MOMMA’s Act

II 116TH CONGRESS 1ST SESSION S. 916 To improve Federal efforts with respect to the prevention of maternal mortality, and for other purposes. IN THE SENATE OF THE UNITED STATES MARCH 27, 2019 Mr. DURBIN (for himself, Ms. DUCKWORTH, Mr. BLUMENTHAL, Mr. VAN HOLLEN, Mr. MERKLEY, Mr. BROWN, Mr. SANDERS, Ms. SMITH, and Mr. KING) introduced the following bill; which was read twice and re- ferred to the Committee on Finance A BILL To improve Federal efforts with respect to the prevention of maternal mortality, and for other purposes. Be it enacted by the Senate and House of Representa- 1 tives of the United States of America in Congress assembled, 2 SECTION 1. SHORT TITLE. 3 This Act may be cited as the ‘‘Mothers and Offspring 4 Mortality and Morbidity Awareness Act’’ or the 5 ‘‘MOMMA’s Act’’. 6 SEC. 2. FINDINGS. 7 Congress finds the following: 8 VerDate Sep 11 2014 22:59 Apr 03, 2019 Jkt 089200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\S916.IS S916 pamtmann on DSKBFK8HB2PROD with BILLS 2 •S 916 IS (1) Every year, across the United States, 1 4,000,000 women give birth, about 700 women suf- 2 fer fatal complications during pregnancy, while giv- 3 ing birth or during the postpartum period, and 4 70,000 women suffer near-fatal, partum-related 5 complications. 6 (2) The maternal mortality rate is often used as 7 a proxy to measure the overall health of a popu- 8 lation. While the infant mortality rate in the United 9 States has reached its lowest point, the risk of death 10 for women in the United States during pregnancy, 11 childbirth, or the postpartum period is higher than 12 such risk in many other developed nations. The esti- 13 mated maternal mortality rate (per 100,000 live 14 births) for the 48 contiguous States and Wash- 15 ington, DC increased from 18.8 percent in 2000 to 16 23.8 percent in 2014 to 26.6 percent in 2018. This 17 estimated rate is on par with such rate for under- 18 developed nations such as Iraq and Afghanistan. 19 (3) International studies estimate the 2015 ma- 20 ternal mortality rate in the United States as 26.4 21 per 100,000 live births, which is almost twice the 22 2015 World Health Organization estimation of 14 23 per 100,000 live births. 24 VerDate Sep 11 2014 22:59 Apr 03, 2019 Jkt 089200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\S916.IS S916 pamtmann on DSKBFK8HB2PROD with BILLS 3 •S 916 IS (4) It is estimated that more than 60 percent 1 of maternal deaths in the United States are prevent- 2 able. 3 (5) According to the Centers for Disease Con- 4 trol and Prevention, the maternal mortality rate var- 5 ies drastically for women by race and ethnicity. 6 There are 12.7 deaths per 100,000 live births for 7 White women, 43.5 deaths per 100,000 live births 8 for African-American women, and 14.4 deaths per 9 100,000 live births for women of other ethnicities. 10 While maternal mortality disparately impacts Afri- 11 can-American women, this urgent public health crisis 12 traverses race, ethnicity, socioeconomic status, edu- 13 cational background, and geography. 14 (6) African-American women are 3 to 4 times 15 more likely to die from causes related to pregnancy 16 and childbirth compared to non-Hispanic White 17 women. 18 (7) The findings described in paragraphs (1) 19 through (6) are of major concern to researchers, 20 academics, members of the business community, and 21 providers across the obstetrical continuum rep- 22 resented by organizations such as March of Dimes; 23 the Preeclampsia Foundation; the American College 24 of Obstetricians and Gynecologists; the Society for 25 VerDate Sep 11 2014 22:59 Apr 03, 2019 Jkt 089200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S916.IS S916 pamtmann on DSKBFK8HB2PROD with BILLS 4 •S 916 IS Maternal-Fetal Medicine; the Association of Wom- 1 en’s Health, Obstetric, and Neonatal Nurses; the 2 California Maternal Quality Care Collaborative; 3 Black Women’s Health Imperative; the National 4 Birth Equity Collaborative; Black Mamas Matter Al- 5 liance; EverThrive Illinois; the National Association 6 of Certified Professional Midwives; PCOS Challenge: 7 The National Polycystic Ovary Syndrome Associa- 8 tion; and the American College of Nurse Midwives. 9 (8) Hemorrhage, cardiovascular and coronary 10 conditions, cardiomyopathy, infection, embolism, 11 mental health conditions, preeclampsia and eclamp- 12 sia, polycystic ovary syndrome, infection and sepsis, 13 and anesthesia complications are the predominant 14 medical causes of maternal-related deaths and com- 15 plications. Most of these conditions are largely pre- 16 ventable or manageable. 17 (9) Oral health is an important part of 18 perinatal health. Reducing bacteria in a woman’s 19 mouth during pregnancy can significantly reduce her 20 risk of developing oral diseases and spreading decay- 21 causing bacteria to her baby. Moreover, some evi- 22 dence suggests that women with periodontal disease 23 during pregnancy could be at greater risk for poor 24 birth outcomes, such as preeclampsia, pre-term 25 VerDate Sep 11 2014 22:59 Apr 03, 2019 Jkt 089200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\S916.IS S916 pamtmann on DSKBFK8HB2PROD with BILLS 5 •S 916 IS birth, and low-birth weight. Furthermore, a woman’s 1 oral health during pregnancy is a good predictor of 2 her newborn’s oral health, and since mothers can 3 unintentionally spread oral bacteria to their babies, 4 putting their children at higher risk for tooth decay, 5 prevention efforts should happen even before chil- 6 dren are born, as a matter of pre-pregnancy health 7 and prenatal care during pregnancy. 8 (10) The United States has not been able to 9 submit a formal maternal mortality rate to inter- 10 national data repositories since 2007. Thus, no offi- 11 cial maternal mortality rate exists for the United 12 States. There can be no maternal mortality rate 13 without streamlining maternal mortality-related data 14 from the State level and extrapolating such data to 15 the Federal level. 16 (11) In the United States, death reporting and 17 analysis is a State function rather than a Federal 18 process. States report all deaths—including mater- 19 nal deaths—on a semi-voluntary basis, without 20 standardization across States. While the Centers for 21 Disease Control and Prevention has the capacity and 22 system for collecting death-related data based on 23 death certificates, these data are not sufficiently re- 24 ported by States in an organized and standard for- 25 VerDate Sep 11 2014 22:59 Apr 03, 2019 Jkt 089200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\S916.IS S916 pamtmann on DSKBFK8HB2PROD with BILLS 6 •S 916 IS mat across States such that the Centers for Disease 1 Control and Prevention is able to identify causes of 2 maternal death and best practices for the prevention 3 of such death. 4 (12) Vital statistics systems often underesti- 5 mate maternal mortality and are insufficient data 6 sources from which to derive a full scope of medical 7 and social determinant factors contributing to ma- 8 ternal deaths. While the addition of pregnancy 9 checkboxes on death certificates since 2003 have 10 likely improved States’ abilities to identify preg- 11 nancy-related deaths, they are not generally com- 12 pleted by obstetrical providers or persons trained to 13 recognize pregnancy-related mortality. Thus, these 14 vital forms may be missing information or may cap- 15 ture inconsistent data. Due to varying maternal 16 mortality-related analyses, lack of reliability, and 17 granularity in data, current maternal mortality 18 informatics do not fully encapsulate the myriad med- 19 ical and socially determinant factors that contribute 20 to such high maternal mortality rates within the 21 United States compared to other developed nations. 22 Lack of standardization of data and data sharing 23 across States and between Federal entities, health 24 VerDate Sep 11 2014 22:59 Apr 03, 2019 Jkt 089200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\S916.IS S916 pamtmann on DSKBFK8HB2PROD with BILLS 7 •S 916 IS networks, and research institutions keep the Nation 1 in the dark about ways to prevent maternal deaths. 2 (13) Having reliable and valid State data ag- 3 gregated at the Federal level are critical to the Na- 4 tion’s ability to quell surges in maternal death and 5 imperative for researchers to identify long-lasting 6 interventions. 7 (14) Leaders in maternal wellness highly rec- 8 ommend that maternal deaths be investigated at the 9 State level first, and that standardized, streamlined, 10 de-identified data regarding maternal deaths be sent 11 annually to the Centers for Disease Control and Pre- 12 vention. Such data standardization and collection 13 would be similar in operation and effect to the Na- 14 tional Program of Cancer Registries of the Centers 15 for Disease Control and Prevention and akin to the 16 Confidential Enquiry in Maternal Deaths Pro- 17 gramme in the United Kingdom. Such a maternal 18 mortalities and morbidities registry and surveillance 19 system would help providers, academicians, law- 20 makers, and the public to address questions con- 21 cerning the types of, causes of, and best practices to 22 thwart, pregnancy-related or pregnancy-associated 23 mortality and morbidity. 24 VerDate Sep 11 2014 22:59 Apr 03, 2019 Jkt 089200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\S916.IS S916 pamtmann on DSKBFK8HB2PROD with BILLS 8 •S 916 IS (15) The United Nations’ Millennium Develop- 1 ment Goal 5a aimed to reduce by 75 percent, be- 2 tween 1990 and 2015, the maternal mortality rate, 3 yet this metric has not been achieved. In fact, the 4 maternal mortality rate in the United States has 5 been estimated to have more than doubled between 6 2000 and 2014. Yet, because national data are not 7 fully available, the United States does not have an 8 official maternal mortality rate. 9 (16) Many States have struggled to establish or 10 maintain Maternal Mortality Review Committees 11 (referred to in this section as ‘‘MMRC’’). On the 12 State level, MMRCs have lagged because States have 13 not had the resources to mount local reviews. State- 14 level reviews are necessary as only the State depart- 15 ments of health have the authority to request med- 16 ical records, autopsy reports, and police reports crit- 17 ical to the function of the MMRC. 18 (17) The United Kingdom regards maternal 19 deaths as a health systems failure and a national 20 committee of obstetrics experts review each maternal 21 death or near-fatal childbirth complication. Such 22 committee also establishes the predominant course of 23 maternal-related deaths from conditions such as 24 preeclampsia. Consequently, the United Kingdom 25 VerDate Sep 11 2014 22:59 Apr 03, 2019 Jkt 089200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\S916.IS S916 pamtmann on DSKBFK8HB2PROD with BILLS 9 •S 916 IS has been able to reduce its incidence of preeclampsia 1 to less than one in 10,000 women—its lowest rate 2 since 1952. 3 (18) The United States has no comparable, co- 4 ordinated Federal process by which to review cases 5 of maternal mortality, systems failures, or best prac- 6 tices. Many States have active MMRCs and leverage 7 their work to impact maternal wellness. For exam- 8 ple, the State of California has worked extensively 9 with their State health departments, health and hos- 10 pital systems, and research collaborative organiza- 11 tions, including the California Maternal Quality Care 12 Collaborative and the Alliance for Innovation on Ma- 13 ternal Health, to establish MMRCs, wherein such 14 State has determined the most prevalent causes of 15 maternal mortality and recorded and shared data 16 with providers and researchers, who have developed 17 and implemented safety bundles and care protocols 18 related to preeclampsia, maternal hemorrhage, and 19 the like. In this way, the State of California has 20 been able to leverage its maternal mortality review 21 board system, generate data, and apply those data 22 to effect changes in maternal care-related protocol. 23 To date, the State of California has reduced its ma- 24 VerDate Sep 11 2014 22:59 Apr 03, 2019 Jkt 089200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\S916.IS S916 pamtmann on DSKBFK8HB2PROD with BILLS 10 •S 916 IS ternal mortality rate, which is now comparable to 1 the low rates of the United Kingdom. 2 (19) Hospitals and health systems across the 3 United States lack standardization of emergency ob- 4 stetrical protocols before, during, and after delivery. 5 Consequently, many providers are delayed in recog- 6 nizing critical signs indicating maternal distress that 7 quickly escalate into fatal or near-fatal incidences. 8 Moreover, any attempt to address an obstetrical 9 emergency that does not consider both clinical and 10 public health approaches falls woefully under the 11 mark of excellent care delivery. State-based maternal 12 quality collaborative organizations, such as the Cali- 13 fornia Maternal Quality Care Collaborative or enti- 14 ties participating in the Alliance for Innovation on 15 Maternal Health (AIM), have formed obstetrical pro- 16 tocols, tool kits, and other resources to improve sys- 17 tem care and response as they relate to maternal 18 complications and warning signs for such conditions 19 as maternal hemorrhage, hypertension, and 20 preeclampsia. 21 (20) The Centers for Disease Control and Pre- 22 vention reports that nearly half of all maternal 23 deaths occur in the immediate postpartum period— 24 the 42 days following a pregnancy—whereas more 25 VerDate Sep 11 2014 22:59 Apr 03, 2019 Jkt 089200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\S916.IS S916 pamtmann on DSKBFK8HB2PROD with BILLS 11 •S 916 IS than one-third of pregnancy-related or pregnancy-as- 1 sociated deaths occur while a person is still preg- 2 nant. Yet, for women eligible for the Medicaid pro- 3 gram on the basis of pregnancy, such Medicaid cov- 4 erage lapses at the end of the month on which the 5 60th postpartum day lands. 6 (21) The experience of serious traumatic 7 events, such as being exposed to domestic violence, 8 substance use disorder, or pervasive racism, can 9 over-activate the body’s stress-response system. 10 Known as toxic stress, the repetition of high-doses 11 of cortisol to the brain, can harm healthy neuro- 12 logical development, which can have cascading phys- 13 ical and mental health consequences, as documented 14 in the Adverse Childhood Experiences study of the 15 Centers for Disease Control and Prevention. 16 (22) A growing body of evidence-based research 17 has shown the correlation between the stress associ- 18 ated with one’s race—the stress of racism—and 19 one’s birthing outcomes. The stress of sex and race 20 discrimination and institutional racism ha [Text truncated for display. 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