actually Black women are
    over performing their counterparts when it comes to home birth
    and not having a hospital birth because of our fear. Imagine
    going into Auschwitz without Auschwitz ever having apologized
    and saying you are now supposed to take care of me and provide
    my health care. That is what happens to Black women when we go
    to the hospital, the same hospitals that for generations harmed
    us now are saying come, we are fine now, with never having
    acknowledge J. Marion Sims, never having acknowledged the
    history of oppression, and we are just supposed to trust you
    because you are nice.
        Mr. Levin. All right. So I am going to count on you to
    follow up with me as a member of this committee, so what
    specifically can I do on that.
        Dr. Crear-Perry. Yes. Right. Thank you.
        Mr. Levin. Ms. Sankofa, protections entitling nursing
    workers to have break time and a private space, right, it is
    tied to nursing a child and lasts only for a year following the
    birth of a child. So in my last minute I want to ask you,
    should we rethink these policies? For example, a woman may be
    lactating after her baby has been adopted. You know, for her
    health, shouldn't she have coverage? After a stillbirth. The
    time limit. I mean my wife breastfed way past 1 year. So are
    these limits too narrow and inappropriate?
        Ms. Sankofa. I think that these limits are put in place to
    really create an opportunity to have deep buy in from all
    members so that we can move the legislation forward. But when
    we look at preterm birth weights, when we look at infant
    mortality rates, I think that a person who is pumping to
    provide milk for a baby who is not their own but who may be
    preterm, I think that is something very, very important to
    consider as a more systemic policy solution because not every
    woman chooses to breastfeed, maybe there are systemic barriers
    for her that make it unavailable. But if milk can still be
    available, that is a thing that we should definitely consider.
        Mr. Levin. Outstanding. Thank you.
        I yield back, Madam Chairwoman.
        Chairwoman Wilson. Thank you so much, Mr. Levin.
        Ms. Stevens.
        Ms. Stevens. Thank you, Madam Chair, and thank you to our
    expert witnesses for your brilliant and elucidating testimony
    and for your comments here today.
        We have an emergency going on in America right now. The
    U.S. has the worst maternal mortality rate among developed
    countries despite an improvement in global maternal mortality.
    This is what we are talking about here today, this is what this
    conversation is about. From the halls of the United States
    House of Representatives, I can't think of a more important
    topic because for every woman that has lost their life, for
    every family bearing that burden, for every woman who has come
    too close to losing her life, crying out in pain, this is
    senseless and these are injustices. And we talk about life
    being precious. I cannot think of a better instance of the
    sanctity and preciousness of life than this, than the life of
    the mother. We are here for the voiceless.
        Thank you, Ms. Underwood, for your leadership in forming
    the Black Maternal Mortality Caucus, because it is high time
    for these issues to come to bear, it is high time for this to
    be on the national news and in every family's household,
    thinking and talking about this and what we are going to do.
    Thank you, ladies for your leadership.
        Ms. Stewart, you represent a phenomenal organization. It is
    in every community's hearts and in our states and it is on our
    mind. And we know about 1 in 33 children born in the United
    States is born with an anomaly, a congenital anomaly. And, you
    know, they are required to go through various surgeries on
    occasion. We are thinking about the cleft palates.
        Could you just describe some of these challenges that
    families face in affording this important care? And also
    legislation that I am a proud co-sponsor of, the Ensuring
    Lasting Smiles Act, and how that would maybe make a difference,
    Ms. Stewart.
        Ms. Stewart. Sure. Thank you for that.
        Ms. Stevens. Thank you.
        Ms. Stewart. And we agree with all of your comments.
        Ms. Stevens. Thank you for your leadership.
        Ms. Stewart. You know, this is really an important issue
    that often doesn't get discussed. And we talk a lot about
    maternal deaths and infant deaths. We don't often talk about
    when a pregnancy doesn't go as expected, the long-lasting
    health impacts that a child has to deal with and what families
    often have to deal with.
        And one of the things that is really a big challenge for
    too many families in this country are the number of children
    that are born with these kind of congenital anomalies or birth
    defects. And about 4 percent of all the children in the U.S.
    are born with these birth defects. Again, the March of Dimes
    has spent a lot of our history trying to deal with eliminating
    birth defects through encouraging women, for example, to take
    folic acid to deal with preventing certain birth defects.
        But the Ensuring Lasting Smiles Act is really a piece of
    legislation that we support strongly, with about 30 other
    organizations. Right now what it is intended to do is ensure
    that all private group and individual health plans cover
    medical necessary services. And what we know is that there are
    many plans that do actually provide for coverage for medically
    necessary surgeries and other kinds of treatments that should
    be made available to children that are born with these kind of
    birth defects. But we are hearing that there are too many
    instances in which some coverage is denied, often because
    insurance companies will claim that a certain kind of surgery,
    especially dental surgeries is where this happens a lot, are
    more cosmetic in nature when we know in fact a baby that is
    born with a cleft palate, for example, will have extreme
    difficulties with breathing or eating and really living a
    normal life.
        And so what we are trying to do with this legislation, and
    ask you all to do, is consider the fact that there should not
    be any family that is denied coverage or having to assume too
    much in terms of cost and to make sure these kind of services
    are available.
        Thank you.
        Ms. Stevens. Well, thank you for that. Your leadership has
    been phenomenal.
        Madam Chair, I have a letter to submit for the record from
    the National Foundation for Ectodermal Dysplasias.
        And with my remaining time I would like to just get one
    more question and cede my time to Congresswoman Underwood.
        Ms. Underwood. Thank you, Congresswoman Stevens.
        Ms. Sankofa submitted an excellent written testimony that
    spoke about the PUMP for Nursing Mothers Act, a bill that fixes
    a legal glitch that currently prevents millions of middle class
    moms from reentering the workforce after giving birth.
        Madam Chair, I would like to ask unanimous consent to
    submit for the record a letter from more than 100 organizations
    endorsing the PUMP for Nursing Mother's Act.
        Chairwoman Wilson. Without objection.
        Ms. Underwood. Thank you, Madam Chair. And thank you, Ms.
    Stevens.
        And I yield back.
        Ms. Stevens. I yield back the remainder of my time.
        Chairwoman Wilson. Mr. Scott, Chairman Scott.
        Mr. Scott. Thank you. Ms. Stewart, it is good to see you
    again.
        Ms. Stewart. Good to see you.
        Mr. Scott. Many of the witnesses talked about the
    substantial number of deaths that are preventable. Can you
    describe the ultimate cost to the health care system of the
    initiatives that would prevent many of these deaths?
        Ms. Stewart. So according to the CDC, about three out of
    every five of these deaths are preventable. A lot of the deaths
    that see as preventable are often due to misdiagnoses or
    delayed diagnoses and a lack of adequate care that is being
    provided to those women.
        One of the things--I don't have the exact numbers--I can
    get you the exact numbers, but one of the things that could be
    very helpful is when women show up at a hospital, for example,
    to deliver their baby, there should be the proper protocols in
    place. And some of those protocols come from something that Dr.
    Crear-Perry mentioned, which are the AIM bundles that ACOG and
    others have been promoting, and that is to ensure that
    hospitals have these improved bundles of care, protocols of
    care, that would prevent these kinds of deaths from happening.
        So, for example, when a woman is hemorrhaging, how do you
    deal with hemorrhage and how do you deal with it in labor and
    delivery when that typically hasn't been a place where you have
    seen a lot of hemorrhage. How can you change practices so those
    kinds of deaths are prevented?
        There are probably some dollar amounts attached to it and
    we can follow up and get you that, but I do think that those
    are some of the things that are important.
        Mr. Scott. Well, things like doulas, have you studied those
    to see whether they save more money than they cost?
        Ms. Stewart. Absolutely. There have been studies that show
    that doulas and midwives, but especially doulas, can reduce and
    prevent unnecessary maternal deaths, can actually improve birth
    outcomes, can actually make sure that mothers are safer and
    have healthier pregnancies.
        Mr. Scott. And a lot of the provision of prenatal care will
    reduce the incidence of low birth weight and ultimately save
    more money than it costs?
        Ms. Stewart. Prenatal care and then I think what we ought
    to look at is in places that we have looked at the March of
    Dimes, these maternal care deserts where there isn't
    traditional prenatal care, how can things like telemedicine and
    other kinds of services be made available. And those are some
    of the gaps that we see that should be addressed.
        Mr. Scott. Now, do you have data that show that the
    prevention initiatives actually work?
        Ms. Stewart. We do. I mentioned one earlier. In addition to
    some of the studies I've referenced around doulas, some of the
    areas around group prenatal care are evidence-based, have been
    shown to reduce preterm birth by 33 percent. So we know that
    has a measurable impact in improving lives and saving lives and
    producing better health outcomes as well.
        Mr. Scott. And what kind of initiatives before pregnancy--
    you mentioned folic acid--before pregnancy and after birth,
    what kind of initiatives can be helpful?
        Ms. Stewart. So I think a couple of things. One is that
    really adequate good prenatal care is really important. But
    what I would say is even before pregnancy a woman has to be
    able to be as healthy as possible. One of the things that we
    are seeing that really is affecting some of these outcomes is
    that women go into pregnancy with many more chronic health
    challenges than existed in the past. So having a woman being
    able to have the health coverage that she needs to address
    obesity challenges, hypertension challenges that she may be
    having so that she improves her health before she is pregnant
    we know can have measurable impact. As well as support that she
    may need in the postpartum period, especially around not only
    her physical health, but also her mental health as well. And
    that mental health coverage needs to be available throughout
    her period of time before, during, and after pregnancy.
        Mr. Scott. Thank you.
        Dr. Crear-Perry, my colleague, Representative McBath,
    mentioned the Family Violence Prevention Services Act is also
    in this committee. Can you talk about the Federal services that
    could be provided that would have the effect of reducing
    violence and how that would reduce maternal deaths?
        Dr. Crear-Perry. So we have a real gap when it comes to
    intimate partner violence as far as policies. Places for people
    to go if they are in danger, so providing support for cities
    like my own of New Orleans, to have housing and have an
    availability for victims of domestic violence would be really
    important. Having policies that allow for safety for moms
    inside of workplaces. Those are all really important. So there
    is a direct tie between the elevated risk that someone has in
    the world when they are pregnant, when it comes to intimate
    partner violence and the ability to mitigate that risk through
    Federal legislation.
        Mr. Scott. Thank you, Madam Chair. I yield back.
        Chairwoman Wilson. Thank you, Mr. Scott.
        Ms. Bonamici.
        Ms. Bonamici. Thank you, Madam Chair. I really appreciate
    this conversation. Thank you to our witnesses for your
    expertise. I think it has been a difficult but very important
    conversation to hear that we are regressing as a country when
    it comes to maternal and infant health. The wellbeing of
    mothers and babies are sort of fundamental measures of any
    nation's development. And to many Americans I think the
    statistics that we have heard today might sound like they are
    coming from a different country or a different time. But it is
    a reality that we have to face, so we must--we must--face it,
    we must address the failings and improve outcomes for all
    families.
        And we touched on several policies, particularly I want to
    point out the inexcusably stark disparities for racial
    minorities.
        I would like to emphasize the point made by several of the
    witnesses, that we can improve the likelihood of health births
    even before pregnancy. Access to comprehensive reproductive
    health, including contraception and prenatal care empowers
    women to make decisions about when and in what circumstances
    they choose to become pregnant.
        I am currently working to update legislation. I introduced
    last session the EQUIP Act that will encourage health care
    providers to routinely ask women of childbearing age about
    their intentions regarding pregnancy and to provide appropriate
    care in response to those conversations. March of Dimes was one
    of the organizations that endorsed the legislation because
    these pregnancy intention screenings improve the likelihood of
    healthy births. It is kind of a win-win because it is good for
    maternal health and it also reduces unintended pregnancies.
        And some of you might have noted that Oregon was the only
    state that has got an A- in the March of Dimes report. In all
    fairness, we don't have a lot of racial diversity, but we also
    have many clinics that are using the sort of One Key Question,
    pregnancy intention screening, and we also sort of aggressively
    expanded Medicaid, we have coordinated care organizations. So
    we are doing a good job in many ways, but there is still a lot
    of work to do. We have to make sure that we are addressing
    those implicit biases.
        Dr. Crear-Perry, you spoke about positive health outcomes
    being dependent on implementation of all sexual and
    reproductive rights. Can you talk about how those rights might
    not be respected in health care setting pre-pregnancy and how
    policies can take that into account?
        Dr. Crear-Perry. So I usually, when I am doing data, I
    point out that although the United States is the worst in the
    world when it comes to maternal mortality and Black women are
    dying at three to four times the rate, that also means a lot of
    White women are dying that should not. And places like Oregon
    give us an example of what we could do better as a country if
    we invested in everyone and invested in things like insurance
    and other things. So it is important for us to think about when
    you restrict access to contraception--so we have data--my
    colleague Maeve Wallace and others, the places that have more
    restrictions on access to contraception have the worst outcomes
    for maternal and child health.
        Ms. Bonamici. Right.
        Dr. Crear-Perry. So when they say language around we are
    making things safer for moms, you are actually making things
    worse. So the data is the opposite of this narrative around
    safety. So restrictions for sex education causes harm, causes
    death.
        Ms. Bonamici. Absolutely.
        Dr. Crear-Perry. Restrictions for access to birth control,
    for LARCs, for abortions. All those things cause harm and cause
    death. The more you put policies in place that are barriers,
    they more that women and children are more likely to die.
        Ms. Bonamici. Right. Our legislature on a bipartisan basis
    passed legislation to fill contraception prescriptions for
    whole year rather than short-term, which my daughter really
    appreciates.
        Dr. Crear-Perry. Right. Yes.
        Ms. Bonamici. So I recently visited a WIC clinic in
    Washington County, Oregon and saw firsthand how important these
    services are for women and families who want to give their
    children a healthy start in life.
        I just want to mention, in light of the public charge
    opinion from the Supreme Court yesterday, I think we are going
    to see more and more families afraid to reach out for services.
    But WIC serves almost 15,000 people county-wide, 79 percent of
    clients are working families and 22 percent are pregnant. We
    know that this nutrition education, and connection is
    beneficial in terms of improving birth weights and reduction in
    premature births and fewer infant deaths.
        Ms. Stewart, studies continue to confirm WIC's role in
    reducing the likelihood of preterm birth. Only a slight
    majority of pregnant WIC recipients, just a little more than 53
    percent, are certified for the program in their first
    trimester. Do you know why this is? And what can we do to
    better encourage certification of pregnant women?
        Ms. Stewart. I think a lot of people are very shocked when
    they find out how important WIC is in terms of serving pregnant
    and postpartum women, infants, and children younger than the
    age of five. Almost half of the 4 million babies that are born
    in the U.S. have been able to access WIC. And so it is an
    important program.
        We do think that having more access and having more
    community workers and community access to make sure that women
    understand how to overcome the barriers--
        Ms. Bonamici. Right.
        Ms. Stewart.--to become eligible for WIC is really
    important. WIC has proven to be one of the most effective
    evidence--based programs to ensure that, to your point, we can
    improve health outcomes, reduce infant mortality, reduce risk
    of preterm birth. We are strong in favor of expanding and
    improving access and looking at ways in which to improve those
    community access points as well.
        Ms. Bonamici. Thank you. And I see my time has expired.
        I just want to say how important paid family leave is. That
    we are the only industrialized country to not have paid family
    leave and what a difference it makes. My state at the state
    level passed paid family leave, but we absolutely must, as a
    country--it is shocking that so many women go back to work
    within just a couple of weeks. I was fortunate. With my first
    child I was able to take 6 months off. Most women can't do
    that. And I still, you know, had to explain to people why I
    needed to take a break to go pump in the restroom. And so, you
    know, having paid leave really makes a difference for a healthy
    start for children and families.
        And I have gone over my time, so I yield back, Madam Chair.
        Thank you very much.
        Chairwoman Wilson. Chairman Scott? Ms. Underwood?
        Ms. Underwood. Thank you, Madam Chair.
        I request unanimous consent to submit a written testimony
    from the American College of Obstetricians and Gynecologists
    for the record.
        Chairwoman Wilson. Without objection.
        Ms. Underwood. Okay. Thank you so much.
        Chairwoman Wilson. Mr. Scott
        Mr. Scott. And, Madam Chair, I ask unanimous consent to
    introduce into the record a report from the Institute for
    Gender and Culture of the Black Women's Blueprint entitled
    ``The Sexual Abuse to Maternal Mortality Pipeline''.
        Chairwoman Wilson. Without objection.
        I remind my colleagues that pursuant to committee practice,
    materials for submission for the hearing record must be
    submitted to the Committee Clerk within 14 days following the
    last day of the hearing, preferably in Microsoft Word format.
    The materials submitted must address the subject matter of the
    hearing. Only a member of the committee or an invited witness
    may submit materials for inclusion in the hearing record.
    Documents are limited to 50 pages each. Documents longer than
    50 pages will be incorporated into the record by way of an
    internet link that you must provide to the Committee Clerk
    within the required timeframe. But please recognize that years
    from now that link may no longer work.
        Again, I want to thank the dynamic witnesses for their
    participation today. What we have heard is very valuable.
    Members of the committee may have some additional questions for
    you and we ask the witnesses to please respond to those
    questions in writing. The hearing record will be held open for
    14 days in order to receive those responses.
        I remind my colleagues that pursuant to committee practice,
    witness questions for the hearing record must be submitted to
    the majority committee staff or Committee Clerk within 7 days.
    The questions submitted must address the subject matter of the
    hearing.
        I now recognize Workforce Protections Chair Adams for her
    closing statement.
        Ms. Adams. Thank you, Madam Chair. I want to join you in
    thanking Ms. Stewart, Ms. Sankofa, and Dr. Crear-Perry for
    their compelling testimony today. I also want to thank my
    colleagues for coming together for this bipartisan hearing.
        Today's discussions confirmed what mothers and communities
    across the country have long known, our Nation's maternal and
    infant health is in crisis and the Federal government must do
    more to stop it. And to that end we must advance proposals that
    address disparities in maternal and infant health and expand
    access to health care and nutrition.
        Further, we must ensure that our Nation's workplaces
    provide critical supports, like designated pumping breaks for
    pregnant workers and new mothers.
        In closing, I am grateful that we could reaffirm today that
    maternal and infant health are not partisan issues and each of
    us here agrees that we have a shared responsibility to serve
    our constituents by supporting affordable quality maternal and
    infant care.
        I look forward to working with my colleagues to ensure that
    any mother anywhere in the United States can receive the
    quality care and support she needs to navigate a healthy
    pregnancy and raise a healthy child. I am a mother and I am a
    grandmother, and so I look forward to having some great
    grandchildren one day.
        But before I yield, I would like to enter into the record a
    statement from the organization A Better Balance in support of
    today's hearing and Federal solutions to improving maternal and
    infant health outcomes among women of color.
        Chairwoman Wilson. Without objection.
        Ms. Adams. Thank you. I now yield to my esteemed colleague
    and Chair of the Subcommittee on Health, Employment, Labor, and
    Pensions, Frederica Wilson, for a closing statement. And thank
    you very much, Madam Chair, for bringing us together.
        I yield back.
        Chairwoman Wilson. I now recognize HELP Ranking Member
    Walberg for his closing statement.
        Mr. Walberg. Thank you, Madam Chairwomen, for this hearing
    and thank you to the panel for being here.
        And I agree, Madam Chairwoman, that this indicates and
    shows that this is not a partisan issue, this is a bipartisan
    issue of concern.
        Now, we may not agree on every point. I think you
    understand that. I think a lot of what we teach out there is
    caught, not taught, by verbs and nouns, pronouns, statements.
    And so I can never--I can never support the fact that abortion
    is a good choice for a woman or a child or society because it
    again reduces the value of a human life itself. And I
    understand there is a disagreement on that.
        I have a concern about any type of support for intimate
    partnership. That term. As a man that says to me I don't have
    to make a commitment that is lasting. I did not educate to my
    sons that way. I am so thankful my son in law was not educated
    that way either. And we can disagree on that.
        But there are a lot of things we can agree on and move
    forward. Certainly I was glad to support funding and continue
    to support funding for Federally qualified community health
    centers. I have a number in my seven-county district that do
    excellent work and provide services that families and
    individuals wouldn't get otherwise. I can see supporting
    extension of Medicaid for mothers and children after birth
    through a legitimate realistic and important period of time to
    make sure that we deal with those issues of concern. I
    certainly can see that.
        So I guess I would end, Madam Chairwoman, and all those who
    are interested here today, that there are some things we can
    agree on to make a pact for. I wrote a few things down. There
    could be more. But let us make a pact to love all babies
    beginning at conception, let us make a pact to love and support
    mothers and motherhood. I hope you see the difference. It is
    special. Let us make a pact to push fathers to do all and
    anything they can to protect and care for their children and
    the mother of their children. Let us make a pact to do that.
    Let us make a pact to motivate all agencies and policy makers
    to implement science and research- based lifesaving procedures
    and policies promoting birth and maternal health. And let us
    make a pact to promote the family structure that fosters
    positive maternal and infant health and functional families.
    And let us make a pact to say you can't have everything without
    sacrifice, so make sure that we promote an understanding of the
    sacrifice that it takes in each individual situation and person
    to ultimately come to the end result of promoting quality
    maternal and infant health and the continuation through their
    whole lifetime.
        Thank you. And with that, I yield back.
        Chairwoman Wilson. Thank you, Mr. Walberg.
        I now recognize myself for a closing statement.
        I want to add my appreciation to the wonderful witnesses
    for taking the time to be with us today. You were phenomenal.
    We have many, many hearings--many--every day and you are a
    panel that I would rate A+. Thank you so much.
        The United States is home to some of the best medical care
    in the world. People come here from across the globe seeking
    medical treatment they cannot otherwise access. Yet each year
    tens of thousands of mothers across the country, particularly
    Black and Brown mothers, cannot access the quality care they
    need to have healthy pregnancies.
        As our witnesses made clear, these mothers face barriers to
    securing proven government services and quality health care.
    They face severe gaps in coverage that restrict access to care
    and they face systemic discrimination and racism throughout our
    health care system. For too long the Federal government has
    done too little to address these complex issues. As a result,
    our Nation's maternal and infant health is falling behind the
    rest of the world.
        The time to act is now. This Congress we have a bipartisan
    opportunity to fight the maternal and infant health crisis
    together. We can and must pass legislation that follows
    research and evidence, supports proven Federal services, and
    expands access to quality health care for all mothers.
        Moving ahead, I look forward to working with my colleagues
    on both sides of aisle. And I am just happy to hear what they
    said today, to advance proposals that achieve those shared
    goals. If we work together, we can succeed in delivering for
    the mothers, the infants, the communities, and the future of
    our country.
        If there is no further business, without objection, this
    committee stands adjourned.
        [[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        [Whereupon, at 1:02 p.m., the subcommittees were
    adjourned.]

                                     [all]