[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]
EXPECTING MORE: ADDRESSING AMERICA'S
MATERNAL AND INFANT HEALTH CRISIS
=======================================================================
JOINT HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH, EMPLOYMENT, LABOR,
AND PENSIONS
AND THE
SUBCOMMITTEE ON WORKFORCE PROTECTIONS
OF THE
COMMITTEE ON EDUCATION
AND LABOR
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTEENTH CONGRESS
SECOND SESSION
__________
HEARING HELD IN WASHINGTON, DC, JANUARY 28, 2020
__________
Serial No. 116-50
__________
Printed for the use of the Committee on Education and Labor
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: www.govinfo.gov
or
Committee address: https://edlabor.house.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
39-730 PDF WASHINGTON : 2022
-----------------------------------------------------------------------------------
COMMITTEE ON EDUCATION AND LABOR
ROBERT C. ``BOBBY'' Scott, Virginia, Chairman
Susan A. Davis, California Virginia Foxx, North Carolina,
Raul M. Grijalva, Arizona Ranking Member
Joe Courtney, Connecticut David P. Roe, Tennessee
Marcia L. Fudge, Ohio Glenn Thompson, Pennsylvania
Gregorio Kilili Camacho Sablan, Tim Walberg, Michigan
Northern Mariana Islands Brett Guthrie, Kentucky
Frederica S. Wilson, Florida Bradley Byrne, Alabama
Suzanne Bonamici, Oregon Glenn Grothman, Wisconsin
Mark Takano, California Elise M. Stefanik, New York
Alma S. Adams, North Carolina Rick W. Allen, Georgia
Mark DeSaulnier, California Lloyd Smucker, Pennsylvania
Donald Norcross, New Jersey Jim Banks, Indiana
Pramila Jayapal, Washington Mark Walker, North Carolina
Joseph D. Morelle, New York James Comer, Kentucky
Susan Wild, Pennsylvania Ben Cline, Virginia
Josh Harder, California Russ Fulcher, Idaho
Lucy McBath, Georgia Steve Watkins, Kansas
Kim Schrier, Washington Ron Wright, Texas
Lauren Underwood, Illinois Daniel Meuser, Pennsylvania
Jahana Hayes, Connecticut Dusty Johnson, South Dakota
Donna E. Shalala, Florida Fred Keller, Pennsylvania
Andy Levin, Michigan* Gregory F. Murphy, North Carolina
Ilhan Omar, Minnesota Van Drew, New Jersey
David J. Trone, Maryland
Haley M. Stevens, Michigan
Susie Lee, Nevada
Lori Trahan, Massachusetts
Joaquin Castro, Texas
* Vice-Chair
Veronique Pluviose, Staff Director
Brandon Renz, Minority Staff Director
------
SUBCOMMITTEE ON HEALTH, EMPLOYMENT, LABOR, AND PENSIONS
FREDERICA S. Wilson, Florida, Chairwoman
Donald Norcross, New Jersey Tim Walberg, Michigan
Joseph D. Morelle, New York Ranking Member
Susan Wild, Pennsylvania David P. Roe, Tennessee
Lucy McBath, Georgia Rick W. Allen, Georgia
Lauren Underwood, Illinois Jim Banks, Indiana
Haley M. Stevens, Michigan Russ Fulcher, Idaho
Joe Courtney, Connecticut Steve C. Watkins, Jr., Kansas
Marcia L. Fudge, Ohio Ron Wright, Texas
Josh Harder, California Dan Meuser, Pennsylvania
Donna E. Shalala, Florida Dusty Johnson, South Dakota
Andy Levin, Michigan Fred Keller, Pennsylvania
Lori Trahan, Massachusetts
Vacancy
SUBCOMMITTEE ON WORKFORCE PROTECTIONS
ALMA S. Adams, North Carolina, Chairwoman
Mark DeSaulnier, California Bradley Byrne, Alabama,
Mark Takano, California Ranking Member
Pramila Jayapal, Washington Mark Walker, North Carolina
Susan Wild, Pennsylvania Ben Cline, Virginia
Lucy McBath, Georgia Ron Wright, Texas
Ilhan Omar, Minnesota Gregory F. Murphy, North Carolina
Haley M. Stevens, Michigan
C O N T E N T S
----------
Page
Hearing held on October 23, 2019................................. 1
Statement of Members:
Adams, Hon. Alma S., Chairwoman, Subcommittee on Workforce
Protections................................................ 6
Prepared statement of.................................... 7
Walberg, Hon. Tim, Ranking Member, Subcommittee on Health,
Employment, Labor, and Pensions............................ 4
Prepared statement of.................................... 5
Walker, Hon. Mark, Ranking Member a Representative in
Congress from the State of North Carolina.................. 7
Prepared statement of.................................... 8
Wilson, Hon. Frederica S., Chairwoman, Subcommittee on
Health, Employment, Labor, and Pensions.................... 1
Prepared statement of.................................... 3
Statement of Witnesses:
Crear-Perry, Dr. Joia, MD, President, National Birth Equity
Collaborative.............................................. 36
Prepared statement of.................................... 39
Sankofa, Ms. Nikia, Executive Director, United States
Breastfeeding Committee.................................... 24
Prepared statement of.................................... 27
Stewart, Ms. Stacey D., President and CEO, March of Dimes.... 9
Prepared statement of.................................... 12
Additional Submissions:
Chairwoman Adams:
Prepared statement from A Better Balance................. 90
Courtney, Hon. Joe, a Representative in Congress from the
State of Connecticut:
Letter dated January 27, 2020 from Locke, Mr. Caleb
Andrew................................................. 94
Jayapal, Hon. Pramila, a Representative in Congress from the
State of Washington:
Letter dated July 10, 2019............................... 95
Johnson, Hon. Dusty, a Representative in Congress from the
State of South Dakota:
Article: Effort Begins To Reduce Risk of Death of S.D.
Mothers During Childbirth.............................. 98
Morelle, Hon. Joseph D., a Representative in Congress from
the State of New York:
Letter dated January 28, 2020 from Johnson and Johnson... 110
Scott, Hon. Robert C. ``Bobby'', a Representative in Congress
from the State of Virginia:
Letter dated January 27, 2020 from National Association
of County and City Health Officials (NACCHO)........... 111
Letter dated January 27, 2020 from undersigned
orgranizations......................................... 113
Prepared statement from Abbott, Mrs. Becky M............. 115
Link: Sexual Abuse To Maternal Mortality Pipeline........ 127
Stevens, Hon. Haley M., a Representative in Congress from the
State of Michigan:
Letter dated January 27, 2020 from National Foundation
for Ectodermal Dysplisias (NFED)....................... 128
Takano, Hon. Mark, a Representative in Congress from the
State of California:
Article: Medicaid Expansion Fills Gaps In Maternal Health
Coverage Leading to Healthier Mothers and Babies....... 130
Underwood, Hon. Lauren, a Representative in Congress from the
State of Illinois:
Prepared statement from Mom Congress..................... 142
Prepared statement from The American College of
Obstetricians Gynecologists............................ 144
Prepared statement from 2020 Mom......................... 151
Link: Eliminating Racial Disparities In Maternal and
Infant Mortality....................................... 153
Chairwoman Wilson:
Prepared statement from American Dental Association (ADA) 154
Prepared statement from American Society of Plastic
Surgeons...............................................
Questions submitted for the record by:
Schrier, Hon. Kim, a Representative in Congress from the
State of Washington
Ms. Underwood............................................ 163
Responses submitted for the record by:
Dr. Crear-Perry.......................................... 166
Ms. Sankofa.............................................. 171
Ms. Stewart.............................................. 177
EXPECTING MORE: ADDRESSING AMERICA'S MATERNAL AND INFANT HEALTH CRISIS
----------
Tuesday, January 28, 2020
House of Representatives
Subcommittee on Health, Education, Labor, and Pensions
Joint with
Subcommittee on Workforce Protections
Committee on Education and Labor
Washington, D.C.
----------
The subcommittees met, pursuant to call, at 10:19 a.m., in
Room 2175, Rayburn House Office Building. Hon. Frederica S.
Wilson (Chairwoman of the Subcommittee on Health, Education,
Labor, and Pensions) presiding.
Present: Representatives Wilson, Adams, Courtney, Fudge,
Takano, DeSaulnier, Norcross, Jayapal, Scott, Morelle, Wild,
Harder, McBath, Underwood, Shalala, Levin, Omar, Stevens,
Trahan, Walberg, Roe, Walker, Fulcher, Mueser, Johnson, Keller,
and Foxx.
Also Present: Representatives Bonamici and Schrier.
Staff Present: Ilana Brunner, General Counsel; Sharon
Crowder, Health Policy Fellow; Emma Eatman, Press Assistant;
Daniel Foster, Health and Labor Counsel; Alison Hard,
Professional Staff; Carrie Hughes, Director of Health and Human
Services; Ariel Jona, Staff Assistant; Stephanie Lalle, Deputy
Communications Director; Andre Lindsay, Staff Assistant; Jaria
Martin, Clerk/Special Assistant to the Staff Director; Kevin
McDermott, Senior Labor Policy Advisor; Max Moore, Office Aid;
Udochi Onwubiko, Labor Policy Counsel; Veronique Pluviose,
Staff Director; Ivorie Stanley, Labor and Health Policy Fellow;
Banyon Vassar, Deputy Director of Information Technology;
Joshua Weisz, Communications Director; Cyrus Artz, Minority
Parliamentarian; Courtney Butcher, Minority Director of Member
Services and Coalitions; Akash Chougule, Minority Professional
Staff Member; Cate Dillon, Minority Staff Assistant; Rob Green,
Minority Director of Workforce Policy; Jeanne Kuehl, Minority
Legislative Assistant; John Martin, Minority Workforce Policy
Counsel; Audra McGeorge, Minority Communications Director;
Alexis Murray, Minority Professional Staff Member; Carlton
Norwood, Minority Press Secretary; Ben Ridder, Minority
Professional Staff Member; and Kelly Tyroler.
Chairwoman Wilson. The Subcommittees on Health, Employment,
Labor, and Pensions and Workforce Protections will come to
order.
Welcome, everyone.
I note that quorum is present, I note for the subcommittee
that Congresswoman Bonamici of Oregon and Congresswoman Schrier
of Washington are permitted to participate in today's hearing
with the understanding that their questions will come only
after all members of the HELP and Workforce Protections
Subcommittees on both sides of the aisle who are present have
had an opportunity to question the witnesses.
The subcommittees are meeting today in a hearing to receive
testimony on addressing our Nation's maternal and infant health
crisis.
Pursuant to Committee Rule 7(c), opening statements are
limited to the Chairs and the Ranking Members. This allows us
to hear from our witnesses sooner and provides all members with
adequate time to ask questions.
I recognize myself now for the purpose of making an opening
statement.
Today we are gathered for a bipartisan hearing to discuss
our responsibility to address America's maternal and infant
health crisis. During this hearing we will confront the
troubling reality that the United States has the worst maternal
mortality rate among developed countries. Each year 700 women
die from pregnancy-related complications and 50,000 women
suffer from life-threatening pregnancy-related complications.
Even as our peer nations across the world make significant
improvements in maternal and infant health, outcomes in the
United States are moving in the opposite direction. In fact,
the U.S. maternal mortality rate in 2016 was nearly 17 per
100,000 live births, more than double the rate in 1987.
This impacts communities across the Nation, including my
own. In Florida, the situation is even more severe. The
maternal mortality rate is 22.3 deaths per 100,000 live births,
well above the national average. Miami-Dade County had a
maternal mortality rate for Black women of 34.3 in 2018, more
than double the national average for all mothers. These numbers
are unacceptably high.
Improving maternal and infant health requires us to focus
not just on the health of mothers during pregnancy, but on
their overall health. That means providing consistent quality
and affordable health insurance to the roughly 11 percent of
reproductive age people, 10.6 million Americans who went
without health insurance in 2017.
Fourteen states still have not expanded Medicaid
eligibility, which pays for 43 percent of births, to cover more
low-income people. In those states, women may lose their
insurance just two months after giving birth. It means
supporting the Special Supplemental Nutrition Program for
Women, Infants, and Children, or WIC, which has proven to help
protect the health of both mothers and infants by providing
breastfeeding support and helping mothers avoid preterm births.
A recent study found that infants born to WIC participants
are 33 percent less likely to die than non-participants.
Despite this track record, WIC saw the lowest number of
participants in over a decade in 2016. Instead of restricting
access to quality health care, Congress must pass legislation
to expand access to programs, like WIC, that have helped
mothers navigate healthy pregnancies for decades.
Finally, and most importantly, addressing the maternal and
infant health crisis means undoing structural racism that
affects every facet of American life, from health care to
housing to education and transportation.
Black mothers are three to four times more likely to die
from pregnancy-related complications than White mothers,
regardless of their education and income. Native American
mothers are two to three times more likely to experience
maternal mortality than White mothers. Simply put, if we are to
stop this crisis we must all work together and address the
complex issues in maternal and infant health.
That is why I am pleased we have an opportunity today, with
the help of our witnesses, to discuss how we can make
meaningful and immediate steps to improve maternal and infant
health for all people. I look forward to today's bipartisan
discussions and thank our witnesses again for joining us.
[The statement of Ms. Wilson follows:]
Prepared Statement of Hon. Frederica S. Wilson, Chairwoman,
Subcommittee on Health, Employment, Labor, and Pensions
Today, we are gathered for a bipartisan hearing to discuss our
responsibility to address America's maternal and infant health crisis.
During this hearing, we will confront the troubling reality that
the United States has the worst maternal mortality rate among developed
countries. Each year, 700 women die from pregnancy-related
complications and 50,000 women suffer from life-threatening pregnancy-
related complications.
Even as our peer nations across the world make significant
improvements in maternal and infant health, outcomes in the United
States are moving in the opposite direction. In fact, the U.S. maternal
mortality rate in 2016 was nearly 17 per 100,000 live births--more than
double the rate in 1987.
This impacts communities across the nation, including my own. In
Florida the situation is even more dire. The maternal mortality rate is
22.3 deaths per 100,000 live births - well above the national average.
Miami-Dade County had a maternal mortality rate for black women of 34.3
in 2018 - more than double the national average for all mothers. These
numbers are unacceptably high.
Improving maternal and infant health requires us to focus not just
on the health of mothers during pregnancy, but on their overall health.
That means providing consistent, quality, and affordable health
insurance to the roughly 11 percent of reproductive age people--10.6
million Americans--who went without health insurance in 2017. Fourteen
states still have not expanded Medicaid eligibility, which pays for 43
percent of births, to cover more low-income people. In those states,
women may lose their insurance just two months after giving birth.
It means supporting the Special Supplemental Nutrition Program for
Women, Infants, and Children, or WIC, which is proven to help protect
the health of both mothers and infants by providing breastfeeding
support and helping mothers avoid preterm births. A recent study found
that infants born to WIC participants are 33 percent less likely to die
than non-participants.
Despite this track record, WIC saw the lowest number of
participants in over a decade in 2016. Instead of restricting access to
quality health care, Congress must pass legislation to expand access to
programs, like WIC, that have helped mothers navigate healthy
pregnancies for decades.
Finally--and most importantly--addressing the maternal and infant
health crisis means undoing structural racism that affects every facet
of American life, from health care, to housing, to education, and
transportation.
Black mothers are three to four times more likely to die from
pregnancy-related complications than white mothers, regardless of
education and income. Native mothers are two to three times more likely
to experience maternal mortality than white mothers.
Simply put, if we are to stop this crisis, we must all work
together and address the complex issues in maternal and infant health.
That is why I am pleased we have an opportunity today, with the help of
our witnesses, to discuss how we can take meaningful and immediate
steps to improve maternal and infant health for all people.
I look forward to today's bipartisan discussions and thank our
witnesses, again, for joining us.
______
Chairwoman Wilson. I now recognize HELP Ranking Member, Mr.
Walberg, for an opening statement.
Mr. Walberg. Thank you, Madam Chairwoman.
Today we are here to discuss the critical issue of infant
and maternal health, and in fact to I would hope to exalt
motherhood and birth itself.
While women around the globe are dying less from
childbirth, here in the United States the rates have been
climbing. Other countries with rising maternal mortality rates,
Afghanistan, Lesotho, and Swaziland. For black women, the
statistics are even more troubling. According to the World
Health Organization, the maternal mortality for black women in
the United States are the same for women in Mexico, Uzbekistan,
and this is unacceptable.
This issue, a matter of literal life and death for women
and babies, demands a serious and thoughtful response. The
exact causes of the United States' high maternal and infant
mortality rates are unclear and varied, but they can be known.
The HELP subcommittee has jurisdiction over employment-
related health benefits and the Employee Retirement Income
security Act, otherwise known as ERISA. So as we study the
important issue before us today, and before this committee
considers the imposition of additional government mandates that
could have unintended consequences on employers and employees
alike, we should closely examine this problem through separate
hearings about the larger issue and propose legislative
solutions.
As we have learned from experience, one size fits all
government requirements more often than not compound the
problem. That is why specific policies from this committee and
Congress must involve a thorough review of the current problem
and a recognition that community, individual, and family
engagement are also key components which need to be recognized
and addressed.
Let us not forget the important role employers are playing
in providing health insurance to mothers and babies. Because of
our strong economy more workers have access to high quality
affordable health insurance at work. The most recent
Congressional Budget Office numbers indicate that 159 million
Americans are covered by employer-sponsored coverage. In
addition, maternity benefits are often the largest type of
health care expenditures for employers. Because of this,
employers proactively offer a number of programs aimed at
increasing quality and lowering cost for employees, and another
reason for an encouraging economic growth and employment.
Many employers offer programs for fertility, prenatal care,
neonatal and premature birth medical care, lactation
consulting, and transparency tools to view provider and
hospital quality metrics as well. Employers also rely on
payment and delivery model reforms to reduce scheduled preterm
births, direct high-risk patients to high-quality providers and
hospitals, or lower costs by offering bundled payments to
providers for childbirth services. Milk delivery services have
also gained popularity with employers by offering convenient
shipping services for employees who travel for business.
While employers, communities, and families are play a
pivotal role in decreasing maternal and infant mortality rates,
we must also ensure that Congress is taking the necessary steps
to guarantee the safety and wellbeing of women and newborn and
unborn infants. We should promote policies in Washington that
encourage a strong family, allow families to flourish, and
protect life at all stages, from conception to natural death.
I know that both sides can agree that maternal and infant
health is an issue worthy of attention. And it is my hope that
we can hold additional legislative hearings on any proposed
solutions and that any subsequent legislation can be considered
in a bipartisan manner. I certainly commit myself to that.
Bottom line, bringing a child into the world should be an
exciting and joyful time for women and their families. In light
of the eternal truth that ``children are a gift, the fruit of
the womb is a reward''. Mothers should feel secure and
confident in their new role and not have to fear for their own
life or their baby's life.
I thank the Chairwoman for scheduling today's hearing and I
look forward to hearing from our witnesses.
I yield back.
[The statement of Mr. Walberg follows:]
Prepared Statement of Hon. Tim Walberg, Ranking Member, Subcommittee on
Health, Employment, Labor, and Pensions
Today, we are here to discuss the critical issue of infant and
maternal health. While women around the globe are dying less from
childbirth, here, in the U.S., the rates have been climbing. Other
countries with rising maternal mortality rates? Afghanistan, Lesotho,
and Swaziland. For black women, the statistics are even more troubling.
According to the World Health Organization, the maternal mortality
rates for black women in the U.S. are the same for women in Mexico and
Uzbekistan. This is unacceptable.
This issue, a matter of literal life and death for women, demands a
serious and thoughtful response.
The exact causes of the United States' high maternal and infant
mortality rates are unclear and varied. The HELP Subcommittee has
jurisdiction over employment-related health benefits and the Employee
Retirement Income Security Act, also known as ERISA. So, as we study
the important issue before us today, and before this Committee
considers the imposition of additional government mandates that could
have unintended consequences on employers and employees alike, we
should closely examine this problem through separate hearings about the
larger issue and proposed legislative solutions. As we have learned
from experience, one-size-fits-all government requirements, more often
than not, compound the problem. That is why specific policies from this
Committee and Congress must involve a thorough review of the current
problem and a recognition that community, individual, and family
engagement are also key components which need to be recognized and
addressed.
Let's not forget the important role employers are playing in
providing health insurance to mothers and babies. Because of our strong
economy, more workers have access to high-quality, affordable health
insurance at work. The most recent Congressional Budget Office numbers
indicate that 159 million Americans are covered by employer-sponsored
coverage. In addition, maternity benefits are often the largest type of
health care expenditures for employers. Because of this, employers
proactively offer a number of programs aimed at increasing quality and
lowering costs for employees.
Many employers offer programs for fertility, prenatal care,
neonatal and premature birth medical care, lactation consulting, and
transparency tools to view provider and hospital quality metrics.
Employers also rely on payment and delivery-model reforms to reduce
scheduled pre-term births; direct high-risk patients to high-quality
providers and hospitals; or lower costs by offering bundled payments to
providers for childbirth services. Milk-delivery services have also
gained popularity with employers by offering convenient shipping
services for employees who travel for business.
While employers, communities, and families all play a pivotal role
in decreasing maternal and infant mortality rates, we must also ensure
that Congress is taking the necessary steps to guarantee the safety and
wellbeing of women and newborn and unborn infants. We should promote
policies in Washington that encourage a strong family, allow families
to flourish, and protect life at all stages, from conception to natural
death.
I know that both sides can agree that maternal and infant health is
an issue worthy of attention, and it is my hope that we can hold
additional legislative hearings on any proposed solutions and that any
subsequent legislation can be considered in a bipartisan manner.
Bottom line, bringing a child into the world should be an exciting
and joyful time for women and their families, in light of the eternal
truth that `children are a gift . . . the fruit of the womb is a
reward.' Mothers should feel secure and confident in their new role,
and not have to fear for their own life or their baby's life.
I thank the Chairwoman for scheduling today's hearing, and I look
forward to hearing from our witnesses.
______
Chairwoman Wilson. Thank you so much, Mr. Walberg.
I now recognize Workforce Protection Subcommittee Chair
Adams for an opening statement.
Ms. Adams. Thank you, Madam Chairwoman, and thank you to
our witnesses for being here today.
As Co-Chair of the Black Maternal Health Caucus alongside
Ms. Underwood, I am grateful for today's bipartisan opportunity
to focus on our role in addressing America's maternal and
infant health crisis. This crisis is devastating communities
across the country, particularly Black and Native communities
that experience far worse outcomes than their White
counterparts. However, in some places in the country, such as
in my home state of North Carolina, there are strategies in
place that have been proven to work in reducing these
disparities. It is up to us as lawmakers to make it easier for
our caregivers to take what works and expand upon it.
Today our witnesses will help us understand and address the
causes behind pregnancy--related mortality and morbidity that
hit our communities every day.
As Chairwoman Wilson noted, expanding access to affordable
health care and nutrition services is an important part of the
solution. However, as women increasingly work later into their
pregnancies and return to work shortly after the baby is born,
we must also ensure that our workplaces support the health of
mothers and infants. In this area Federal law falls woefully
short.
For example, Federal law currently does not guarantee all
new mothers the right to express breast milk. Workplace
breastfeeding supports such as designated pumping breaks and
private space are particularly critical for both maternal and
infant health. Unfortunately, while employers are required to
provide pumping breaks and break time for some workers, a gap
in the law has caused millions of overtime-exempt employees to
fall through the cracks. Further, even covered workers have
limited avenues to ensure their employers provide pumping
breaks and a private space. I think we can all agree that this
is unacceptable. There is no question that our country is
facing a maternal and infant health crisis. There is no
question that our mothers and infants are suffering preventable
tragedies that rarely occur in other developed nations. The
only question is whether we will come together and fulfill our
responsibility to find solutions and to take action.
Again, I want to thank all of the witnesses for joining us
today and, Madam Chair, I yield back.
[The statement of Ms. Adams follows:]
Prepared Statement of Hon. Alma S. Adams, Chairwoman, Subcommittee on
Workforce Protections
Thank you, Chairwoman Wilson. As the co-chair of the Black Maternal
Health Caucus alongside Ms. Underwood, I am grateful for today's
bipartisan opportunity to focus on our role in addressing America's
maternal and infant health crisis.
This crisis is devastating communities across the country,
particularly Black and Native communities that experience far worse
outcomes than their white counterparts. However, in some places in the
country, such as in my home state of North Carolina, there are
strategies in place that have been proven to work in reducing these
disparities. It's up to us as lawmakers to make it easier for our
caregivers to take what works and expand upon it.
Today, our witnesses will help us understand and address the causes
behind pregnancy-related mortality and morbidity that hit our
communities every day.
As Chairwoman Wilson noted, expanding access to affordable health
care and nutrition services is an important part of the solution.
However, as women increasingly work later into their pregnancies and
return to work shortly after the baby is born, we must also ensure that
our workplaces support the health of mothers and infants. In this area,
federal law falls woefully short.
For example, federal law currently does not guarantee all new
mothers the right to express breast milk. Workplace breastfeeding
supports, such as designated pumping breaks and private space, are
particularly critical for both maternal and infant health.
Unfortunately, while employers are required to provide pumping breaks
and break time for some workers, a gap in the law has caused millions
of overtime exempt employees to fall through the cracks. Furthermore,
even covered workers have limited avenues to ensure their employers
provide pumping breaks and a private space.
I think we can all agree that this is unacceptable. There is no
question that our country is facing a maternal and infant health
crisis. There is no question that our mothers and infants are suffering
preventable tragedies that rarely occur in other developed nations. The
only question is whether we will come together and fulfill our
responsibility to find solutions and take action.
Thank you, again, to our witnesses for joining us today.
______
Chairwoman Wilson. I now recognize Workforce Protection's
Ranking Member Walker for an opening statement.
Mr. Walker. Thank you, Madam Chair.
Bringing a child into the world should be an exciting and
joyful time for women and their families, not one clouded by
fear and by worry. Unfortunately, infant and maternal mortality
rates in the United States paint an abysmal picture. From 1990-
2015 the U.S. mortality rate increased by 34 percent. To put
that number into proper perspective, the global rate for
maternal mortality decreased by 44 percent over that same time
period. As for the United States infant mortality rates, they
are declining, but remain 71 percent higher than the comparable
country average.
Considering that the cause of these worsening and
troublesome trends aren't clear, we must be cautious of
implementing government mandates on employers that could end up
potentially doing more harm than good. With that said, though,
public policy has an important role to play in this issue,
which is why there are protections under Federal law that
safeguard mothers and their newborn babies' health.
For example, the Fair Labor Standards Act, the FLSA,
requires employers to provide reasonable workplace
accommodations and break time for nursing mothers for 1 year
after their child's birth. Women with children are the fastest
growing segment of the workforce. According to the Department
of Health and Human Services, 6 in every 10 new mothers are in
the workforce. So the types of accommodations included in the
FMLSA help our nation's workers and job creators succeed.
We agree that maternal and infant mortality trends are an
important concern which deserves our attention. In the past
Congress has been able to come together in a bipartisan manner
to tackle serious policy challenges. For example, last year
Congress passed H.R. 6, the SUPPORT for Patients and
Communities Act, bipartisan legislation to address the opioid
crisis, including mothers and infants affected by this terrible
epidemic. Our hope is that we can continue this bipartisan work
as we discuss solutions to address maternal and infant health
here today.
In closing, hundreds of maternal deaths occur every year.
These statistics are heartbreaking. As a Nation with some of
the most advanced obstetrics and emergency care, we can and we
should do better. But it is important that we legislate with a
reasoned approach backed by a careful examination of the issue,
which is why this hearing is a good starting point.
Again, thank you, Madam Chairwoman, for scheduling today's
hearing. I look forward to a thoughtful discussion and hearing
from all of our witnesses on how we can improve maternal and
infant health conditions.
I yield back.
[The statement of Mr. Walker follows:]
Prepared Statement of Hon. Mark Walker, a Representative in Congress
from the State of North Carolina
Thank you, Madame Chairwoman. Bringing a child into the world
should be an exciting and joyful time for women and their families, not
one clouded by fear and worry.
Unfortunately, infant and maternal mortality rates in the U.S.
paint an abysmal picture. From 1990 to 2015, the U.S. maternal
mortality rate increased by 34 percent. To put that number into
perspective, the global rate for maternal mortality decreased by 44
percent over the same time. As for U.S. infant mortality rates, they
are declining, but remain 71 percent higher than the comparable country
average.
Considering that the cause of these worsening and troublesome
trends is unclear, we must be cautious of implementing government
mandates on employers that could end up doing more harm than good.
With that said, public policy has an important role to play in this
issue, which is why there are protections under federal law that
safeguard mothers and their newborn babies' health.
For example, the Fair Labor Standards Act (FLSA) requires employers
to provide reasonable workplace accommodations and break time for
nursing mothers for one year after their child's birth.
Women with children are the fastest-growing segment of the
workforce. According to the Department of Health and Human Services,
six in every 10 new mothers are in the workforce. So, the types of
accommodations included in the FLSA help our nation's workers and job
creators succeed.
We agree that maternal and infant mortality trends are an important
concern which deserves our attention. In the past, Congress has been
able to come together in a bipartisan manner to tackle serious policy
challenges. Last year, Congress passed H.R. 6, the SUPPORT Patients and
Communities Act, bipartisan legislation to address the opioid crisis,
including mothers and infants affected by this terrible epidemic. Our
hope is that we can continue this bipartisan work as we discuss
solutions to address maternal and infant health here today.
In closing, hundreds of maternal deaths occur every year. These
statistics are heartbreaking. As a nation with some of the most
advanced obstetric and emergency care, we can and should do better. But
it is important that we legislate with a reasoned approach backed by a
careful examination of the issue, which is why this hearing is a good
starting point.
Again, thank you, Madame Chairwoman for scheduling today's hearing.
I look forward to a thoughtful discussion and hearing from our
witnesses on how we can improve maternal and infant health outcomes.
______
Chairwoman Wilson. Thank you.
Without objection, all other members who wish to insert
written statements into the record may do so by submitting them
to the Committee Clerk electronically in Microsoft Word format
by 5:00 p.m. on February 10, 2020.
I will now introduce our witnesses.
Stacey Stewart is the President and CEO of the March of
Dimes. In this role Stewart heads the organization leading the
fight for the health of all moms and babies.
Nikia Sankofa is the Executive Director of the United
States Breastfeeding Committee, an independent nonprofit
coalition of more than 100 influential professional,
educational, and governmental organizations that share a common
mission to drive collaborative efforts for policy and practices
that create a landscape of breastfeeding support across the
United States.
Dr. Joia Crear-Perry is the Founder and President of the
National Birth Equity Collaborative and a board member of the
Black Mamas Matter Alliance. She is a thought leader around
racism as a root cause of health inequities.
Welcome to each of you powerful Black women.
We appreciate all of you for being here today and we look
forward to your testimony.
Let me remind the witnesses, we have read your written
statements and they will appear in full in the hearing record.
Pursuant to Committee Cule 7(d) and committee practice, each of
you is asked to limit your oral presentation to a 5-minute
summary of your written statement.
Let me also remind the witnesses that pursuant to Title 18
of the U.S. Code, Section 1001, it is illegal to knowingly and
willfully falsify any statement, representation, writing,
document, or material fact presented to Congress, or otherwise
conceal or cover up a material fact.
Before you begin your testimony please remember to press
the button on the microphone in front of you so that it will
turn on and the members can hear you. As you begin to speak the
light in front of you will turn green. After 4 minutes the
light will turn yellow to signal that you have 1 minute
remaining. When the light turns red, your 5 minutes have
expired and we ask that you please wrap it up.
We will let the entire panel make their presentations
before we move to member questions. When answering a question,
please remember to once again turn your microphone on.
I will now recognize Ms. Stacey Stewart. Welcome, Ms.
Stewart.
TESTIMONY OF STACEY D. STEWART, PRESIDENT AND CEO, MARCH OF
DIMES
Ms. Stewart. Thank you and good morning, Chairwoman Wilson
and Chairwoman Adams, also Ranking Member Walberg and Ranking
Member Byrne, and members of the subcommittees. It is a
pleasure for me to be here today, and thank you for inviting me
to testify.
My name is Stacey Stewart. I am President and CEO of the
March of Dimes. Every day at March of Dimes we lead the fight
for the health of all moms and all babies. We began that fight
more than 80 years ago as an organization dedicated to
eradicating Polio in the United States, a goal that we
achieved. We continue that fight today as we work to address
some of the biggest threats to moms and babies, such as
premature birth and maternal mortality, through research,
through education, programs, and advocacy.
March of Dimes' mission is more important than ever before
as our Nation, as many of you all have mentioned, is in the
midst of a maternal and infant health crisis. Two babies die
every hour in the United States and one woman dies every 12
hours as the result of complications from pregnancy and
childbirth.
The most recent March of Dimes report card shows that the
Nation's preterm birth rate rose for the fourth year in a row
in 2018 and it revealed unacceptable disparities in outcomes
for babies born in certain communities. Infants of color and
those born in the southeastern United States are much more
likely to be born too soon. In fact, the preterm birth rate
among Black women is 49 percent higher than the rate among all
other women.
The state of maternal health mirrors that of infants born
too soon. Outcomes are getting worse and those worsening
outcomes are driven by disparities. Each year approximately 700
women die from pregnancy complications, and for every maternal
death another 70 women suffer life threatening health
challenges. That is 50,000 women every year. These startling
statistics make the U.S. one of the most dangerous developed
places in the developed world in which to give birth.
The threat is especially acute for women of color. Black
mothers of all ages are three times more likely to die from
pregnancy-related causes and complications than their White
peers. For Black and American Indian and Alaska Native women
over the age of 30 rates of maternal death are 4 to 5 times
higher.
We need your help to address this crisis by focusing on
policies that will improve both maternal and infant health.
March of Dimes was pleased by the passage of the Preventing
Maternal Deaths Act and the PREEMIE Reauthorization Act in late
2018. Both of these bills continue vital programs to collect
enhanced data on the causes of maternal mortality and premature
birth.
Fortunately, we don't have to wait for new data to take
additional action. We know that the causes of this crisis are
diverse. They can be traced issues in our health care system,
including quality of care and implicit bias. They stem from
factors in our homes, on our workplaces, in our communities.
There are additional steps you can take today to address
this crisis. A full description of those steps can be found in
my written testimony, but I will address policies most relevant
to the subcommittees' jurisdictions now.
First, Congress should take all necessary steps to ensure
that women have access to comprehensive and affordable health
care before, during, and after pregnancy and guaranteeing her
newborn has the same from birth. The Patient Protection and
Affordable Care Act codified a number of vital provisions,
including protecting individuals with pre-existing conditions,
guaranteeing coverage for maternity care, and ending annual and
lifetime caps on coverage. Lawmakers must protect and build
upon these protections.
The March of Dimes supports creating a new special
enrollment period for pregnancy, as outlined in the Healthy MOM
Act, to ensure all pregnant women have access to prenatal care.
We also support efforts to protect families from surprise bills
by simplifying the process for enrolling newborns in a family's
health plan.
Congress can guarantee women and infants have access to
both preventive care and treatment by strengthening the ACA's
requirement that health plans cover preventive services for
women and infants without cost sharing. Further, lawmakers
should require health plans to cover a minimum number of free
health care provider visits each year, as outlined in the
Primary and Behavioral Health Care Access Act.
While health insurance and health care services are
essential to healthy moms and babies, we cannot address this
public health crisis by focusing exclusively on doctors'
offices and hospitals. We have to address the barriers in our
communities as well. We also applaud efforts to improve the WIC
program. We strongly support reforms to ensure that every mom,
no matter where she works, can continue to breastfeed if she
chooses.
I look forward to expounding upon some of the proposals
that we are talking about today, and thank you for having me.
[The statement of Ms. Stewart follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Chairwoman Wilson. Thank you, Ms. Stewart.
We will now recognize Ms. Nikia Sankofa.
Welcome.
TESTIMONY OF NIKIA SANKOFA, EXECUTIVE DIRECTOR, UNITED STATES
BREASTFEEDING COMMITTEE
Ms. Sankofa. Good morning, Chairwoman Wilson and Chairwoman
Adams and Ranking Members Walberg and Walker.
Thank you for this opportunity to participate in today's
hearing to discuss American's maternal and infant health
crisis. It is an honor to share the insights I have gained from
2 decades of public health work at the community and national
levels.
I am the Executive Director of the United States
Breastfeeding Committee, an independent nonprofit coalition of
more than 100 national, tribal, regional, state, and community
organizations working together to drive policies and practices
that create a landscape of breastfeeding support throughout the
country.
Breastfeeding is a proven primary prevention strategy,
building a foundation for lifelong health and wellness.
Compared with formula fed children breastfed infants have a
reduced risk of illness, infection, and infant death. Women who
breastfeed their children have a reduced long-term risk of
diabetes, cardiovascular disease, and certain cancers.
The evidence for the value of breastfeeding to children and
women's health is scientific, robust, and continuously being
reaffirmed by new research. Leading health organizations
recommend exclusive breastfeeding for about 6 months followed
by continued breastfeeding as complementary foods are
introduced for at least the first year of life.
You might think that infant feeding decisions are a
personal family matter, but we are all shaped by our
circumstances. Lack of education in the prenatal period,
maternity care practices that do not prioritize breastfeeding,
returning home after birth unsure of where to go for support,
and having lack of access to counseling and supplies, such as
breast pumps, can compromise the early establishment of
breastfeeding. And lack of support in the community and
employment settings can stand in the way of continued
breastfeeding.
Recent data show that 84 percent of infants were ever
breastfeed, meaning that they initiated breastfeeding,
indicating that most mothers in the United States want to
breastfeed and start out doing so. But only a quarter are still
breastfeeding exclusively at 6 months and 60 percent of mothers
report that they did not breastfeed for as long as they
intended.
Some of these barriers to breastfeeding exist outside of
the mother's sphere of power or control and they
disproportionately impact young women, those with low income,
and women of color. This is reflected in significantly lower
breastfeeding rates across all tracked indicators for these
populations.
The key to supporting families and alleviating
breastfeeding disparities is investing in upstream policy
systems and environmental change solutions that deconstruct
barriers and build environments where healthy choices, like
sustained breastfeeding, can be the easy default option for
most families.
Some well-known breastfeeding policy systems and
environment change solutions include the Baby-Friendly Hospital
Initiative, WIC's Breastfeeding Peer Counselor Program, and the
2010 Break Time for Nursing Mothers law, which was unanimously
passed out of a bipartisan committee in recognition of the role
that breastfeeding plays in infant and maternal health.
Even with these systemic solutions in place, we know more
must be done. A simple and commonsense policy solution to
addressing ongoing workplace barriers is within reach of this
committee. The Providing Urgent Maternal Protections for
Nursing Mothers Act, the PUMP Act, was introduced with
bipartisan support for breastfeeding employees and it helps
breastfeeding employees while clarifying implementation
processes for employers across the Nation.
Nearly one in four women of childbearing age, that is 9
million employees, are excluded from coverage under the current
Break Time law, and as such they have no clear right to break
time and a private space to pump breast milk. Although state
legislation covers more than half of these employees, creating
Federal laws ensures that employers from all sectors are
considered and employees from all communities are supported
under a national law that recognizes the important of breast
milk in human and population health.
Without protections breastfeeding employees face serious
health consequences, including risk of painful illness and
infection, diminished milk supply, or inability to continue
breastfeeding. According to a recent report from the University
of California's Center for WorkLife Law, the consequences of
this coverage gap also include harassment at work, reduced
wages, and job loss, putting some new mothers in the position
of risking their family's economic security by attempting to
continue breastfeeding and working.
The PUMP for Nursing Mothers Act would strengthen the 2010
Break Time law by closing the coverage gap for women who are
not currently covered, providing employers clarity on when
pumping time must be paid and when it may be unpaid, and
providing remedies for nursing mothers.
We know that the vast majority of people become parents
during their lifetime and their needs and the needs of their
infants are neither surprising nor difficult to meet if we plan
appropriately.
Thank you for this opportunity.
[The statement of Ms. Sankofa follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Chairwoman Wilson. Thank you, Ms. Sankofa.
We now recognize Dr. Joia Crear-Perry.
Welcome.
TESTIMONY OF JOIA CREAR-PERRY, MD, PRESIDENT, NATIONAL BIRTH
EQUITY COLLABORATIVE
Dr. Crear-Perry. Thank you so much. Thank you, Chairwoman
Wilson, Chairwoman Adams, Ranking Members Walberg and Byrne, as
well as members of the House Committee on Education and Labor,
for allowing me, Dr. Joia Crear-Perry, to provide testimony for
this Expecting More: Addressing America's Maternal and Infant
Health Crisis hearing representing the National Birth Equity
Collaborative and the Black Mama's Matter Alliance.
We can support improvements for all workers of reproductive
age to grow their families with the appropriate wages, dignity,
and protections they deserve. Women are integral to every
industry in the U.S. Can they trust this body to support them
through their pregnancy and return to the workforce? We can
begin by shoring up the existing state investments for new
mothers that are based upon evidence, like diversifying our
workforce, scaling and deepening the ACOG Alliance for
Innovation on Maternal Health, and building a community for
respectful care, increasing our investment in the CDC-supported
Perinatal Quality Collaboratives, mandating implicit bias and
anti--racism training, and uplifting the leadership influence
of the National Institutes of Health, Office of Research on
Women's Health, Federal Divisions.
We can solidify these investments by heeding the
recommendations of entities like us at the Black Mamas Matter
Alliance.
As has been mentioned, the CDC defines pregnancy-related
death as a death of a woman while pregnant or within 1 year of
the end of pregnancy, regardless of outcome, duration, or site
of the pregnancy, from any cause related to or aggravated by
pregnancy and its management. Based on that definition, the CDC
found in their surveillance 2,726 women died in the United
States between 2011 and 2014, and of those 1,010, or 38 percent
were Black. Based on that data and estimates of maternal
mortality data from the CDC, a modest estimate of loss of
preventable causes is about 1,000-1,500 Black mothers in the
last decade. That is a caravan of coach buses each year. This
is unacceptable.
Furthermore, over 60 percent of these deaths were
preventable. As a Black woman from the Deep South who is an
obstetrician and a mother, my strong desire to end this
inequity is amplified every time I look into the faces of my
daughter and my patients. The legacy of a hierarchy of human
value based upon the color of our skin continues to cause
differences in health outcomes, including maternal mortality.
Racism is the risk factor, not my Black skin. There is not
Black gene. Race is a social and political construct. Maternity
mortality extends beyond the period of pregnancy and birth.
Nine months of prenatal care cannot counter underlying social
determinants of health inequities, in housing, political
participation, transportation. Currently we do not have access
to maternity care that is culturally congruent. Lack of
workforce diversity and provider shortages are a direct
consequence of policies created in halls like this that date
back to the 1921 Sheppard-Towner Act, among others.
I am the founder of the National Birth Equity Collaborative
and on the founding board of the Black Mamas Matter Alliance.
The National Birth Equity Collaborative creates solutions that
optimize Black maternal and infant health through training,
policy and advocacy, research, and community centered
collaboration. When working with large hospital systems as we
currently do, health departments, and large legacy
organizations to build a culture of reproductive justice, we
have learned that Federal policy and investment is critical. As
Black birthing people we have been devalued for generations,
and that devaluation shows up in your policy choices that you
pick today.
The Black Mamas Matter Alliance serves as a national voice
and coordinating entity for stakeholders advancing maternal
health, rights, and justice and intentionally centers Black
women's leadership. BMMA has a network of organizations with
reach and relationships and capacity that you could support for
an intergenerational movement.
Ultimately, what Black women in the United States need is
accountability. We need to know that our lives are valued. This
accountability may be complicated, by government still has an
obligation to act. Racism, classism, and gender oppression are
killing us from rural to urban America. This is not about
intentions. Lack of action is unintentionally killing us and it
is a human rights imperative.
This hearing that calls for us to expect more is an
opportunity for esteemed members of this Education and Labor
Committee to look deeply at all the ways policies around our
social determinants of health are causing maternal morbidity
and mortality. We must be willing to continue to name this
problem directly.
Yes, Black Mamas Matter.
[The statement of Dr. Crear-Perry follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Chairwoman Wilson. Thank you, Dr. Crear-Perry.
Under Committee Rule 8(a) we will now question witnesses
under the 5-minute rule.
I will now yield myself 5 minutes.
Dr. Crear-Perry, in your testimony you discuss the history
of the Sheppard-Towner Act of 1921 and the impact it had on
midwifery, and Black midwifery in particular. How many Black
midwives are in practice and what policies do you think
Congress could pursue to increase the number of Black midwives?
Dr. Crear-Perry. Well, we currently know that less than 5
percent of midwives in practice are Black and we also know that
there is a shortage of midwifery in general in this country.
When that Act was enacted we were still operating in a belief
that people of color and Black people were not fully capable of
providing the care that everyone needs. And so we did things
like that were harmful and didn't value the women who had been
birthing America for generations.
So there is an opportunity for us to say well what is it
that people and patients want. When we interview women, they
really want less intervention, they want a midwife, they want
someone who looks like them, who understands them. So an
opportunity through Congress is to increase the workforce
development, have nursing programs at HBCUs, like my own
hometown of Grambling, to ensure that we have access to
midwifery programs, because that is a direct pipeline. There
are nursing schools at a lot of the HBCUs that do not have
access to midwifery programs as well.
Chairwoman Wilson. Thank you.
In your testimony you discuss some of the history of racism
within the field of obstetrics and gynecology. Today, we know
that when Black women seek medical treatment they receive a
lower quality of care than their White counterparts. Can you
say more about the role of Dr. J. Marion Sims in this history
of OB/GYN?
Dr. Crear-Perry. Yes, thank you so much.
So as you may know, Dr. J. Marion Sims traveled across the
United States with three Black women who were enslaved. Their
names were Lucy, Betsey, and Anarcha. I would like to uplift
their names because they are human beings who existed, who we
don't even honor and they don't have statues. We have statues
and honors for J. Marion Sims. We name--if you are an OB/GYN
and you reach for a retractor, you are asking for a Sims
retractor. That name comes from a man who traveled around the
country doing experiments on women without any anesthesia and
then he wrote, based upon the fact that these Black women could
handle these surgeries with anesthesia, that we clearly did not
feel pain the same way that White women did. And that believe
still pervades today. There are studies that show, from
prestigious universities in the United States, that medical
students still believe that Black people do not feel pain the
same way. As if melanin has something to do with your pain
receptors.
So it is important for us to really think about all the
ways that racism is embedded in how we created obstetrics and
gynecology, how we decimated midwifery, and how we still
provide care today and how we do not acknowledge those truths.
We are not taught even about J. Marion Sims when you are
training in medical school or residency. So you don't even have
an understanding of the retractor that you are asking for and
how it was used and created on the bodies of people who were
not valued.
Chairwoman Wilson. Okay, thank you.
About 1 in 33 children in the United States is born with a
congenital anomaly. Some of these conditions, such as a cleft
palate, can have serious impact on a child's ability to breathe
and to speak.
Ms. Stewart, does March of Dimes support legislation such
as Ensuring Lasting Smiles Act that would close this gap in
coverage for these children?
Ms. Stewart. Thank you, Chairwoman.
Yes, the Ensuring Lasting Smiles Act is Federal legislation
that would do some very important things.
First of all, it would ensure that all private group and
individual health plans cover medically necessary services,
including needed dental procedures as a result of congenital
anomalies. And, as you mentioned, about 4 percent of children
in the U.S. are born with these kinds of anomalies or birth
defects. And of course the March of Dimes in our history has
been very dedicated to addressing the issues of birth defects
among children.
But the issue is that while most private health plans do
provide coverage for surgical treatment of many of these
anomalies and there are many states that actually require
insurers to provide coverage for health services related to
some of these birth defects, we still hear that there are too
many health plans that often deny claims and appeals for oral
or dental related procedures, like orthodontia or dental
implants and other procedures. And what this means for these
families is that they are often left to have to figure out how
to pay for these services on their own. And some of those
expenses can be extraordinary and often devastating financially
to many of these families.
So we support the Ensuring Lasting Smiles Act along with
over 30 other organizations because we think that when babies
are born, due to no fault of their own or their families, with
these kind of birth defects, they deserve and need the
treatment, often these dental surgeries to make sure that not
only can they really thrive as kids, but they can actually
function as normal human beings, because some of these kinds of
birth defects affect their ability to breathe, their ability to
eat. They are more than just cosmetic surgeries, they are
actually medically necessary, and medically indicated
surgeries. So we are in strong support of the Ensuring Lasting
Smiles Act because we believe that it will provide the support
that is needed to so many of these families.
Some of these families are even here today, like the Abbott
family from Wisconsin I just got a chance to meet, and families
that have been really impacted by some of these issues. And
without some of the support from the Ensuring Lasting Smiles
Act we would leave too many families too vulnerable--
Chairwoman Wilson. Thank you.
Ms. Stewart.--and without the care that the need.
Chairwoman Wilson. Thank you very much.
I ask unanimous consent to enter into the record letters of
support for this legislation.
I now recognize member Walberg, my Ranking Member for his
round of questions.
Mr. Walberg. Thank you, Madam Chairwoman, and thanks to the
panel for being here today and taking the effort to join us
this morning.
Ms. Stewart, last Congress I was proud to serve as member
of the Energy and Commerce Committee as we passed a bipartisan
bill, H.R. 1318, the Preventing Maternal Deaths Act, which
reauthorized funding for the Centers for Disease Control and
Prevention programs that support state and local maternal
mortality surveillance and prevention programs, added
additional funding for state governments to establish maternal
mortality review commissions. H.R. 1318 was signed into law by
President Trump in December 2018. These state commissions
worked to collect, to track, analyze, and report data on
maternal and infant outcomes in states that have established
these commissions.
How has the increased availability of data impacted
maternal safety and quality improvement initiatives?
Ms. Stewart. Thank you.
Well, one of the things that is really important as we
address the maternal and infant health crisis is being able to
collect good data, good, reliable data across the country. And
thank you for your support for the Preventing Maternal Deaths
Act, because it did provide the impetus for every state to be
able to establish what we call a maternal mortality review
committee. We now have every state, with the exception of
three, that have established these MMRCs. And what they are
doing is actually going collecting the data. The underlying
data is really important to understand the cause of death, why
a mother may have died as a result, and tie it back to
obviously the fact that she may have just had a baby or any of
the causes due to pregnancy and childbirth.
These state-based committees are full of experts who really
analyze this data and then help design recommendations or
interventions to prevent further deaths from happening. So
before this, we didn't have this kind of data collection
effort. Now that we do, we are able to look more deeply at the
underlying causes of maternal mortality and morbidity and
design at a federal level or at a state level the kinds of
interventions that will hopefully prevent these kinds of deaths
from happening in the future. We would not be able to do this
work and accelerate our interventions and our successes with
this crisis if we didn't have more robust data collection.
Mr. Walberg. It will certainly take some time for that to
work in, but we are seeing benefits already?
Ms. Stewart. We are starting to see benefits. We still have
three states that need to establish MMRCs and then we need to
start collecting the data and reporting it up.
Mr. Walberg. What are those states?
Ms. Stewart. South Dakota, North Dakota, and Wyoming, as I
understand it.
Mr. Walberg. Okay. Dr. Crear-Perry, high-risk pregnancies
can pose significant challenges to all women and to health
providers. I am a grandfather and when I am asked how many
grandkids I have, I say one in heaven and five on the ground.
My first two were twin boys born at 24 weeks, 1.12 ounces, 12
inches long. John Timothy is in heaven waiting, but thanks to
the wonderful care that they received in Northwestern
University Hospital on the north side of Chicago, Mike is now
13 and almost 6 feet tall, healthy, and going strong. But my
daughter-in-law also was part of that process, and thank god
she was given great care and pulled through.
So it is an important issue that we are talking about
today. Some hospitals have successfully implemented standard
protocols to address common high-risk scenarios. In looking at
labor and delivery issues, hemorrhaging, high blood pressure,
et cetera, how can these protocols help increase quality and
decrease maternal mortality rates?
Dr. Crear-Perry. I had a one pounder myself. He is now 23
years old. He was supposed to come with me this morning, but he
played video games too late last night, so he is not here with
me. So I appreciate that.
Mr. Walberg. So he is normal?
Dr. Crear-Perry. Exactly. So I am making him watch it on
YouTube.
No, so it is important of course that the way that those
tools work is we can have standards for hospitals. So, for
example, the Joint Commission just passed--who accredits
hospitals--asked the hospitals--they have about a year to get
it together to report on hemorrhage and how they are using the
bundles. And so we have seen improvements. In fact, the State
of California saw a large decrease in the number of deaths
after really implementing the use of those hemorrhage bundles
and hypertension. And what they found, though, is that there
still was bias around who was implementing the bundles. So now
we are going back and we are saying how can we do this in a
more equitable way and how can we do things like work on our
implicit biases.
But it is important to have those tools so that you have a
standard of how you are supposed to take care of patients.
Mr. Walberg. Okay. I appreciate that.
In the very limited time here, Ms. Stewart, we talked about
the United States and its problem. As U.S. maternal mortality
rates continue to increase, are other countries experiencing
similar increases and are we learning something from that as
well?
Ms. Stewart. Well, we are sort of unique in that we are one
of the few, if any, of the largest industrialized countries in
the world with increasing maternal mortality rates. I think it
was mentioned earlier that we kind of stand alone in that
respect.
I do think there are things that we learned from other
countries where the rates have been declining, where you see a
range of other supportive policies to make sure that women are
provided the support that they need. In the UK, for example,
there are lots of supports that women are given through
midwifery care and through other kinds of home visiting
programs that actually are providing a lot of support to women
during pregnancy and even postpartum. Our country lacks in
terms of the ability to expand these kinds of policies to many
women and that leaves many women falling through the cracks.
We also know a couple of things. One is that we will not
solve this issue just by looking at the 9 months of pregnancy.
We have to look at women before they are pregnant, during
pregnancy, and after pregnancy. We also have to make sure that
we look at health care and health and wellness for women. It is
not just something that happens in the doctor's office because
so many of the issues that impact a woman and her health and
the baby's health have to do so much with their environment and
what we call the social determinants of health, how they live
their day to day lives. And until we get a full handle on
policies that address the totality of how women live in this
country, we won't be able to address this issue in the way we
need.
Mr. Walberg. Thank you. I yield back.
Chairwoman Wilson. Thank you. Thank you, Ranking Member
Walberg.
I remind my colleagues that pursuant to committee practice
materials for submission for the hearing record must be
submitted to the Committee Clerk within 14 days following the
last day of the hearing, preferably in Microsoft.
And now we will hear from our members. Dr. Adams, who has
been on the forefront of this issue here in Congress, along
with Nurse Underwood. I commend them.
Now, Dr. Adams.
Ms. Adams. Thank you, Madam Chair.
Dr. Crear-Perry, thank you for highlighting the importance
of training providers as a strategy to reduce the racial
disparities that we are seeing in maternal and infant health
outcomes. And that is why I introduced the Maternal CARE Act,
which would create implicit bias training grants.
In your experience working with physicians and other health
care providers, how common is implicit bias training and what
kind of gaps do you see in the training of health care
providers?
Dr. Crear-Perry. So right now it keeps me very busy doing
implicit bias training, and we just did one in Kaiser in
Atlanta. We trained their entire maternal and child health
division. So that is everybody from the people who answer the
phone to the actual high-risk OB/GYNs.
So there is an opportunity we have right now to really
build up on these trainings. My organization is one of several
that do these trainings. I know the March of Dimes has created
some work around that as well.
And the importance is that we need to understand our own
biases in health care and how we were taught those things. And
biases are not--they are coded in us, we can change it. We
don't have to believe that Black people are broken, we don't
have to believe that women can't do things. Those are things
that we have been taught, and so they are part of our implicit
biases now. But we can change that.
Ms. Adams. Thank you.
My home state of North Carolina has a program called
Pregnancy Care Management and provides needs assessments,
coordination of care, and other supports for eligible women
with at-risk pregnancies. The program has been cited as a
factor in--in halving the Black maternal death rate in North
Carolina. Why is coordination of care and supportive services
particularly effective for Black mothers? And what can Congress
do to support these types of programs?
Dr. Crear-Perry. I have the honor of working with Dr.
Menard and others at UNC around that work, the Pregnancy
Medical Home work, and this idea that you can have
coordination. Because as was mentioned by Ms. Stewart, we are
losing people in the gaps. They don't have access to the
coordination around breastfeeding or if they need
transportation or housing. So this coordinated care model,
which was I think spun out through Medicaid, allows for you to
then also have coordination with other services in North
Carolina and they have seen a decrease in their Black maternal
health mortality, they also saw the gap close in the disparity
in North Carolina. So you should be really proud of your home
state for putting that forward.
Ms. Adams. Well, I am, you know, of some things. So do you
agree that WIC has an opportunity to play a greater role in
this conversation?
Dr. Crear-Perry. I love our WIC partners. We did a training
of implicit bias at the WIC conference last year as well. And
so because they touch more moms than most anybody--I mean
people go to WIC when they don't go to their pediatrician, when
they don't go--they definitely don't go to their postpartum
visit to see us, and so WIC is an important partner. They
already have boots on the ground and they know the mothers.
Ms. Adams. Thank you.
Ms. Sankofa, recently the Department of Labor finalized
regulations narrowing its interpretation of joint employment
status under the Fair Labor Standards Act, which contains the
nursing mother's protections that you discussed. Although the
rule does not have the force and effect of law, it tells us how
the Department will be enforcing joint employment standards for
determining if an employer must comply with these requirements.
What is the impact of this, and especially where the
nursing mother has limited ability to take legal action against
the employer?
Ms. Sankofa. I think that is an excellent question and I
appreciate it because I really think that it makes it more
difficult for the lactating mother to really enforce their
right to have a clean and private place to pump and store their
milk while they are at work.
As I said at the end of my oral testimony, when employees
don't have a clean and adequate safe space, private space in
order to pump their milk, they have to make these difficult
tradeoffs, and this tradeoff is do you want to stay employed
and have economic viability for your family, or do you want to
provide the nutritional biological standard for your infant.
And I think it is important--we often say that breast is best,
while it is true, breast is the nutritional standard, it is
what everybody is supposed to have, it is how people are fed,
and everything else is actually something that is inferior to
breast milk.
Ms. Adams. All right. Okay. So protections that entitle
nursing workers to break time and private space to express milk
are only available to those who are eligible for overtime pay,
so who are we leaving out by only protecting who is eligible
for overtime pay, and is there a policy reason why these women
should not have the right to break time and a private space to
express milk?
Ms. Sankofa. We are leaving out, as I said, up to 9 million
workers in the United States. And those are typically salaried
employees. That includes people who you know, like if you all
have children, you have teachers in your life. So it includes
teachers, it includes nurses, it includes software engineers,
it includes many of the people who you encounter every day. And
I don't know that there is actually a policy reason that these
families are not covered by the Break Time for Nursing Mothers
law. I think that placement in statute made that gap present.
And I think that the PUMP Act gives us the opportunity to kind
of right size. We have 10 years of recognized defects within
the system to be able to really see where we can take the next
step to kind of close that gap.
Ms. Adams. Great. Thank you very much, Madam Chair. I yield
back.
Thank you for your responses.
Chairwoman Wilson. Thank you, Dr. Adams.
Mr. Walker?
Mr. Walker. Thank you, Madam Chair.
As I listen today I appreciated the passion of all the
witnesses here today. It makes me think of my wife, who is a
family nurse practitioner, and her boss, Dr. Lisa David, is the
chair there at Wake Forest Baptist Medical Center, and they
work with infants and children with cleft palates and do great
work. So a quick shout out to them and their work.
Ms. Stewart, you mentioned the increase in the Nation's
preterm birth rate to 10 percent. And I am sad to say maybe
this picks up with Dr. Adams there, that our home state of
North Carolina even has a higher rate, a 10.4 percent, I
believe a D rating.
The March of Dimes report card I believe is where that was
listed. What would you say attributed to this shift in the
preterm birth rate after a decade of decline?
Ms. Stewart. So unfortunately we don't know all the answers
of why the preterm birth rate has increased. What we know is
that in general health outcomes for moms and babies have
generally declined in this country over the past many years.
And there are a various number of reasons for it.
First of all, I will just let you know the March of Dimes
has six prematurity research centers, five in this country, one
in the UK, all working together to try to look at some of the
underlying causes, biological reasons why some of this is
happening. But we also know that the impact of the way women
and families--women especially--live in this country could also
have a serious impact. So the degree of stress on women,
especially before pregnancy and after, during pregnancy and
even after.
We also know that--a lack of access to care. We have too
many women living in places where even if they have coverage
they may not have care, and those are two different things. So
we have, even in a state like North Carolina, places, counties
that are considered maternal care deserts where women are not
able to access the kind of prenatal care that they need in
order to have successful pregnancies.
So there are a variety of reasons for it.
Mr. Walker. Gotcha. Yeah. You and certainly my wife would
know more than I, but I believe preterm or premature birth is
defined as before 37 weeks, is that correct?
Ms. Stewart. Before 37.
Mr. Walker. It is the number one cause of infant death in
the United States, with an average of 275 babies being born
preterm per week. I know it is in North Carolina.
What challenges or complications can infants face who are
born preterm, and what challenges do their mothers face as
well?
Ms. Stewart. Well, either I can talk about it or Dr. Joia
Crear-Perry can because she has personal experience with it.
Mr. Walker. Sure.
Ms. Stewart. But we work on this issue as a primary issue
for the March of Dimes. As I mentioned, 380,000 babies born
every year prematurely, again, before 37 weeks of gestation.
What we know is a lot of those preterm births are happening in
the period between 34 and 36 weeks, so very late preterm, but
some of the most devastating effects happen for a baby like Dr.
Crear-Perry's baby, born at a very early preterm stage, so at
21 weeks or 23 weeks of gestation.
And for those babies, the effects can be devastating.
Babies can have developmental delays, cognitive delays,
physical disabilities, and a whole range of lifelong health
complications that are very expensive to address.
One of the things that the March of Dimes did is we updated
a study on the cost of preterm birth. About over a decade ago
we looked at it at a cost of $26 billion in this country, it is
now well over $30 billion. So it has a significant cost of the
country from a productivity standpoint, as well as families and
those children individually.
Mr. Walker. Thank you.
Certainly I am someone that believes that life is precious,
whatever term that it might be in. I know that is not our
discussion today, but any kind of biases before or after
something is important to me. And I know, Dr. Crear-Perry, that
is kind of your kind of specialty area, if it is; and someone
who tries to advocate for all people, I would be concerned
about that. So you are telling me that you see biases in there.
I want to take that at face value, but I also want to ask you
on those biases, do you believe they are intended? Is it out of
ignorance? Is it out of an intentional--can you break that--I
have got a minute left. I am going to skip my final question
because I want to hear from you on that as well, because that
is important to me.
Thank you.
Dr. Crear-Perry. They are definitely not intended. They are
definitely things that we all kind of grew up believing. I
believed--I was taught in medical school by my professors that
there were three races, mongoloid, caucasoid, and negroid. That
was what I was taught. So I believed that the reason that I had
a baby preterm is because I was Black, because there was
something inately--so that is a bias that we have been teaching
that we have to undo, that we have to retrain. As my
grandmother would say, we have to unlearn us, right. We have
learned some things that are incorrect. So it is an opportunity
for us to really--we are all the same. There is no difference
between you and I. Our biology is the same. And so how do we
then think about what are we doing as a country to ensure that
we both have a good outcome?
Mr. Walker. Thank you, Dr. Crear-Perry. I appreciate your
passion in that area.
With that, I yield back to Madam Chair.
Chairwoman Wilson. Thank you so much.
And now Mr. Courtney from Connecticut.
Mr. Courtney. Thank you, Madam Chairwoman, and to both
Chairs and Ranking Members for holding this hearing.
The topic here today should shock the conscience of every
American. And what I want is to just thank all the witnesses.
Just that, you know, you have put forth some really, you know,
manageable, doable solutions that, again based on your
testimony, I think should encourage us all that we actually
have the tools to address this. So, again, thank you all for
being here today.
And also that, you know, these two subcommittees I think
really, you know, also are positioned to move forward on these
issues.
Ms. Stewart, you mentioned--and I think Dr. Perry also in
your testimony alluded to the fact that the ACA when it passed
obviously moved the ball forward in terms of maternity care,
Medicaid coverage, and also the essential health benefits. But
I do think, as Ms. Stewart's testimony indicated, I think it
would surprise people to know that the age 26 coverage, which
is hands down probably one of the most popular, if not the most
popular provision of the law, does not extend to dependent
adult children in terms of maternity benefits. The number we
have is that it is about 4.2 million women, ages 19-25 that are
covered under their parents' health insurance plans, again have
that gap. And Mercer, which is a pretty credible think tank
study, found that approximately 70 percent of employers don't
cover maternity care for dependents.
So, again, this is the subcommittee that actually wrote the
age 26 provision, because we have ERISA jurisdiction. Again, I
wonder, Ms. Stewart, if you could just sort of talk a little
bit about how that is maybe contributing to this issue, that
gap.
Ms. Stewart. No, I really appreciate it. And I think you
are right in that it is certainly one of the most popular
provisions in the ACA, that health plans offer dependent
coverage for children up to the age of 26. And the inclusion of
an essential health benefit--so it is a part of ACA--has also
been a huge benefit to pregnant women for maternity coverage.
What we know though is the essential health benefits only apply
in the individual and small group markets. So these health
plans for these large employers who are not required to provide
coverage for maternity care for dependents leaves this large
gap and this large loophole, about 4 million young women who
are covered as dependents but don't have access to this kind of
coverage.
So we think that it is very important to deal with this
loophole that potentially puts a lot of women at risk, it
subjects them potentially to a lot of out of pocket costs if
they become pregnant. And certainly this gap in coverage is
actually threatening their own health and potentially the
health of their baby if they are not able to receive the proper
prenatal coverage and the kind of care that they may need. So
addressing this loophole will be very important. And it is,
again, millions of women that are left in this gap.
Mr. Courtney. Dr. Perry, I don't know if you would like to
comment as well.
Dr. Crear-Perry. As a person who has a 26 year old
daughter, I was super depressed when she had to get off my
insurance. So I appreciate that exists and that it is popular.
And you think about who gets pregnant, it is 21-26 year
olds, and we are leaving off millions by not having this
loophole addressed. So it is important for us to recognize if
mortality is something we care about and morbidity and
parenting and mothering, then we would not leave a space where
people don't have access to care.
Mr. Courtney. Thank you. I have a 25-year-old, so we are
holding on by our fingernails.
And, again, Ms. Wilson, I want to just to again thank you
for bringing up the issue of the Ensuring Lasting Smiles Act
and the impact of that sort of fragile coverage for congenital
birth defects.
I have a letter which I ask to be admitted to the record
from Caleb Andrew Lock, who is a 10-year-old just passionate
advocate who represents Rhode Island and Connecticut and
describes his own situation, which as he points out, if it was
caused by a car accident it would be covered, but the fact that
it is a congenital defect runs into this obstacle, which is
just completely unacceptable.
So, again, thank you for addressing that issue and
hopefully that bill will move forward because of the spotlight
you are putting on it here today.
And with that, I yield back.
Chairwoman Wilson. So ordered.
Dr. Roe, you know all about this.
Dr. Roe. Thank you, Madam Chair.
And, Ms. Stewart, this has nothing to do with this hearing,
but we are working on your pension issue at the March of Dimes,
okay?
Ms. Stewart. It only helps us deal with our other issues
too. Thank you so much.
Dr. Roe. And I want to congratulate this entire committee.
Every one of you finished in exactly 5 minutes, so
congratulations.
A few things I want to go over very quickly. And, Ms.
Sankofa, I want to get this on the record thanking you for
advocating breastfeeding and I think that is a huge thing that
you have done. And also to encourage women out there that may
be watching this to use the WIC program.
My background, I am an obstetrician. And I have got a
little head start on your, Dr. Perry. I have delivered almost
5,000 babies. And one of the things I noticed in my practice, a
couple of things that have not been mentioned at all, is
obesity and drug addiction.
In our state of Tennessee, in 1998 we had 50 opioid-
addicted babies in the entire State of Tennessee. It would have
been a rarity to ever see in our--now we have a NICU, of which
the surgeon general will be there this Thursday visiting our
children's hospital, specifically for opioid addicted babies.
And I know absolutely it is depressing to me to see maternal
mortality rate in the late '70s being lower than it is today
with all the enormous amount of resources and money we have
spent.
And would you, Dr. Perry, go--I think it is very important,
the definition of maternal mortality and is it described that
way, defined that way in other countries?
Dr. Crear-Perry. I don't want to mess up the real
definition so I could read it again, but how we define it is a
global definition. So up to 42 days it is a standard and no
matter the site or the--within 42 days of delivery. What we
also are starting to do in the United States though is
recognize women are dying up to a year later. So although the
international standard is 42 days, we really don't have--we
know that people die from opioid and substance abuse 3 months
later, right. And it is still tied to the pregnancy. So we are
now tracking deaths up to a year and really pushing the
international community to start thinking about doing the same
thing.
Dr. Roe. Just to give you an example, in our state this
year we are trying to take our Medicaid-covered patients, whose
coverage in maternal would be out at 6-8 weeks postpartum, and
extend that for a year.
Dr. Crear-Perry. Yes, yes. Exactly.
Dr. Roe. Because what we are finding is some of these women
who are opioid addicted will go overdose later.
Dr. Crear-Perry. Yes. Yes.
Dr. Roe. And I think that is important for every state to
do that.
Dr. Crear-Perry. It is critical. And if you think about us
as OB/GYNs, we believed 6 weeks was the magical thing, and so
we had insurance end at 6 weeks, but that doesn't match
actually the science. The science shows us that women have
cardiomyopathy within 6 months to a year later and can die. So
all these other things around childbirth are still impacting
your body, and there is nothing magical about 42 days.
Dr. Roe. I totally agree with that. And the risk factors
that you see for maternal mortality would be age, obviously.
Women are older when they have their children. Ethnicity, which
you mentioned, obesity, lifestyle, which could be opioids, drug
addiction, other things, preeclampsia. We know those things.
But why do you see--because to me to have it almost double--
Dr. Crear-Perry. Right.
Dr. Roe.--is one of the most distressing things with the
amount of money that we put into maternal health in this
country.
Dr. Crear-Perry. Right. And so it would be a few things.
One of them is our lack of investment in community-based
organizations and hospitals are--when you practiced, you knew
everybody around you, I am sure, and we just don't have that
kind of system anymore. So how do we have a system that values
the community members who are close and understand the moms,
and so really getting back to being close to that.
We also increased our c-section rate, you know that.
Dr. Roe. Yeah.
Dr. Crear-Perry. And so a lot of women are dying from
hemorrhage and other things after having a c-section. We have
one of the highest c-section rates in the world, and we then
export that to other countries. India starts following us and
having high c-sections too. So we need to really think about
why we are doing some of the choices we are doing. And this
body has a greater capacity to hold systems accountable for
making choices.
Dr. Roe. That was one of the other thing I was going to
bring up. I have looked at--when I stopped delivering babies I
looked at my primary cesarean section rate.
Dr. Crear-Perry. Yeah.
Dr. Roe. And I was trained in Memphis, very similar to
where you are in New Orleans.
Dr. Crear-Perry. Mm-hmm, yeah, exactly.
Dr. Roe. And it was 8 percent.
Dr. Crear-Perry. Yup.
Dr. Roe. Primary cesarean section rate.
Dr. Crear-Perry. Yup.
Dr. Roe. Now it is probably 30-35 percent.
Dr. Crear-Perry. Exactly, exactly.
Dr. Roe. And the mortality rate is much higher, as we
know--
Dr. Crear-Perry. Exactly.
Dr. Roe.--in cesarean births as opposed to a natural birth.
I would like some firm things. We did this in Memphis many,
many years ago. We had neighborhood clinics--
Dr. Crear-Perry. Yup.
Dr. Roe.--for women who had a hard time getting--this is
urban areas.
Dr. Crear-Perry. Exactly.
Dr. Roe. I live in a rural area. And someone mentioned an
OB/GYN desert.
Dr. Crear-Perry. Yup.
Dr. Roe. I represent four counties and four, almost five,
of them have zero obstetrical care in those counties, which
means they have to drive long distances.
Dr. Crear-Perry. Right.
Dr. Roe. In Memphis we had neighborhood clinics and we had
nurses that took care of those. If there was a certain issue,
then they were sent to the hospital clinic--
Dr. Crear-Perry. Right.
Dr. Roe.--to get evaluated. If their blood pressure was
above a certain amount. That seemed to work pretty well when we
took the care to--and this was 50 years ago.
Dr. Crear-Perry. Exactly. We stopped investing in those
kind of things and we stopped in perinatal birth workers. We
know community health workers work, we know that investments in
people who are closer to the community work, and then you don't
have to make people come all the way downtown for a visit. We
can now use technology. Telehealth is an opportunity for us to
really increase the access. I mean we have so many
opportunities. Sometimes we just have to allow for the room for
people to build up some of the things that they have learned
and that we have been doing on the ground.
Dr. Roe. Dr. Perry, do you think that malpractice--
Dr. Crear-Perry. Yup.
Dr. Roe.--has--we haven't mentioned that at all.
Dr. Crear-Perry. I know.
Dr. Roe. A lot of young doctors--
Dr. Crear-Perry. You and I could talk about this all day.
Dr. Roe. Yeah, exactly. We won't say anything bad about
lawyers too much. But anyway, I think that didn't affect me
much. I trained in a different time.
Dr. Crear-Perry. Yup.
Dr. Roe. But I see our younger physicians--
Dr. Crear-Perry. Yes.
Dr. Roe.--that are really impacted I think by that.
Dr. Crear-Perry. For sure. People quit practice because--my
malpractice insurance was $80,000 a year, and that was--you
know, and I had to pay that first before I could pay rent or
pay employees. So the cost of how much you pay for malpractice
is so prohibitive. And then we are not going to fix maternal
health through lawsuits. So that is our current structure in
the United States, if we are going to fix this we just sue our
way out of it. And that is just not working. This is an
imperative that we really come up with policies that are bigger
than lawsuits to fix health.
Dr. Roe. Madam Chair, I want to thank you for having this.
We can go on, Dr. Perry and I all day.
Dr. Crear-Perry. Exactly.
Dr. Roe. I want to thank you for having this. I think we
should continue this, because this is a travesty in the United
States to have these kinds of mortality rates. And I do hope we
continue this conversation.
Dr. Crear-Perry. Thank you.
Chairwoman Wilson. Thank you, thank you. I knew you would
be interested, Dr. Roe.
Ms. Fudge from Ohio.
Ms. Fudge. Thank you very much, Madam Chair. Thank you all
so much for being here. It is good to see my friend, Ms.
Stewart. Thank you as well.
It is interesting to me that we talk about the number--many
of the reasons. Now, let me just say that I am from Cuyahoga
County, Ohio and you don't need to go much further than
Cuyahoga County and Summit County in my district to see the
tragic disparities in infant mortality. There are as many White
addicted people as there are Black addicted people, but
according to MomsFirst, which is a home visitation program in
the City of Cleveland, of the 13,872 births in 2018, 120
infants died within the first year of life. Black babies make
up a little over one-third of all of those births, but
accounted for more than two-thirds of the infant deaths. And in
Summit County, the infant mortality rate among non-Hispanic
Black families are more than three times that of non-Hispanic
White families. So there is just more than just what we are
hearing.
And I am really glad that Dr. Roe likes the whole concept
of community health centers, we just need to fund them.
Ms. Sankofa, how can we remove barriers to breastfeeding
for Black mothers?
Ms. Sankofa. The reality is that I think that most of the
solutions exist within the communities that are having the
problem. And the most important thing that I think that anybody
can do is listen to the communities that you intend to serve.
I used to run a breastfeeding project at a different
organization and we did implementations of community-level
breastfeeding support interventions at 72 community-based
organizations and local health departments across the country.
And the thing that really made sense was to have a community
specific understanding, meaning you have to do some level of
community assessment to evaluate what are the systemic and
structural barriers that exist for that community. The problem
in Cuyahoga County is not going to be the same exact problem in
Memphis, and so you have to have different solutions. And I
think that those solutions have to be policy systems and
environmental change solutions that really look at creating
spaces of continuity of care. Breastfeeding happens at the
hospital. It needs to be educated prenatally. It happens in the
community. And all of those different spheres and spaces where
women go, they need to be interacting and speaking to one
another in a way that make sure that people don't fall through
the gaps.
Ms. Fudge. Thank you very much.
Dr. Crear-Perry, can you speak to the phenomenon of
weathering and its impact on maternal health outcomes for Black
women?
Dr. Crear-Perry. So although we look fabulous, you know,
Black don't crack as we say, on the inside the impact of racism
is really bothering our bodies. And Dr. Geronimus for about 20
years has been doing studies that show that we have--work out
of UCSF, out of UNC, that shows that the biological impact of
racism on our bodies causes us to have higher rates of
hypertension, higher rates of preterm birth. And so instead of
looking for a pill or a shot to fix weathering, what we can
begin to do is hold people accountable, hold systems
accountable for things that are harming our bodies, like
racism, classism, and gender oppression.
Ms. Fudge. Pregnant women just don't feel, I feel it here
every day.
Let me, before I go any further, thank the organizations in
my district that work to help eliminate these disparities. I
think it is important for us to say thank you. They are First
Year Cleveland, MomsFirst, Birthing Beautiful Communities, and
Full Term First Birthday, Greater Akron.
It is important to know that there is help. And so often we
don't know where to get help. Because these kinds of agencies
and organizations, they just get by, so it is difficult for
them sometimes to let people know that they are even there.
You talked, I think, Ms. Stewart, about having coverage but
not access. I represent some of the best health care in the
world--in the world. Cleveland Clinic, University Hospitals,
Rainbow Babies, and I could go on and on and on, yet my people
don't have the kind of access they need. You talked about how
we get people to a place of health, but it starts way before
pregnancy. And so I just appreciate the work that you all do. I
thank you and I think the Chairs for having this hearing,
because it is an epidemic that nobody is dealing with in any
big way. So I hope that I can be helpful in some way going
forward, especially because there are so many of my babies that
we are losing.
I thank you and I yield back.
Chairwoman Wilson. Thank you, Ms. Fudge. Thank you very
much.
Mr. Fulcher.
Mr. Fulcher. Thank you, Madam Chairman.
And I have got a question for Dr. Perry, but I have to
share my bias first. I love babies. I like all of them. And I
like the name of your group, the Black Mamas Matter Alliance,
and I am sure that probably extends to the Black Babies Matter
Alliance too, so it is great.
We know that women of color have about a three times more
likelihood of having an abortion than not. And that is kind
of--I wanted to just talk to you about that because we are
confronted with a situation where in this case Planned
Parenthood is the number one provider in that, and just
historically they have targeted that community, the women of
color community, and they provide many more abortions there
than elsewhere. And that is just wrong to me. And it is just--
the data is so obvious. And why women of color? And why do they
target there? And it just seems unconscionable to me that
people are making money off that and somehow we tolerate it.
And I just wanted to get your thoughts.
Dr. Crear-Perry. I am not a representative of Planned
Parenthood, although I work with them extensively. So I am
speaking on behalf of Joia and not the organization.
So how black women interact with health care is a lot based
upon the history, historical injustices and oppressions. And so
perhaps instead of thinking it as they are being preyed upon by
Planned Parenthood, that we are being provided a service
because we don't have access to Medicaid expansion in some
states, we don't have access to all the other services, we
don't have hourly wage jobs that we can leave, so we don't have
all the social things that people need to be able to make
different choices around birth options.
Mr. Fulcher. The result of that is that we are losing
babies.
Dr. Crear-Perry. Exactly. So the result of us not making
choices in this building to support Black women means that
Black women have to make a lot of different choices around
their bodies.
So if we decided that we believe that we should have access
to paid leave, maybe that would impact who chooses to have an
abortion or not. Like there are choices that you all make here
as policy makers that impact how we can live our lives. That is
much more impactful upon our lives than any one organization
like Planned Parenthood. They are one small organization, you
are the government. So how you decide to support women and how
you decide to support Black women and listen to Black women,
really matters way more than what Planned Parenthood does.
Mr. Fulcher. Thank you.
Madam Chair, if I might just follow up.
And I hear what you are saying and that makes sense. At the
same time, I don't think that crosses their mind one little
bit. I don't think they care. I think that their whole deal is
looking at the bottom line, because that is--when we get
approached for funding and we get that kind of pressure, all
right, I understand the point you are making, but I am just
trying to communicate a point. I don't think they care one bit.
Dr. Crear-Perry. So I am going to give you a counterpoint.
Our wonderful congresswoman from Cleveland mentioned Cleveland
Clinic. They choose not to open labor and delivery in the part
of the city where they had--their big hospital is because they
don't make money there. They have a labor and delivery in the
suburbs, right, so they have their hospital that is in the
neighborhood that needs the most care for pregnant moms. They
make a choice to say we are not going to do any labor and
delivery here, we are not going to provide services for the
people in this community.
So I would say that most organizations, big health care
systems, make choices based upon money and that is a choice
that the United States has made in general around how we
provide care. If we took that conversation outside of where you
can make money--because I could go back and forth with you
about all the systems and where they choose to put clinics,
where they choose to put hospitals. Those are choices based
upon money, based upon choices around Medicare and private
insurance that are made here; that we could make very different
choices.
Mr. Fulcher. Thank you, Madam Chair.
And I will close my comments. And thank you, Dr. Perry. I
will just say this. Let us agree on this.
Dr. Crear-Perry. Okay.
Mr. Fulcher. Maybe that is a two-pronged approach, because
I think you bring up some good points and to the extent I and
colleagues can be supportive of that, then I am happy to try to
do that.
And at the same time, for those who I am convinced are
preying on our community of color, I am not supporting that.
And so please know you are appreciated, your work is
appreciated.
Dr. Crear-Perry. Thank you.
Mr. Fulcher. And hopefully we can work together on a two-
pronged approach to try and make things better, okay?
Dr. Crear-Perry. Sound great. Thank you.
Mr. Fulcher. I yield back. Thank you.
Chairwoman Wilson. Mm-hmm. Thank you.
Mr. Takano of California.
Mr. Takano. Thank you, Madam Chair, Chairwoman Wilson and
Chairwoman Adams for this critical hearing on maternal health
and infant health.
The United States has some of the best physicians,
hospitals, and groundbreaking medicine in the world, and yet it
is also the most dangerous and worst place to give birth among
any of the developed countries. A 2019 report from the Centers
for Disease Control and Prevention found that three in five
pregnancy related deaths could have been prevented. And
unfortunately, the number of infant and maternal deaths are
increasing every year. We know there is a link between having
access to health coverage and the decrease in maternal
mortality and severe maternal morbidity. A report by Georgetown
University's Health Policy Institute found that in Medicaid
expansion states like California, they have seen decreasing
maternal and infant mortality rates.
Madam Chair, at this moment I would like to ask unanimous
consent to enter into the record the report from Georgetown
University.
Chairwoman Wilson. Without objection.
Mr. Takano. Thank you, Madam Chair.
My first question is for Ms. Stewart. Ms. Stewart, what
benefits do you believe extending Medicaid coverage for mothers
beyond 60 days will have?
Ms. Stewart. Well, thank you for that. And I appreciate you
raising that issue of the CDC study that said that three out of
five of the cases of maternal death could have been avoided,
and it could have been avoided with improved care, not having
delayed or misdiagnoses, and a whole range of other issues. So
we know that this issue is completely within our ability to
control.
We also know that the issue of maternal deaths is spread
across the period of time from pregnancy, right at the time of
the childbirth, and then from the period of time from one week
out from having the baby out to 1 year.
When we look at the issue of Medicaid coverage, we know
that for many women who actually were able to receive Medicaid
coverage for the birth of their child, after several months
over 50 percent of them are often dropped from Medicaid
coverage, which means that they have had chronic health
challenges, even some that were exacerbated, or any health
challenges exacerbated because of pregnancy or childbirth, they
are often left without coverage.
And so the idea of expanding Medicaid coverage for all
women, and for not only during the period of the childbirth,
but for women to make sure that they have the care that they
need, both in terms of their physical conditions, but also
their mental health conditions as well, because a lot of the
challenges that women may face often are not just as a result
of issues that affect their health, maybe related to obesity or
hypertension, but also due to mental health concerns as well.
So we think that the ability and the need to have to extend
Medicaid coverage to make sure that women have the coverage
they need out to 1 year is essential in terms of dealing with
the kinds of postpartum challenges that many women experience
after having birth.
Mr. Takano. So, again, the reasonable length of time that
coverage should be extended is?
Ms. Stewart. We propose, and I think there is a lot of
agreement that out to a year is really important.
Mr. Takano. To a year? To a year?
Ms. Stewart. A year.
Mr. Takano. What can we learn from other developed
countries that have lower mortality rates? What do we know?
Ms. Stewart. So I think--and I mentioned it earlier--I mean
think there are a lot of things that we can look at. One is
that, you know, a lot of countries actually have far more
supportive policies for families. So issues like paid family
leave, more supportive policies within the workplace, really
more extended care for women, access to other alternative forms
of care, like midwives have been really important and really
productive effective ways to help women have more successful
pregnancies.
Mr. Takano. Thank you.
As Chairwoman Adams has stated, nursing workers that are
eligible for overtime pay under the Fair Labor Standards Act
are entitled to break time and a private space to express
mother's milk. This is an important workplace right that helps
promote the health of both the baby and the mother.
Ms. Sankofa, when an employer violates a nursing mother's
right to break time and private space to express milk, how can
the nursing mother hold her employer accountable?
Ms. Sankofa. Thank you. That is actually a really difficult
thing for the actual employee to do. There is a significant gap
that has surfaced in terms of remedial measures related to the
break time law. The employee has to reach out to the Department
of Labor, Wage and Hours for the Department of Labor to express
that they are--to file a claim and then the Department of Labor
has to investigate whether or not there was an actual
violation. And before anything extra can happen, the Department
of Labor actually has to take the step to take it to court or
not.
And so when it goes to court there is nothing that mothers
actually get from that process typically because it is for--the
break time law is not necessarily a paid aspect of that
process. And so there is no actual thing that you get back even
if it goes to court via the Department of Labor.
And so I think that--
Mr. Takano. Thank you.
Mr. Takano. So I think that movement to the PUMP Act is a
very efficient way of trying to create a space where the
traditional spaces of the FLSA can be implemented so that the
same type of remedial actions that exist for other violations
of employee accommodations--employers already know how to work
with this and this puts it within that same level of statue
within the law.
Mr. Takano. Thank you, Ms. Sankofa.
I am sorry I went over. Madam Chair, I am yielding back. I
just want to acknowledge the work of Barbara Anderson, a
constituent of mine who has done tremendous work on this topic
as a nurse midwife who has been a scholar and researcher.
So I apologize for going over. I yield back.
Thank you. And thank you for the answer, Ms. Sankofa. Very
helpful
Chairwoman Wilson. Thank you. Thank you very much.
Dr. Foxx.
Ms. Foxx. Thank you, Madam Chairman.
I have great respect for my colleague from Tennessee and I
yield him 30 seconds.
Dr. Roe. Just very quickly, we don't have enough people
breastfeeding, we have a maternal mortality rate that is too
high. Why don't we take a public health approach? Remember only
you could prevent forest fires? We all remember that. If you
are old enough you do. Why don't we have a public health
approach to educate the public and the country? I will bet you
that most Americans have no idea that the mortality rate is
that high. So why don't we look at the surgeon general, March
of Dimes, and so forth and do a public health education
approach to our people in the country?
I yield back.
Ms. Foxx. Thank you, Dr. Roe.
Ms. Stewart, as we like to say in this committee, states
are the laboratories of innovation, most often for the better,
but sometimes not so. We can learn a lot from what states are
doing to address infant and maternal mortality and find out
what works and what does not.
What state initiatives are underway to address infant and
maternal mortality? What are the preliminary results of these
initiatives and programs?
Ms. Stewart. Well, I actually think one of the states that
has probably had the most success on the issue of maternal
mortality for sure has been one that was mentioned earlier, in
California. California was one of the early states to actually
create what essentially is now one of our maternal mortality
review committees and actually use data to actually drive
decisions on where maternal deaths were happening and what
interventions--working with health care providers, working with
hospitals, and others to make real progress. They have made
measurable progress over many years. They still are working on
some of the inequity issues that they experience. In other
words, they saw large decreases in terms of maternal deaths,
but they were still seeing unacceptable--and they are still
seeing unacceptably high rates--not to speak for them--
unacceptably high rates among those women of color.
So I think there still are--I think one of the most
important things that we have not done as a country and in
states is have the appropriate data, which is why I go back to
the action that you all took to create maternal mortality
review committees. It has been a huge step forward. But now
that we are learning more, we can do more to actually prevent
some of the causes and the underlying causes of death.
Ms. Foxx. Well, thank you. And I think there has been a
huge emphasis in this Congress in the last 3 or 4 years on
evidence-based decision making. We have talked about it in all
areas. We want to be able to do what works instead of just
throwing money at programs for the sake of throwing money at
programs or thinking our district deserves a certain amount of
money. We really do need to be using our scarce resources very,
very wisely.
Let me ask you another question, Ms. Stewart. As we
consider this important issue from the perspective of this
committee and examine potential solutions which are in the
jurisdiction of this committee, how can employers and health
plans work with providers to support decreased maternal and
infant mortality? We have heard from employers about
partnerships with other organizations, including the March of
Dimes, to promote value-based care, reduce unnecessary
interventions, increase transparency around provider quality.
Are you aware of any partnerships among providers, employer-
sponsored health plans, and organizations that are working to
improve the quality of maternal health?
Ms. Stewart. Well, I think there are a lot of employers
that are becoming much more aware of some of these issues. And
I think one of the things that I mean you all have the ability
to impact, and one of the policies that I think is most
effective in terms of providing the support that often families
need, is around paid family leave. It is not the only thing,
but it certainly is one thing that can make a big difference.
If a woman has had a problematic pregnancy, if she is having to
stay at home to take care of a child, she should not have to be
forced between having to return back to work or stay at home to
take care of her baby and then face income interruption that
could be devastating to her family.
So I think the kinds of accommodations that would be
provided by making sure that there is sufficient paid family
leave for a woman to have to deal with maybe her own health
issues or the health issues of a baby are incredibly important.
I also think that a lot of employers are now much more
aware of some of these issues than ever before and are open to
making sure that there is more information and more awareness,
as was mentioned earlier, around some of these challenges. And
I think the more and more that we can pursue building the
awareness and expanding public education--we have had at the
March of Dimes an incredible relationship with the CDC to
provide broad information to the public around a lot of health
challenges as it relates to maternal and infant death. We think
we need to do more of that.
And then the last thing I would just say is I think a lot
of employers have a vested interest in this. When a baby is
born prematurely it has a significant cost to that employer.
And so a lot of employers are very--and even when a mother has
her own health challenges, if that employer is left without a
productive worker or if that mother dies and is no longer
there, there are significant costs to the employer. So I think
there are tremendous opportunities to go to employers and look
for partnerships to expand the kind of information and access
to care that women need and the families need.
Chairwoman Wilson. Thank you very much.
Ms. Foxx. As I have said before, I think that employers
understand what you are talking about and that any time an
employee is out there is a significant loss to everyone. And so
I do think there is a great deal of concern on the part of
employers for their employees and they would like to do things
that make it better for everyone concerned.
Thank you, Madam Chairman. I yield back.
Chairwoman Wilson. Thank you.
Ms. Jayapal.
Ms. Jayapal. Thank you, Madam Chair.
Thank you all so much for your excellent testimony. Very,
very powerful. And I can tell you, as a mom myself who
delivered my kid at 26 1/2 weeks, 1.14 ounces, serious threat
to my own mortality and certainly to theirs, and morbidity,
this is an issue that I have worked on myself and followed for
a long time.
I think we are, you know, the richest country in the
history of the world and we spend by far the greatest amount of
money on health care, and yet we have such abysmal health
outcomes, as you have gone through.
And I completely agree with you, Dr. Crear-Perry, when you
said that we should expect more, that we should demand more,
and that we must address the maternal mortality crisis in this
country, and that we have to do so by clearly calling out the
racism and discrimination within our existing health care
system that makes it so much more dire for communities of color
and especially for Black mothers. So thank you for that.
Let me start with you, Dr. Crear-Perry. Your testimony
illustrates how for-profit insurance and payment systems have a
significant impact on maternal health outcomes. Can you talk to
us about how high out of pocket costs, like private insurance
premiums, co-pays, and deductibles, exacerbate racial
inequalities in our health care system?
Dr. Crear-Perry. Well, you know, the data shows us that
Black women, despite income or education, are more likely to
die in childbirth. So that means that most of the Black women
who are receiving care are not on Medicaid, they are the
private insurance payers that you all have legislative power
and authority over. So when you allow for those institutions to
charge huge deductibles, when you allow for those institutions
to say that we are not going to cover your child when your
child is pregnant, you are allowing those organizations to then
harm women, specifically Black women, because we are also so
exposed to having morbidity and mortality in childbirth.
So it is important for us to not only think about
governmental insurance when we talk about this maternal
mortality crisis, because we, all three of us sitting up here,
just as well as you, have education and access and we still
have poor outcomes, right. So it is important for us to really
think about our private insurers and the choices that they make
that harm our bodies.
Ms. Jayapal. And can you also talk to us about the huge
gaps in coverage for prenatal services, doulas, patient support
for after birth, and home care if we had a plan--as my Medicaid
for All plan does--
Dr. Crear-Perry. Exactly.
Ms. Jayapal.--provide comprehensive services of this
nature? How would that benefit maternal health outcomes?
Dr. Crear-Perry. Because we talk a lot right now about
improving doula care. And I usually hear that conversation in
the Medicaid population. And once again, it leaves off that we
don't cover any of these things for folks on insurance. I, as a
city employee who ran a city health department, had to
negotiate with the insurance company around coverage for my
staff. People don't realize there is an individual who is
making choices for your care at your job. They are negotiating
with the insurance company and they are deciding what they are
covering. We could make a rule that they have to cover doulas
and they have to cover midwifery and they have to cover them at
parity. Those are choices that one individual at your job
should not be making for you.
Ms. Jayapal. And if every person had guaranteed coverage of
comprehensive services under a universal health care system,
like Medicare for All, with no cost barriers, what do you think
would happen to the impact on reducing or even eliminating
disparities in health care access and outcomes?
Dr. Crear-Perry. We see a little bit of a glimpse of what
that would look like in places that did expand Medicaid. We see
an improvement in outcomes just with that one small ask. Even
in a program that is chronically underfunded, that people don't
have a lot of access with, we still see improvements in
outcomes. So if everybody had access to insurance and coverage,
then we would see an even bigger uptick of what we could look
like as a country to the rest of the world to show that we are
really all that we dream to be.
Ms. Jayapal. I really thank you for your testimony. I
think, as people know, I have been pushing for a universal
health care system because I believe it is not out of reach, it
is what other countries do. We certainly spend enough money
that we should be able to do it here. And that would mean that
we are all guaranteed the same level of high-quality
comprehensive coverage with no premiums, co-pays, and
deductibles or out-of-network doctors.
And also, by the way, a more efficient system for our
safety net and rural hospitals as well.
Madam Chair, I seek unanimous consent to enter into the
record a letter from a coalition of racial justice
organizations, including the NAACP, LULAC, and the Black
Women's Health Imperative, making the case for why Medicare for
All is a racial justice issue.
Chairwoman Wilson. So ordered.
Ms. Jayapal. Thank you, Madam Chair.
And I just want to thank you all again for your excellent
testimony and for lifting up the issues that particularly Black
women and women of color face and this critically important
issue that we all need to push for immediate action on.
Thank you. I yield back.
Chairwoman Wilson. Thank you. Thank you.
Mr. Johnson.
Mr. Johnson. Thank you, Madam Chair. I would start by
noting that yesterday, as I was eating my Wheaties, I read an
excellent article by the South Dakota News Watch that printed
in my local newspaper, the Mitchell Daily Republic, and it
dealt with this very issue. And I thought it was an in depth
and insightful piece, and so I would ask unanimous consent to
introduce into the record, ``Effort Begins to Reduce Risk of
Death of South Dakota Mothers During Childbirth'' into the
record.
Chairwoman Wilson. Without objection.
Mr. Johnson. Thank you very much.
This is probably for your, Doctor, but if any of the
panelists want to weigh in, I would be interested to get their
take as well. I was intrigued by some of the best practices
that this article brought out, things that seemed to me to be
relatively low hanging fruit. I will give a couple of examples.
Weighing blood absorbing pads so that we can better ascertain
how much blood loss a mother has had during childbirth. That
doesn't seem very difficult to implement.
Dr. Crear-Perry. Exactly.
Mr. Johnson. Blood pressure cuffs, so that medical
professionals can have real time information. So if they
forget, if the Ms. a measurement time, they are still alerted
to when that mother--when we have got a blood pressure problem.
Again, I view this as relatively low hanging fruit. When
you look at the implementation of these practices across the
country, on a scale from 1, being we are not doing any of them,
and 10, we have perfect implementation of these best practices,
where do you think we are as a country?
Dr. Crear-Perry. Yeah. Oh, man, 3 1/2 maybe. The good news
is because--
Ms. Stewart. Two.
Dr. Crear-Perry. Two? Yeah. I mean you bring up the blood
loss one. So as an OB/GYN we weren't measuring blood loss that
way. You might be surprised to know that we would do things
like look and say, ah, looks about like 1,000 milliliters. Like
that is how we estimated blood loss. So it is a big shift in
practice to actually weigh and measure the pads. So what you
then have to do is say to the people who feel like, well I have
always done really great care, that you--actually women are
dying because we are not doing this correctly as a field. This
is a systems change, this is not about you as an individual and
the care you provide, but a systems change. So that system
shift has been difficult because people still believe in their
own individual, that they as an individual provider are doing
great things. So having legislation, having standards by
governing bodies then makes for room for implementation to
occur. As long as it is optional--and I will even go back to
the--it was exciting to have the CDC give money to states
around maternal mortality, but we don't require it, so that is
why you still have three states who haven't done it.
So there are times that we need government to act, to put
together policies that require things, like you need to count
the blood loss.
Mr. Johnson. Yes.
Ms. Stewart. Can I add to that too? Because I think those
are practices, like measuring, monitoring whether or not women
are hemorrhaging and how much they are hemorrhaging, so that we
actually know how at risk they are. After they have had the
baby they go home and they are experiencing problems that were
not dealt with when they were in the hospital.
But the real issue is that we have to--we are not going to
deal with the issue at the point of a woman almost at the point
of death, right. I mean if she is hemorrhaging to the extent,
she is so close to potentially losing her life. The issue is
how do we move more upstream, how do we address these issues of
women's health before they are pregnant? What we find is that
increasingly more women that are pregnant have chronic health
conditions, they are obese, hypertension. One of the leading
causes of death for women as a result of pregnancy and
childbirth are heart-related challenges. So how do we make sure
that women are able to manage their health before they are
pregnant so that they don't have these problems exacerbated as
a result of pregnancy and childbirth?
Mr. Johnson. So maybe a follow up, Dr. Crear-Perry. You
know, we mentioned standards and national bodies. You know,
this article talks about the joint commission, which I think
has some oversight or engagement with they said about 80
percent of hospitals in the country. I mean if I am looking to
some repository of best practices, if I am looking to a source
that really has it right, is the joint commission a good place
for me to pay attention to?
Dr. Crear-Perry. So I was on the Joint Commission task
force to create those measures. And so I think there are people
in that room--the American College of OB/GYN has the AIM
bundles. It is a great place where you can look to find a
repository of best practices. And that is really who through
HRSA has been funded to build the policies out. The CDC has the
Perinatal Quality Collaboratives, and they really need more
funding to uplift those collaboratives. In South Carolina they
are doing--I just spoke at your annual meeting around maternal
mortality in South Carolina--and really having more investment
in the Perinatal Quality Collaboratives would be so important.
Because you get the numbers and the data and someone has to
implement it. So who is going to say to the people in South
Carolina, are you measuring your blood loss? It is going to
come from that Perinatal Quality Collaborative who needs
support from legislation.
Mr. Johnson. Well, thank you very much.
And, Madam Chair, what an important topic and what a
meaningful conversation we have had.
Thank you.
Chairwoman Wilson. Mr. Morelle from New York.
Mr. Morelle. Thank you. I find it completely unacceptable
that 1 in 700 American women dying of pregnancy-related causes
each year and tens of thousands facing severe health
implications. So I appreciate very much, Madam Chair, you and
the Ranking Members for convening this hearing today to talk
about what we need to do to protect mothers and children.
There has been a lot of conversation about what goes on in
other states, so I just want to just share a little bit about
what we are doing in New York if I can get a little equal time
for the Empire State.
We have actually made I think significant improvements. We
were just a decade ago I think about 46th in the Nation, which
is really obviously just a horrendous number, but we have now
moved up to 23rd, at least as it relates to maternal health
outcomes. We have made significant investments in the last
decade. Today we have 86 hospitals participating in the New
York State Perinatal Quality Collaborative, which better
assesses and manages obstetric hemorrhage. Last year we took
steps to create our own maternal mortality review board,
building on the success of collaborations in many other states
that have been mentioned here today. But we still have a long
way to go.
And I note that my son and daughter-in-law are expecting a
grandchild very soon, so I am really paying attention to a lot
of what you are talking about today, more than perhaps I knew
about when I was an expectant father. But I do, after the
testimony, and I do want to get to a couple of different
questions if I might.
First, Ms. Stewart, obviously it has been talked about, the
estimated 60 percent of all maternal deaths could have been
prevented. I am interested, I understand in the state of
California and elsewhere hospitals have found success using
simple innovations, hemorrhage carts, quantitative blood loss,
elective c-section reductions, all methods that resulted in
lower rates of death as I understand it among pregnant women in
hospitals. And I am just trying to understand what are some of
the changes that can be made among the medical community that
relates to providing care during pregnancy and delivery first
and foremost. I know that there is the post, but I am just
curious, during delivery and immediately after--during
pregnancy, delivery, and then immediately after. If you could
talk about some of those impediments or barriers.
Ms. Stewart. So I think one of the things that we have to
realize is that women have been having babies for a long time
before hospitals existed.
Mr. Morelle. Now that may be the truest statement ever said
in a congressional hearing.
Ms. Stewart. This has actually been going on for a while,
and even before hospitals were even around. And what existed--
now, there were some not great outcomes before and hopefully
our medical community has really sought to look at ways it can
improve those outcomes over time, but one of the things that we
found are some unintended consequences. One of the things that
Dr. Crear-Perry mentioned is dramatic increase in c-sections,
right. So 1 out of 3 deliveries now is by c-section. And we
know that puts that mom's health at risk, right.
Mr. Morelle. I am sorry to interrupt, but in recent years
has that number gone up or down?
Ms. Stewart. It has been going up.
Mr. Morelle. Still, continuous?
Ms. Stewart. It has been going up. We actually at the March
of Dimes had a big influence on the number of elective c-
sections, which we actually were able to see a decline in
elective c-sections. Especially during the period of time
before this last 4 year period of an increase in preterm birth
rates we were actually seeing a decline. And we think a big
contributor to that may have been a reduction in elective c-
sections.
Mr. Morelle. I see.
Ms. Stewart. But we are seeing overall c-sections increase
and it is not often, you know, fully elected by the mom, right.
One of the things I think that we can really look at is the
fact that we can go back to some practices that actually did
work for us in the past before we had a very medicalized
process of delivering babies, right. So in New York, you all
are doing a whole experiment on doulas as a part of the
Medicaid program. We think and we encourage health care
professionals, medical professionals, doctors, to have better
relationships with midwives and with doulas. Studies have shown
that doula care can often reduce the level of c-sections, can
increase and improve health outcomes for moms and babies. We
think that if these kinds of services were more available,
maybe in addition to their traditional medical care, we could
probably see some outcomes improve over time.
Those are just some of the things that--
Mr. Morelle. Right. Thank you.
And I only have a few seconds left, but I did want to hear
Dr. Crear-Perry, the issues of unconscious bias related to both
gender and race affecting pregnancy-related care, could you
just talk a little bit more about that?
Dr. Crear-Perry. Yeah. I mean I have the pleasure of
working with your staff there in New York around this work. And
they are doing some trainings with their staff because what we
are recognizing is unconscious bias makes us do things like if
we believe it is a Black woman and their blood pressure is 160/
90, the hospital will say, oh, but they all kind of run high,
so they won't treat it. And then the next thing you know, that
woman is seizing and in the ICU. So the bias around believing
that we all kind of have hypertension when we don't is killing
people.
So those are kind of the important things for us to be able
to unpack.
Mr. Morelle. Great. Thank you.
Thank you, Madam Chair. I do ask unanimous consent to
submit into the record a letter from Johnson & Johnson
applauding this subcommittee's leadership in addressing the
urgent health crisis that affects families around the country
and expressing their commitment to the goal of eliminating
preventable maternal deaths globally.
Chairwoman Wilson. Without objection.
Ms. Wild from Pennsylvania.
Ms. Wild. Thank you, Madam Chairwoman.
First, I just want to thank this panel for not only the
content of your written testimony, but the passion that you
bring to this subject, very easy to listen and absorb what you
have said. And it is just such an important subject. I feel as
though in a country where we say that we value family values so
much, that we often miss the boat when it comes to policies and
accommodations and efforts that need to be made to truly
promote family values, and of course maternal health is key to
that.
And I appreciate the systemic approach that all of you seem
to have adopted to the problem of America's maternal and infant
health crisis, because it seems to me, both in my own thinking
but also you have fleshed it out for me in your testimony, that
it really has to be a holistic approach, it has to start very
early in life, it has to start with education, it has to start
with making sure that young women and men are able to get a
good education so that they can go on to get good jobs where
they have more flexibility and hopefully better health care
benefits and that kind of thing. We have to make sure that our
workplaces are safer and that workplace accommodations for
pregnant women and new moms are made. We need improved health
care from all perspectives, not just pre and postnatal care,
but overall preventive health, whether it be blood pressure
checks, routine mammograms, immunizations, gynecologic care,
and that kind of thing.
So with all of that said--none of that was a question--but
I want to ask--and I could ask any of you these questions
because you are all very well qualified--but let me just start
with Dr. Perry.
I won't ask it ask it as a leading question. Do you believe
that better access to contraception is an important component
of women's health?
Dr. Crear-Perry. For sure. We know for sure that if you
don't have access to be able to make choices around your body
that you can enter care later, you can enter care sicker, that
you are not making fully informed choices for yourself. And so
I love that you used family value. So the value of valuing what
the woman wants and valuing what her needs are and meeting her
wherever that is. And you can have your own beliefs in your own
house, but our job really is to support what people believe for
themselves and what they want for themselves.
Ms. Wild. And before we even get to the issue of
contraception, I assume you feel the same way about sex
education--
Dr. Crear-Perry. Yes.
Ms. Wild.--both in the schools and outside the schools--
Dr. Crear-Perry. Exactly, exactly.
Ms. Wild.--throughout our communities?
Dr. Crear-Perry. Yeah. And it is important as a person
who--you know, as a mother and as an OB/GYN, so many patients
don't know basic information about their bodies and we are
expecting them to navigate a world where we haven't given them
the tools to be able to do that.
Ms. Wild. Right. And same thing with the protection against
intimate partner violence.
Dr. Crear-Perry. Yes, for sure.
Ms. Wild. And, Ms. Stewart, I will address my comments to
you, just because I see you nodding. That is a similarly
important component of this, am I right?
Ms. Stewart. It is important. And I just want to mention
one thing on contraception too. Science tells us that one of
the most effective ways to reduce preterm birth if a woman has
had a preterm birth already is to ensure that there is
appropriate birth spacing. And that means that a woman has to
be given the ability to make the choice as to when she has a
baby. And certainly ensuring that there is an 18 month gap at
least between the time when she has had a baby and the time
that she becomes pregnant again has been proven to actually
reduce the risk of a subsequent preterm birth.
But we also know that protections around intimate partner
violence are really important. I mean we have seen an
increase--I live in Maryland and we saw a dramatic increase in
the kind of violent activity targeted towards pregnant women
and our state took action there. And I think it is important
that at a Federal level we address the fact that too many
pregnant women are subject to the kind of violent treatment by
their partners or significant others that really put them at
risk and then also put their babies at risk too.
Ms. Wild. So Dr. Perry--I am switching back--am I correct
that not all health plans, even under the ACA, cover the
services that we have just talked about?
Dr. Crear-Perry. For sure. And, you know, it is just really
frightening to think that we have made so many steps forward,
but we keep getting steps back. So really making a commitment
for people to have access to all the services would be
important.
Ms. Wild. So my colleague, Mr. Fulcher, across the aisle
commented on Planned Parenthood.
Dr. Crear-Perry. Yes.
Ms. Wild. And my question to you is what is the role of
community health centers and places like Planned Parenthood to
fill these gaps in services?
Dr. Crear-Perry. Right. So because we do not have a
universal health care system we need players like Planned
Parenthood and others, we need organizations like Federally
Qualified Health Centers. Here in DC there is an FQHC that has
a birthing center inside of a Federally Qualified Health Center
with a Black midwife, Ebony Marcelle, who is running this
center, to have a full range of reproductive options. Also in
Memphis there is an option.
So we need the Planned Parenthoods, we need the clinics, we
need quality care provided for people in their neighborhoods
who--and all their needs met across the reproductive spectrum.
Ms. Wild. Thank you very much.
My time is up. I yield back.
Chairwoman Wilson. Thank you.
Ms. McBath from Georgia.
Ms. McBath. Thank you, Chairwoman Adams and Chairwoman
Wilson. I appreciate you both for being so instrumental in
highlighting the need for transformative maternal health in
this country. And I also want to thank the panel for coming to
address Congress on this very, very pressing issue.
And we all know the statistics, so we don't have to go over
them again. We have all seen the failure to make progress on
this problem. That is the reason why you are here today. This
problem runs far deeper than many want to even acknowledge and
we have a responsibility to these families to make sure that
their safety and the health is the number one priority.
Research is clear, access to care and other socioeconomic
factors play a significant role in maternal mortality rates in
Georgia and throughout this country. And actually Georgia has
the second highest maternal mortality rate in the country.
Dr. Crear-Perry, what should we be doing to ensure that
women have access to not only the health care, but also the
other supports that they need to be healthy during pregnancy,
childbirth, and postpartum?
Dr. Crear-Perry. Well, it is exciting to see--thank you--
that there is a move to extend Medicaid for a year. I think
Georgia is one of the states that could really benefit from
that. Having not done Medicaid expansion, really letting the
science show us that you need to have insurance for at least a
year after you have a baby, so that would be an important move.
I think also in Georgia and other states, looking at our
policies around access to work leave, it is not even just when
you have the baby. If you are a high-risk pregnant person, you
need to go to the doctor more often. If you are choosing
between your hourly job and being able to make twice a week
appointments at a doctor's office where you sit for four and
five hours at the waiting room, right. You don't have time for
that, you have to go to work. And so when do we make room for
paid leave and structures that allow for people to be healthy,
not just when the baby comes home, but caring about mom while
she is pregnant?
Ms. McBath. Thank you for that, because I was a high-risk
pregnancy myself and actually had to take short-term
disability--
Dr. Crear-Perry. Exactly.
Ms. McBath.--because when I was working as a flight
attendant there were no particular considerations that were
made for us as pregnant women.
Dr. Crear-Perry. Exactly, exactly.
Ms. McBath. So I had to go on short-term disability just to
be able to make sure that I brought my son into the world.
Dr. Crear-Perry. Exactly.
Ms. McBath. A few months ago I worked with Representative
Gwen Moore, Tom Cole, and John Katko to introduce the Family
Violence Prevention and Services Improvement Act. As you know,
FVPSA provides necessary funding to help survivors of domestic
violence, and it should not go unaddressed today that there
truly is a correlation between intimate partner violence and
maternal health.
Dr. Crear-Perry. Yup.
Ms. McBath. Dr. Crear-Perry, can you share more about why
pregnancy puts women at a higher risk of experiencing intimate
partner violence?
Dr. Crear-Perry. Yeah. So we know that the stressors that
are impacting mom are also impacting dad. So we want to move to
a space of restorative justice, right. How do we think about
intimate partner violence in a lens of if we don't provide
supports for families for people of color across the United
States, when a mom gets pregnant, you are going to see dad act
out, you are going to see the partner act out and become more
violent because they don't have the resources they need and
they feel very--that they can't meet the needs of what they are
supposed to have done. If we really want to improve intimate
partner violence, if we really understand why it happens, that
people are not just mad and sad and acting out, but they are a
part of a larger system, then important for us to invest in
both moms and making sure they are safe, and really thinking
through how are we educating our sons. I have two. What are we
doing around people and their access to how they think about
pregnancy and birthing in their communities.
Ms. McBath. So let me go on and ask you what are some of
the health consequences of intimate partner violence for
pregnant women and their infants?
Dr. Crear-Perry. Yes. We know in some states it is one of
the top leading causes of maternal mortality, right. In our own
state of Louisiana, my home state. So we could look and see a
policy choice. If you say if I call the police, if I live in
HUD housing or in Section 8 housing, because of intimate
partner violence I can get kicked out, when I am pregnant that
rule makes me at higher risk of actually dying, right. Because
I am afraid to lose my place I am not going to call anybody to
come. And so that is a policy change that improves it. So we
lobbied or we advocated for getting rid of that rule, that
people cannot be kicked out of Section 8 housing because they
are calling the police for domestic violence. That improved the
outcomes for Black women who were pregnant in the State of
Louisiana.
So those are the kind of policy choices that are not around
individual choices, but you are putting people at risk of harm
when you create solutions that don't think through what will
happen to someone who is impacted.
So morbidity and mortality, having risk of death is the
highest risk that you can have, and it is really high during
pregnancy.
Ms. McBath. Thank you so much.
I yield back the balance of my time.
Chairwoman Wilson. Thank you.
Ms. Underwood of Illinois.
Ms. Underwood. Thank you, Madam Chair.
On January 28, 2017, 3 years ago from today, I lost a
friend. Dr. Shalon Irving was a classmate of mine at the MPH
program at Johns Hopkins University. She went on to become a
CDC epidemiologist, a lieutenant commander at the U.S. Public
Health Service Commissioned Corps. She was highly educated,
financially secure, surrounded by a strong network of family
and friends. She was covered by quality health insurance. She
is a Black woman and she lost her life 3 weeks after giving
birth to her baby girl, Soleil, her first child.
Three years after that tragedy we are here to address a
crisis that cuts across education levels, income brackets,
geographic regions, and type of insurance. Moms and babies are
losing their lives at unacceptably high rates in the United
States. And families like Shalon's are left picking up the
pieces.
The name of today's hearing is Expecting More. And when it
comes to America's maternal and infant health crisis, we need
to expect more. We need to pay more attention, take more
action, and make more progress.
Ms. Stewart, through your work leading the March of Dimes
you have heard too many stories like Shalon's in America. Why
are protective factors, like education and wealth, failing to
insulate American moms from elevated risk of maternal mortality
and severe morbidity?
Ms. Stewart. So, first of all, I am very grateful that you
tell that story and that you celebrate the life of your friend
who unexpectedly and wrongfully has passed away and
unfortunately is no longer with us. And I think the point you
are raising around the maternal mortality rate for Black women
as it relates to no other issue other than the racism that they
probably experience as a result of their health care
experience, is really one of the most critical issues that we
have to talk about in this country.
The fact that we can look at an educated Black woman and
she dies at a rate that is five times more than her White
counterpart, is just simply unacceptable. And if it is not due
to their income level, it is not due to education level, it is
not due to medical coverage or health care coverage or
insurance, or all these things, then what else is it? It has
simply to do with how they are being received and treated by
the system where they are expecting to receive quality care and
the system is failing them.
And so I think part of what we are doing at the March of
Dimes is acknowledging and working with many partners to say
what can we do as one participant in the system to change these
kinds of outcomes and to help the system realize that there is
implicit bias in the system that medical providers, though they
don't intend to, are making judgments about Black women and are
then therefore causing Black women to receive inadequate care,
often putting their lives at risk.
And so part of what we are doing, just one of the things
that we are doing is, in addition to have entire health equity
approach to our work, is looking at certain programs like
introducing an implicit bias program. Dr. Crear-Perry talked
about the work she is doing in that space. We have worked with
an organization to create a whole new implicit bias program for
many of our hospital and other health care provider partners to
make sure that they are aware of the implicit bias that they
may be experiencing on a daily basis, that it is actually
influencing the lives of the patients that are attempting to
serve.
Ms. Underwood. Yeah, putting their lives at risk.
Ms. Stewart. Absolutely.
Ms. Underwood. Earlier this month the Commonwealth Fund
published a report showing that the Affordable Care Act
narrowed racial and ethnic disparities in insurance coverage.
And we know that in the context of today's hearing, coverage
leads to better outcomes for moms and babies, and yet as we
speak the Affordable Care Act is being threatened by a
Republican repeal lawsuit.
Ms. Stewart, what is at stake with this reckless attack on
health care and how could it exacerbate existing racial and
ethnic disparities and maternal and infant health outcomes?
Ms. Stewart. So we know that the ACA has been an incredible
support to expanding coverage for so many women. And it is
especially true for women of color, where their rate of women
that have qualified under ACA has grown at more than twice the
rate of women overall between the period of 2013 and 2015. And
what this has been doing is allowing women to access the care
they need.
Again, to talk about this issue is really to underscore the
importance of women getting the kind of preventive care they
need before pregnancy and during pregnancy. The fact that they
now--many of these women, women of color, have more access to
the kinds of coverage that is available to the ACA, especially
because of essential health benefits being involved.
Ms. Underwood. Yes.
Ms. Stewart. So no cost sharing applied to all kinds of
well women visits, all kinds of prenatal care visits that are
really essential and incredibly important. You know, we still
look at prenatal care visits and still know that too many women
are not able to access the kind of prenatal care that they
need. If ACA is removed, if they don't have access to being
able to get the kind of health coverage that the ACA provides
for women, especially women of color, we are likely to see a
worsening of outcomes for those women and a worsening of
outcomes for their babies. It simply would be devastating to so
many of the families that we are trying to serve.
Ms. Underwood. Thank you.
Madam Chair, my time is expired. I could sit here all day
and talk about this issue. It is so important. Thank you for
your leadership and for convening us here today. Thank you to
the witnesses, and thank you for being a member of the Black
Maternal Health Caucus.
Chairwoman Wilson. Thank you.
Dr. Shalala.
Ms. Shalala. Thank you very much, Madam Chair. Let me
congratulate Representative Adams and Underwood for their
leadership of the Black Maternal Health Caucus. Those of us
that joined it, we have a simple goal, save Black women's lives
and tackle racial disparities in health care.
My colleague from Florida has already indicated the
statistics in our own Miami-Dade County, which the racial
disparities are simply criminal and not acceptable. But the
root cause of the statistics for maternal death are often
misunderstood. The public image of maternal death is a woman
who has a medical emergency, like a hemorrhage, while in labor,
rather than four out of five of these deaths happen in the
weeks and months before or after birth. And ensuring women have
access to comprehensive and affordable care during and after
pregnancy is absolutely critical.
I do want to put on the record that over 96 percent of
Planned Parenthood services are really in women's health. It is
to help women be and stay health before, after, and between
pregnancies. And Planned Parenthood does not, unlike the myths,
make money on abortions. Planned Parenthood is supported by
charity and by contributions from millions of Americans.
I want to ask a very specific question, because what I am
interested in is in Federal programs. We have talked a bit
about Federal programs and about filling in the gaps. We know
that chronic medical conditions, including obesity,
cardiovascular disease, hypertension are chief contributors to
maternal mortality, yet we have also heard that Federal
programs are not designed to support women's overall health
before and in between pregnancies. Medicaid's pregnancy
coverage only extends to 60 days of postpartum, WIC's
postpartum coverage only covers 1 year for breastfeeding women,
and the ACA has real limitations, including those that were
pointed out on women under 26. If we are going to write a
comprehensive bill here, it is really going to be a bill that
fills the gaps while we are waiting for universal seamless
health coverage that would make a difference for all Americans.
So I would like to ask each of you what your top two or
three recommendations would be, specifically on program
supports and program improvements, because what we might do is
simply go through all the programs and do a comprehensive bill
that fills in the gaps on the programs. That would be I think a
lifesaving step for all of us.
Let us start with Ms. Stewart.
Ms. Stewart. So I guess a couple of things I will mention.
I think one of the most important things that can be done is
the extension and expansion of Medicaid up to 1 year. I think
the fact that we have too many women that are being dropped
from coverage within 60 days to several months after childbirth
is a real challenge. And it is inhibiting their ability to seek
the kind of continued medical care that they need.
A couple of other things that I will mention though. I
think it is really important to look at what Medicaid covers
beyond just the medical care for the health care provider. We
know that access to Medicaid reimbursement for doulas, for
midwifes, and I would even say--we are involved in a program
that is involving group prenatal care. That is an evidence-
based program and it is shown to reduce the rate of preterm
birth by up to 30 percent. But in many states we are not able
to receive Medicaid reimbursement. But we know that is the kind
of care that women often need beyond just their traditional
health care. So there are things like that.
And the last thing I will just mention is we do have some
gaps and some barriers, for example, around newborns being
added to health plans. We find that they are too many families
who have a 30-day window to add their newborn to a health plan
and often miss that window. And then as a result, especially if
their baby is in the NICU, they may be subject to exorbitant
health care costs because they missed that window. And so
closing that gap would be also very important.
Dr. Crear-Perry. So I will go by agency. So HRSA, you could
improve how we do National Healthy Start. It is a great
program, it is community led, community driven. CDC, we can
bolster up the PQC, the Perinatal Quality Collaboratives. They
are the driving force of how we are going to get policy done.
We have not invested in those. And then in the NIH, you can
uplift the Office of Women's Health. It is just an office, so
it has no budget. So we think women are more than half of the
population and yet we don't have any dedicated institute or
center for women's health. So it would be exciting to see you
all look at these big larger institutions and how you could
change them.
I mean really investing in community birth workers on the
ground, lay folks who have been doing the work for the
community for a long time. I mean the education policy, we
wanted an education plan. Black maternal health week is coming
up, so there will be a lot of investment--April 11-17--looking
all the folks on the ground who are doing work.
Ms. Shalala. Thank you.
Chairwoman Wilson. Thank you very much.
Mr. Levin from Michigan.
Mr. Levin. Thank you very much, Madam Chairwoman.
It is an honor to be here with the Chairwomen of these
subcommittees, with Congresswoman Underwood. I thank her for
her leadership. And with all three of you to talk about this
incredibly important issue.
It is simply outrageous and unacceptable that so many women
and babies of color die at disproportionate rates in this
country. And we need to be able to talk about racism in this
country. I want all of my White siblings in spirit who may be
freaked out if I can just speak plainly about being called a
racist, or worried that they might be whenever we talk about
racism. Look at this situation. This is structural racism. In
our society, when people like Congresswoman Underwood's friend
die, who have every advantage in life, there is no explanation
but structural racism. So let us all take a deep breath, relax
our shoulders, and get on with the conversation. Because we
just commemorated Holocaust Remembrance Day and we say never
again, and what does it mean. It means we must not be silent in
the face of injustice. This is clear injustice in our society
and we all have a role to play and none of us can be silent.
Now, Dr. Crear-Perry, I am worried I am going to get in
trouble with you. I was not planning on raising this, but I
think your very first answer to a question was about midwives.
So I have four kids and we had home births with midwives, but
it was not legal in Maryland. So we had illegal home births
with the lay midwife. So here I am confessing. Koby was born 26
years ago.
Mr. Scott. Statute of limitations.
Mr. Levin. Yeah, I hope so, Mr. Chairman. And at the same
time I am I think the only member of this body who has run a
state workforce system. So I feel personally responsible for--
so talk to me about the training at, you know, HBCUs, at other
institutions. What do we need to do to train more midwives?
Because it is certainly a crucial part of the answer here.
Dr. Crear-Perry. Thank you. In the same way that you want
our colleagues to not have their shoulders raised when we talk
about racism, which is what I have to do a lot with folks, I
have to have my colleagues in OB/GYN not have their shoulders
raised when we talk about midwifery.
Mr. Levin. That is why I thought I might get in trouble.
Dr. Crear-Perry. No, no, actually my shoulders are relaxed,
I am good. Because I don't feel threatened. We need this. Every
country that has better outcomes than us has a much more robust
midwifery workforce. They have invested in training women
across the country who actually are doing the births. We
provide care in an ICU that could be done, like you did, at
home. And that is just a fact. And we are afraid of change, but
that fear is harming Black women. And actually Black women are
over performing their counterparts when it comes to home birth
and not having a hospital birth because of our fear. Imagine
going into Auschwitz without Auschwitz ever having apologized
and saying you are now supposed to take care of me and provide
my health care. That is what happens to Black women when we go
to the hospital, the same hospitals that for generations harmed
us now are saying come, we are fine now, with never having
acknowledge J. Marion Sims, never having acknowledged the
history of oppression, and we are just supposed to trust you
because you are nice.
Mr. Levin. All right. So I am going to count on you to
follow up with me as a member of this committee, so what
specifically can I do on that.
Dr. Crear-Perry. Yes. Right. Thank you.
Mr. Levin. Ms. Sankofa, protections entitling nursing
workers to have break time and a private space, right, it is
tied to nursing a child and lasts only for a year following the
birth of a child. So in my last minute I want to ask you,
should we rethink these policies? For example, a woman may be
lactating after her baby has been adopted. You know, for her
health, shouldn't she have coverage? After a stillbirth. The
time limit. I mean my wife breastfed way past 1 year. So are
these limits too narrow and inappropriate?
Ms. Sankofa. I think that these limits are put in place to
really create an opportunity to have deep buy in from all
members so that we can move the legislation forward. But when
we look at preterm birth weights, when we look at infant
mortality rates, I think that a person who is pumping to
provide milk for a baby who is not their own but who may be
preterm, I think that is something very, very important to
consider as a more systemic policy solution because not every
woman chooses to breastfeed, maybe there are systemic barriers
for her that make it unavailable. But if milk can still be
available, that is a thing that we should definitely consider.
Mr. Levin. Outstanding. Thank you.
I yield back, Madam Chairwoman.
Chairwoman Wilson. Thank you so much, Mr. Levin.
Ms. Stevens.
Ms. Stevens. Thank you, Madam Chair, and thank you to our
expert witnesses for your brilliant and elucidating testimony
and for your comments here today.
We have an emergency going on in America right now. The
U.S. has the worst maternal mortality rate among developed
countries despite an improvement in global maternal mortality.
This is what we are talking about here today, this is what this
conversation is about. From the halls of the United States
House of Representatives, I can't think of a more important
topic because for every woman that has lost their life, for
every family bearing that burden, for every woman who has come
too close to losing her life, crying out in pain, this is
senseless and these are injustices. And we talk about life
being precious. I cannot think of a better instance of the
sanctity and preciousness of life than this, than the life of
the mother. We are here for the voiceless.
Thank you, Ms. Underwood, for your leadership in forming
the Black Maternal Mortality Caucus, because it is high time
for these issues to come to bear, it is high time for this to
be on the national news and in every family's household,
thinking and talking about this and what we are going to do.
Thank you, ladies for your leadership.
Ms. Stewart, you represent a phenomenal organization. It is
in every community's hearts and in our states and it is on our
mind. And we know about 1 in 33 children born in the United
States is born with an anomaly, a congenital anomaly. And, you
know, they are required to go through various surgeries on
occasion. We are thinking about the cleft palates.
Could you just describe some of these challenges that
families face in affording this important care? And also
legislation that I am a proud co-sponsor of, the Ensuring
Lasting Smiles Act, and how that would maybe make a difference,
Ms. Stewart.
Ms. Stewart. Sure. Thank you for that.
Ms. Stevens. Thank you.
Ms. Stewart. And we agree with all of your comments.
Ms. Stevens. Thank you for your leadership.
Ms. Stewart. You know, this is really an important issue
that often doesn't get discussed. And we talk a lot about
maternal deaths and infant deaths. We don't often talk about
when a pregnancy doesn't go as expected, the long-lasting
health impacts that a child has to deal with and what families
often have to deal with.
And one of the things that is really a big challenge for
too many families in this country are the number of children
that are born with these kind of congenital anomalies or birth
defects. And about 4 percent of all the children in the U.S.
are born with these birth defects. Again, the March of Dimes
has spent a lot of our history trying to deal with eliminating
birth defects through encouraging women, for example, to take
folic acid to deal with preventing certain birth defects.
But the Ensuring Lasting Smiles Act is really a piece of
legislation that we support strongly, with about 30 other
organizations. Right now what it is intended to do is ensure
that all private group and individual health plans cover
medical necessary services. And what we know is that there are
many plans that do actually provide for coverage for medically
necessary surgeries and other kinds of treatments that should
be made available to children that are born with these kind of
birth defects. But we are hearing that there are too many
instances in which some coverage is denied, often because
insurance companies will claim that a certain kind of surgery,
especially dental surgeries is where this happens a lot, are
more cosmetic in nature when we know in fact a baby that is
born with a cleft palate, for example, will have extreme
difficulties with breathing or eating and really living a
normal life.
And so what we are trying to do with this legislation, and
ask you all to do, is consider the fact that there should not
be any family that is denied coverage or having to assume too
much in terms of cost and to make sure these kind of services
are available.
Thank you.
Ms. Stevens. Well, thank you for that. Your leadership has
been phenomenal.
Madam Chair, I have a letter to submit for the record from
the National Foundation for Ectodermal Dysplasias.
And with my remaining time I would like to just get one
more question and cede my time to Congresswoman Underwood.
Ms. Underwood. Thank you, Congresswoman Stevens.
Ms. Sankofa submitted an excellent written testimony that
spoke about the PUMP for Nursing Mothers Act, a bill that fixes
a legal glitch that currently prevents millions of middle class
moms from reentering the workforce after giving birth.
Madam Chair, I would like to ask unanimous consent to
submit for the record a letter from more than 100 organizations
endorsing the PUMP for Nursing Mother's Act.
Chairwoman Wilson. Without objection.
Ms. Underwood. Thank you, Madam Chair. And thank you, Ms.
Stevens.
And I yield back.
Ms. Stevens. I yield back the remainder of my time.
Chairwoman Wilson. Mr. Scott, Chairman Scott.
Mr. Scott. Thank you. Ms. Stewart, it is good to see you
again.
Ms. Stewart. Good to see you.
Mr. Scott. Many of the witnesses talked about the
substantial number of deaths that are preventable. Can you
describe the ultimate cost to the health care system of the
initiatives that would prevent many of these deaths?
Ms. Stewart. So according to the CDC, about three out of
every five of these deaths are preventable. A lot of the deaths
that see as preventable are often due to misdiagnoses or
delayed diagnoses and a lack of adequate care that is being
provided to those women.
One of the things--I don't have the exact numbers--I can
get you the exact numbers, but one of the things that could be
very helpful is when women show up at a hospital, for example,
to deliver their baby, there should be the proper protocols in
place. And some of those protocols come from something that Dr.
Crear-Perry mentioned, which are the AIM bundles that ACOG and
others have been promoting, and that is to ensure that
hospitals have these improved bundles of care, protocols of
care, that would prevent these kinds of deaths from happening.
So, for example, when a woman is hemorrhaging, how do you
deal with hemorrhage and how do you deal with it in labor and
delivery when that typically hasn't been a place where you have
seen a lot of hemorrhage. How can you change practices so those
kinds of deaths are prevented?
There are probably some dollar amounts attached to it and
we can follow up and get you that, but I do think that those
are some of the things that are important.
Mr. Scott. Well, things like doulas, have you studied those
to see whether they save more money than they cost?
Ms. Stewart. Absolutely. There have been studies that show
that doulas and midwives, but especially doulas, can reduce and
prevent unnecessary maternal deaths, can actually improve birth
outcomes, can actually make sure that mothers are safer and
have healthier pregnancies.
Mr. Scott. And a lot of the provision of prenatal care will
reduce the incidence of low birth weight and ultimately save
more money than it costs?
Ms. Stewart. Prenatal care and then I think what we ought
to look at is in places that we have looked at the March of
Dimes, these maternal care deserts where there isn't
traditional prenatal care, how can things like telemedicine and
other kinds of services be made available. And those are some
of the gaps that we see that should be addressed.
Mr. Scott. Now, do you have data that show that the
prevention initiatives actually work?
Ms. Stewart. We do. I mentioned one earlier. In addition to
some of the studies I've referenced around doulas, some of the
areas around group prenatal care are evidence-based, have been
shown to reduce preterm birth by 33 percent. So we know that
has a measurable impact in improving lives and saving lives and
producing better health outcomes as well.
Mr. Scott. And what kind of initiatives before pregnancy--
you mentioned folic acid--before pregnancy and after birth,
what kind of initiatives can be helpful?
Ms. Stewart. So I think a couple of things. One is that
really adequate good prenatal care is really important. But
what I would say is even before pregnancy a woman has to be
able to be as healthy as possible. One of the things that we
are seeing that really is affecting some of these outcomes is
that women go into pregnancy with many more chronic health
challenges than existed in the past. So having a woman being
able to have the health coverage that she needs to address
obesity challenges, hypertension challenges that she may be
having so that she improves her health before she is pregnant
we know can have measurable impact. As well as support that she
may need in the postpartum period, especially around not only
her physical health, but also her mental health as well. And
that mental health coverage needs to be available throughout
her period of time before, during, and after pregnancy.
Mr. Scott. Thank you.
Dr. Crear-Perry, my colleague, Representative McBath,
mentioned the Family Violence Prevention Services Act is also
in this committee. Can you talk about the Federal services that
could be provided that would have the effect of reducing
violence and how that would reduce maternal deaths?
Dr. Crear-Perry. So we have a real gap when it comes to
intimate partner violence as far as policies. Places for people
to go if they are in danger, so providing support for cities
like my own of New Orleans, to have housing and have an
availability for victims of domestic violence would be really
important. Having policies that allow for safety for moms
inside of workplaces. Those are all really important. So there
is a direct tie between the elevated risk that someone has in
the world when they are pregnant, when it comes to intimate
partner violence and the ability to mitigate that risk through
Federal legislation.
Mr. Scott. Thank you, Madam Chair. I yield back.
Chairwoman Wilson. Thank you, Mr. Scott.
Ms. Bonamici.
Ms. Bonamici. Thank you, Madam Chair. I really appreciate
this conversation. Thank you to our witnesses for your
expertise. I think it has been a difficult but very important
conversation to hear that we are regressing as a country when
it comes to maternal and infant health. The wellbeing of
mothers and babies are sort of fundamental measures of any
nation's development. And to many Americans I think the
statistics that we have heard today might sound like they are
coming from a different country or a different time. But it is
a reality that we have to face, so we must--we must--face it,
we must address the failings and improve outcomes for all
families.
And we touched on several policies, particularly I want to
point out the inexcusably stark disparities for racial
minorities.
I would like to emphasize the point made by several of the
witnesses, that we can improve the likelihood of health births
even before pregnancy. Access to comprehensive reproductive
health, including contraception and prenatal care empowers
women to make decisions about when and in what circumstances
they choose to become pregnant.
I am currently working to update legislation. I introduced
last session the EQUIP Act that will encourage health care
providers to routinely ask women of childbearing age about
their intentions regarding pregnancy and to provide appropriate
care in response to those conversations. March of Dimes was one
of the organizations that endorsed the legislation because
these pregnancy intention screenings improve the likelihood of
healthy births. It is kind of a win-win because it is good for
maternal health and it also reduces unintended pregnancies.
And some of you might have noted that Oregon was the only
state that has got an A- in the March of Dimes report. In all
fairness, we don't have a lot of racial diversity, but we also
have many clinics that are using the sort of One Key Question,
pregnancy intention screening, and we also sort of aggressively
expanded Medicaid, we have coordinated care organizations. So
we are doing a good job in many ways, but there is still a lot
of work to do. We have to make sure that we are addressing
those implicit biases.
Dr. Crear-Perry, you spoke about positive health outcomes
being dependent on implementation of all sexual and
reproductive rights. Can you talk about how those rights might
not be respected in health care setting pre-pregnancy and how
policies can take that into account?
Dr. Crear-Perry. So I usually, when I am doing data, I
point out that although the United States is the worst in the
world when it comes to maternal mortality and Black women are
dying at three to four times the rate, that also means a lot of
White women are dying that should not. And places like Oregon
give us an example of what we could do better as a country if
we invested in everyone and invested in things like insurance
and other things. So it is important for us to think about when
you restrict access to contraception--so we have data--my
colleague Maeve Wallace and others, the places that have more
restrictions on access to contraception have the worst outcomes
for maternal and child health.
Ms. Bonamici. Right.
Dr. Crear-Perry. So when they say language around we are
making things safer for moms, you are actually making things
worse. So the data is the opposite of this narrative around
safety. So restrictions for sex education causes harm, causes
death.
Ms. Bonamici. Absolutely.
Dr. Crear-Perry. Restrictions for access to birth control,
for LARCs, for abortions. All those things cause harm and cause
death. The more you put policies in place that are barriers,
they more that women and children are more likely to die.
Ms. Bonamici. Right. Our legislature on a bipartisan basis
passed legislation to fill contraception prescriptions for
whole year rather than short-term, which my daughter really
appreciates.
Dr. Crear-Perry. Right. Yes.
Ms. Bonamici. So I recently visited a WIC clinic in
Washington County, Oregon and saw firsthand how important these
services are for women and families who want to give their
children a healthy start in life.
I just want to mention, in light of the public charge
opinion from the Supreme Court yesterday, I think we are going
to see more and more families afraid to reach out for services.
But WIC serves almost 15,000 people county-wide, 79 percent of
clients are working families and 22 percent are pregnant. We
know that this nutrition education, and connection is
beneficial in terms of improving birth weights and reduction in
premature births and fewer infant deaths.
Ms. Stewart, studies continue to confirm WIC's role in
reducing the likelihood of preterm birth. Only a slight
majority of pregnant WIC recipients, just a little more than 53
percent, are certified for the program in their first
trimester. Do you know why this is? And what can we do to
better encourage certification of pregnant women?
Ms. Stewart. I think a lot of people are very shocked when
they find out how important WIC is in terms of serving pregnant
and postpartum women, infants, and children younger than the
age of five. Almost half of the 4 million babies that are born
in the U.S. have been able to access WIC. And so it is an
important program.
We do think that having more access and having more
community workers and community access to make sure that women
understand how to overcome the barriers--
Ms. Bonamici. Right.
Ms. Stewart.--to become eligible for WIC is really
important. WIC has proven to be one of the most effective
evidence--based programs to ensure that, to your point, we can
improve health outcomes, reduce infant mortality, reduce risk
of preterm birth. We are strong in favor of expanding and
improving access and looking at ways in which to improve those
community access points as well.
Ms. Bonamici. Thank you. And I see my time has expired.
I just want to say how important paid family leave is. That
we are the only industrialized country to not have paid family
leave and what a difference it makes. My state at the state
level passed paid family leave, but we absolutely must, as a
country--it is shocking that so many women go back to work
within just a couple of weeks. I was fortunate. With my first
child I was able to take 6 months off. Most women can't do
that. And I still, you know, had to explain to people why I
needed to take a break to go pump in the restroom. And so, you
know, having paid leave really makes a difference for a healthy
start for children and families.
And I have gone over my time, so I yield back, Madam Chair.
Thank you very much.
Chairwoman Wilson. Chairman Scott? Ms. Underwood?
Ms. Underwood. Thank you, Madam Chair.
I request unanimous consent to submit a written testimony
from the American College of Obstetricians and Gynecologists
for the record.
Chairwoman Wilson. Without objection.
Ms. Underwood. Okay. Thank you so much.
Chairwoman Wilson. Mr. Scott
Mr. Scott. And, Madam Chair, I ask unanimous consent to
introduce into the record a report from the Institute for
Gender and Culture of the Black Women's Blueprint entitled
``The Sexual Abuse to Maternal Mortality Pipeline''.
Chairwoman Wilson. Without objection.
I remind my colleagues that pursuant to committee practice,
materials for submission for the hearing record must be
submitted to the Committee Clerk within 14 days following the
last day of the hearing, preferably in Microsoft Word format.
The materials submitted must address the subject matter of the
hearing. Only a member of the committee or an invited witness
may submit materials for inclusion in the hearing record.
Documents are limited to 50 pages each. Documents longer than
50 pages will be incorporated into the record by way of an
internet link that you must provide to the Committee Clerk
within the required timeframe. But please recognize that years
from now that link may no longer work.
Again, I want to thank the dynamic witnesses for their
participation today. What we have heard is very valuable.
Members of the committee may have some additional questions for
you and we ask the witnesses to please respond to those
questions in writing. The hearing record will be held open for
14 days in order to receive those responses.
I remind my colleagues that pursuant to committee practice,
witness questions for the hearing record must be submitted to
the majority committee staff or Committee Clerk within 7 days.
The questions submitted must address the subject matter of the
hearing.
I now recognize Workforce Protections Chair Adams for her
closing statement.
Ms. Adams. Thank you, Madam Chair. I want to join you in
thanking Ms. Stewart, Ms. Sankofa, and Dr. Crear-Perry for
their compelling testimony today. I also want to thank my
colleagues for coming together for this bipartisan hearing.
Today's discussions confirmed what mothers and communities
across the country have long known, our Nation's maternal and
infant health is in crisis and the Federal government must do
more to stop it. And to that end we must advance proposals that
address disparities in maternal and infant health and expand
access to health care and nutrition.
Further, we must ensure that our Nation's workplaces
provide critical supports, like designated pumping breaks for
pregnant workers and new mothers.
In closing, I am grateful that we could reaffirm today that
maternal and infant health are not partisan issues and each of
us here agrees that we have a shared responsibility to serve
our constituents by supporting affordable quality maternal and
infant care.
I look forward to working with my colleagues to ensure that
any mother anywhere in the United States can receive the
quality care and support she needs to navigate a healthy
pregnancy and raise a healthy child. I am a mother and I am a
grandmother, and so I look forward to having some great
grandchildren one day.
But before I yield, I would like to enter into the record a
statement from the organization A Better Balance in support of
today's hearing and Federal solutions to improving maternal and
infant health outcomes among women of color.
Chairwoman Wilson. Without objection.
Ms. Adams. Thank you. I now yield to my esteemed colleague
and Chair of the Subcommittee on Health, Employment, Labor, and
Pensions, Frederica Wilson, for a closing statement. And thank
you very much, Madam Chair, for bringing us together.
I yield back.
Chairwoman Wilson. I now recognize HELP Ranking Member
Walberg for his closing statement.
Mr. Walberg. Thank you, Madam Chairwomen, for this hearing
and thank you to the panel for being here.
And I agree, Madam Chairwoman, that this indicates and
shows that this is not a partisan issue, this is a bipartisan
issue of concern.
Now, we may not agree on every point. I think you
understand that. I think a lot of what we teach out there is
caught, not taught, by verbs and nouns, pronouns, statements.
And so I can never--I can never support the fact that abortion
is a good choice for a woman or a child or society because it
again reduces the value of a human life itself. And I
understand there is a disagreement on that.
I have a concern about any type of support for intimate
partnership. That term. As a man that says to me I don't have
to make a commitment that is lasting. I did not educate to my
sons that way. I am so thankful my son in law was not educated
that way either. And we can disagree on that.
But there are a lot of things we can agree on and move
forward. Certainly I was glad to support funding and continue
to support funding for Federally qualified community health
centers. I have a number in my seven-county district that do
excellent work and provide services that families and
individuals wouldn't get otherwise. I can see supporting
extension of Medicaid for mothers and children after birth
through a legitimate realistic and important period of time to
make sure that we deal with those issues of concern. I
certainly can see that.
So I guess I would end, Madam Chairwoman, and all those who
are interested here today, that there are some things we can
agree on to make a pact for. I wrote a few things down. There
could be more. But let us make a pact to love all babies
beginning at conception, let us make a pact to love and support
mothers and motherhood. I hope you see the difference. It is
special. Let us make a pact to push fathers to do all and
anything they can to protect and care for their children and
the mother of their children. Let us make a pact to do that.
Let us make a pact to motivate all agencies and policy makers
to implement science and research- based lifesaving procedures
and policies promoting birth and maternal health. And let us
make a pact to promote the family structure that fosters
positive maternal and infant health and functional families.
And let us make a pact to say you can't have everything without
sacrifice, so make sure that we promote an understanding of the
sacrifice that it takes in each individual situation and person
to ultimately come to the end result of promoting quality
maternal and infant health and the continuation through their
whole lifetime.
Thank you. And with that, I yield back.
Chairwoman Wilson. Thank you, Mr. Walberg.
I now recognize myself for a closing statement.
I want to add my appreciation to the wonderful witnesses
for taking the time to be with us today. You were phenomenal.
We have many, many hearings--many--every day and you are a
panel that I would rate A+. Thank you so much.
The United States is home to some of the best medical care
in the world. People come here from across the globe seeking
medical treatment they cannot otherwise access. Yet each year
tens of thousands of mothers across the country, particularly
Black and Brown mothers, cannot access the quality care they
need to have healthy pregnancies.
As our witnesses made clear, these mothers face barriers to
securing proven government services and quality health care.
They face severe gaps in coverage that restrict access to care
and they face systemic discrimination and racism throughout our
health care system. For too long the Federal government has
done too little to address these complex issues. As a result,
our Nation's maternal and infant health is falling behind the
rest of the world.
The time to act is now. This Congress we have a bipartisan
opportunity to fight the maternal and infant health crisis
together. We can and must pass legislation that follows
research and evidence, supports proven Federal services, and
expands access to quality health care for all mothers.
Moving ahead, I look forward to working with my colleagues
on both sides of aisle. And I am just happy to hear what they
said today, to advance proposals that achieve those shared
goals. If we work together, we can succeed in delivering for
the mothers, the infants, the communities, and the future of
our country.
If there is no further business, without objection, this
committee stands adjourned.
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[Whereupon, at 1:02 p.m., the subcommittees were
adjourned.]
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