[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

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

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                    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.]

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