[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]
IMPROVING MATERNAL HEALTH: LEGISLATION TO ADVANCE PREVENTION EFFORTS
AND ACCESS TO CARE
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTEENTH CONGRESS
FIRST SESSION
__________
SEPTEMBER 10, 2019
__________
Serial No. 116-58
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Energy and Commerce
govinfo.gov/committee/house-energy
energycommerce.house.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
40-850 PDF WASHINGTON : 2021
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COMMITTEE ON ENERGY AND COMMERCE
FRANK PALLONE, Jr., New Jersey
Chairman
BOBBY L. RUSH, Illinois GREG WALDEN, Oregon
ANNA G. ESHOO, California Ranking Member
ELIOT L. ENGEL, New York FRED UPTON, Michigan
DIANA DeGETTE, Colorado JOHN SHIMKUS, Illinois
MIKE DOYLE, Pennsylvania MICHAEL C. BURGESS, Texas
JAN SCHAKOWSKY, Illinois STEVE SCALISE, Louisiana
G. K. BUTTERFIELD, North Carolina ROBERT E. LATTA, Ohio
DORIS O. MATSUI, California CATHY McMORRIS RODGERS, Washington
KATHY CASTOR, Florida BRETT GUTHRIE, Kentucky
JOHN P. SARBANES, Maryland PETE OLSON, Texas
JERRY McNERNEY, California DAVID B. McKINLEY, West Virginia
PETER WELCH, Vermont ADAM KINZINGER, Illinois
BEN RAY LUJAN, New Mexico H. MORGAN GRIFFITH, Virginia
PAUL TONKO, New York GUS M. BILIRAKIS, Florida
YVETTE D. CLARKE, New York, Vice BILL JOHNSON, Ohio
Chair BILLY LONG, Missouri
DAVID LOEBSACK, Iowa LARRY BUCSHON, Indiana
KURT SCHRADER, Oregon BILL FLORES, Texas
JOSEPH P. KENNEDY III, SUSAN W. BROOKS, Indiana
Massachusetts MARKWAYNE MULLIN, Oklahoma
TONY CARDENAS, California RICHARD HUDSON, North Carolina
RAUL RUIZ, California TIM WALBERG, Michigan
SCOTT H. PETERS, California EARL L. ``BUDDY'' CARTER, Georgia
DEBBIE DINGELL, Michigan JEFF DUNCAN, South Carolina
MARC A. VEASEY, Texas GREG GIANFORTE, Montana
ANN M. KUSTER, New Hampshire
ROBIN L. KELLY, Illinois
NANETTE DIAZ BARRAGAN, California
A. DONALD McEACHIN, Virginia
LISA BLUNT ROCHESTER, Delaware
DARREN SOTO, Florida
TOM O'HALLERAN, Arizona
------
Professional Staff
JEFFREY C. CARROLL, Staff Director
TIFFANY GUARASCIO, Deputy Staff Director
MIKE BLOOMQUIST, Minority Staff Director
Subcommittee on Health
ANNA G. ESHOO, California
Chairwoman
ELIOT L. ENGEL, New York MICHAEL C. BURGESS, Texas
G. K. BUTTERFIELD, North Carolina, Ranking Member
Vice Chair FRED UPTON, Michigan
DORIS O. MATSUI, California JOHN SHIMKUS, Illinois
KATHY CASTOR, Florida BRETT GUTHRIE, Kentucky
JOHN P. SARBANES, Maryland H. MORGAN GRIFFITH, Virginia
BEN RAY LUJAN, New Mexico GUS M. BILIRAKIS, Florida
KURT SCHRADER, Oregon BILLY LONG, Missouri
JOSEPH P. KENNEDY III, LARRY BUCSHON, Indiana
Massachusetts SUSAN W. BROOKS, Indiana
TONY CARDENAS, California MARKWAYNE MULLIN, Oklahoma
PETER WELCH, Vermont RICHARD HUDSON, North Carolina
RAUL RUIZ, California EARL L. ``BUDDY'' CARTER, Georgia
DEBBIE DINGELL, Michigan GREG GIANFORTE, Montana
ANN M. KUSTER, New Hampshire GREG WALDEN, Oregon (ex officio)
ROBIN L. KELLY, Illinois
NANETTE DIAZ BARRAGAN, California
LISA BLUNT ROCHESTER, Delaware
BOBBY L. RUSH, Illinois
FRANK PALLONE, Jr., New Jersey (ex
officio)
CONTENTS
----------
Page
Hon. Anna G. Eshoo, a Representative in Congress from the State
of California, opening statement............................... 2
Prepared statement........................................... 3
Hon. Michael C. Burgess, a Representative in Congress from the
State of Texas, opening statement.............................. 4
Prepared statement........................................... 5
Hon. Frank Pallone, Jr., a Representative in Congress from the
State of New Jersey, opening statement......................... 6
Prepared statement........................................... 8
Hon. Greg Walden, a Representative in Congress from the State of
Oregon, opening statement...................................... 9
Prepared statement........................................... 11
Witnesses
Wanda Irving, Mother of Dr. Shalon Irving........................ 12
Prepared statement........................................... 15
Patrice Harris, M.D., President, Board of Trustees, American
Medical Association............................................ 22
Prepared statement........................................... 24
Answers to submitted questions............................... 173
Elizabeth A. Howell, M.D., Director, Blavatnik Family Women's
Health Research Institute, Icahn School of Medicine at Mount
Sinai.......................................................... 32
Prepared statement........................................... 34
Answers to submitted questions............................... 180
David Nelson, M.D., Chief of Obstetrics, Parkland Health and
Hospital System................................................ 38
Prepared statement........................................... 40
Answers to submitted questions............................... 185
Usha Ranji, Associate Director, Women's Health Policy, Kaiser
Family Foundation.............................................. 44
Prepared statement........................................... 46
Answers to submitted questions............................... 194
Submitted Material
H.R. 1897, the Mothers and Offspring Mortality and Morbidity
Awareness (MOMMA's) Act \1\
H.R. 1551, the Quality Care for Moms and Babies Act \1\
H.R. 2602, the Healthy MOMMIES Act \1\
H.R. 2902, the Maternal Care Access and Reducing Emergencies
(Maternal CARE) Act \1\
Statement of Stacey D. Stewart, President and Chief Executive
Officer, March of Dimes, September 10, 2019, submitted by Ms.
Eshoo.......................................................... 100
Statement of the American College of Obstetrics and Gynecology,
September 10, 2019, submitted by Ms. Eshoo..................... 106
Statement of the American Hospital Association, September 10,
2019, submitted by Ms. Eshoo................................... 115
Statement of America's Health Insurance Plans, September 10,
2019, submitted by Ms. Eshoo................................... 120
----------
\1\ The legislation has been retained in committee files and also is
available at https://docs.house.gov/Committee/Calendar/
ByEvent.aspx?EventID=109919.
Report of the Center for American Progress, ``Eliminating Racial
Disparities in Maternal and Infant Mortality,'' by Jamila
Taylor, et al., May 2019, submitted by Ms. Eshoo \2\
Letter of September 9, 2019, from American College of Nurse-
Midwives, et al., to Mr. Engel and Hon. Steve Stivers,
submitted by Ms. Eshoo......................................... 127
Statement of Premier, Inc., September 10, 2019, submitted by Ms.
Eshoo.......................................................... 128
Statement of Gauss Surgical, Inc., September 10, 2019, submitted
by Ms. Eshoo................................................... 130
Report of Premier, Inc., ``Bundle of Joy: Maternal & Infant
Health Trends,'' submitted by Ms. Eshoo........................ 136
Article of December 7, 2017, ``Nothing Protects Black Women From
Dying in Pregnancy and Childbirth,'' by Nina Martin and Renee
Montagne, ProPublica and NPR, submitted by Ms. Eshoo........... 151
----------
\2\ The report has been retained in committee files and also is
available at https://docs.house.gov/meetings/IF/IF14/20190910/109919/
HHRG-116-IF14-20190910-SD006.pdf.
IMPROVING MATERNAL HEALTH: LEGISLATION TO ADVANCE PREVENTION EFFORTS
AND ACCESS TO CARE
----------
TUESDAY, SEPTEMBER 10, 2019
House of Representatives,
Subcommittee on Health,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 10:01 a.m., in
the John D. Dingell Room 2123, Rayburn House Office Building,
Hon. Anna G. Eshoo (chairwoman of the subcommittee) presiding.
Members present: Representatives Eshoo, Engel, Butterfield,
Matsui, Castor, Sarbanes, Lujan, Schrader, Kennedy, Cardenas,
Welch, Ruiz, Dingell, Kuster, Kelly, Barragan, Blunt Rochester,
Rush, Pallone (ex officio), Burgess (subcommittee ranking
member), Upton, Shimkus, Guthrie, Griffith, Bilirakis, Long,
Bucshon, Brooks, Mullin, Hudson, Carter, Gianforte, and Walden
(ex officio).
Also present: Representatives Schakowsky and Soto.
Staff present: Jacquelyn Bolen, Counsel; Jeffrey C.
Carroll, Staff Director; Waverly Gordon, Deputy Chief Counsel;
Tiffany Guarascio, Deputy Staff Director; Stephen Holland,
Health Counsel; Zach Kahan, Outreach and Member Service
Coordinator; Josh Krantz, Policy Analyst; Una Lee, Chief Health
Counsel; Aisling McDonough, Policy Coordinator; Meghan Mullon,
Staff Assistant; Joe Orlando, Staff Assistant; Kaitlyn Peel,
Digital Director; Tim Robinson, Chief Counsel; Kimberlee
Trzeciak, Chief Health Advisor; Rick Van Buren, Health Counsel;
Margaret Tucker Fogarty, Minority Staff Assistant; Caleb Graff,
Minority Professional Staff Member, Health; Peter Kielty,
Minority General Counsel; J. P. Paluskiewicz, Minority Chief
Counsel, Health; Brannon Rains, Minority Legislative Clerk;
Zack Roday, Minority Director of Communications; and Kristen
Shatynski, Minority Professional Staff Member, Health.
Ms. Eshoo. The Subcommittee on Health will come to order.
Welcome back, everyone. I hope you had a productive August
and that you have got some rest with your families, and we will
roll up our sleeves and get back to work.
The Chair now recognizes herself for 5 minutes for an
opening statement.
And the witnesses, please come to the table. And thank you
each one for being here.
OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF CALIFORNIA
``The United States is the most dangerous place in the
developed world to deliver a baby.'' That is a quote and the
conclusion after major investigation by USA Today last year.
Each year, about 700 American women die and 50,000 women are
severely injured due to complications related to childbirth. If
you are a Black woman in the United States, it is even more
dangerous to give birth.
Black and American Indian and Alaska Native women are three
to four times more likely to die from pregnancy-related causes.
This is absolutely unacceptable. And what is more, it is
preventable. The CDC estimates that more than 60 percent--more
than 60 percent--of these deaths could be prevented.
Our witnesses will instruct us today that there is a clear
way to save mothers' lives. We need to make sure that women
have high-quality care and coverage before, during, and after
their pregnancy. And the four bills we are considering today do
just that.\1\
---------------------------------------------------------------------------
\1\ The legislation has been retained in committee files and also
is available at https://docs.house.gov/Committee/Calendar/
ByEvent.aspx?EventID=109919.
---------------------------------------------------------------------------
Congresswoman Kelly's MOMMA's Act uses standardized data to
inform healthcare professionals about the best practices and
protocols to manage a mother's care in an emergency, such as
when a mother hemorrhages after birth. This data-driven
approach was spearheaded in my district at Stanford,
California's Maternal Quality Care Collaborative, which has
reduced severe health problems from pregnancy-related
hemorrhages by 21 percent to date and has contributed to
reducing the maternal mortality rate in California by a
whopping 55 percent.
Representative Engel's Quality Care for Moms and Babies Act
also works to improve maternal care through data by using care
surveys, quality measures, and perinatal quality
collaboratives.
Both Congresswoman Kelly's legislation and Congresswoman
Pressley's Healthy MOMMIES Act recognizes that to truly make
progress, women must be able to get medical care when they need
it.
Women are more likely to die of a pregnancy-related
condition in the weeks following birth than during pregnancy or
delivery, but many American mothers lack health insurance
during that critical postpartum period. Every year, hundreds of
thousands of mothers are kicked off Medicaid only 2 months
after giving birth. The MOMMA'S Act and the Healthy MOMMIES Act
extend Medicaid for a full year postpartum. These bills make
sure the Medicaid safety net is there for women at one of the
most vulnerable times in their lives, and this extension makes
sense. That is why State legislatures in California, New
Jersey, Texas, South Carolina, and Illinois are seriously
considering measures to extend Medicaid for 1 year for eligible
new mothers.
Finally, the Maternal CARE Act introduced by Congresswoman
Alma Adams addresses the insidious way racism kills Black
mothers. The bill funds implicit bias training programs for
health professionals. As Nina Martin describes in her
investigative series ``Lost Mothers,'' African-American mothers
repeatedly report being devalued and disrespected by medical
providers who did not take their medical concerns seriously.
I will conclude as I began: The United States is the most
dangerous place in the developed world to deliver a baby. Shame
on us. I believe a high maternal death rate is a reflection of
how much a society values women. As the first chairwoman of
this subcommittee, I think it is time we reverse this by making
a healthcare system that better cares for women.
[The prepared statement of Ms. Eshoo follows:]
Prepared Statement of Hon. Anna G. Eshoo
``The U.S. is the most dangerous place in the developed
world to deliver a baby.'' This quote was the conclusion of a
major investigation by USA Today last year.
Each year, about 700 American women die and 50,000 women
are severely injured due to complications related to
childbirth. If you're a Black woman in the U.S., it is even
more dangerous to give birth. Black women are three to four
times more likely to die from childbirth than White women.
This is unacceptable, and what's more, it's preventable.
The CDC estimates more than 60% of these deaths could be
prevented.
Our witnesses will instruct us today that there is a clear
way to save mothers' lives.
We need to make sure women have high quality care and
coverage before, during, and after their pregnancy. The four
bills we're considering today do just that.
Congresswoman Kelly's MOMMA's Act (H.R. 1897) uses
standardized data to inform healthcare professionals about the
best practices and protocols to manage a mother's care in an
emergency, such as when a mother hemorrhages after birth.
This data-driven approach was spearheaded in my district.
Stanford's California Maternal Quality Care Collaborative has
reduced severe health problems from pregnancy-related
hemorrhages by 21% and has contributed to reducing the maternal
mortality rate in California by 55%.
Representative Engel's Quality Care for Moms and Babies Act
(H.R. 1551) also works to improve maternal care through data by
using care surveys, quality measures, and perinatal quality
collaboratives.
Both Congresswoman Kelly's MOMMA's Act (H.R. 1897) and
Congresswoman Pressley's Healthy MOMMIES Act (H.R. 2602)
recognize that to truly make progress, women must be able to
get medical care when they need it.
Women are more likely to die of a pregnancy-related
condition in the weeks following birth than during pregnancy or
delivery, but many American mothers lack health insurance
during that critical postpartum period.
Every year, hundreds of thousands of mothers are kicked off
Medicaid only 2 months after giving birth.
The MOMMA's Act and the Healthy MOMMIES Act extend Medicaid
for a full year postpartum. These bills make sure the Medicaid
safety net is there for women at one of the most vulnerable
times in their lives.
This extension makes sense. That's why State legislatures
in California, New Jersey, Texas, South Carolina, and Illinois
are seriously considering measures to extend Medicaid for 1
year for eligible new mothers.
Finally, the Maternal CARE Act (H.R. 2902), introduced by
Congresswoman Alma Adams, addresses the insidious way racism
kills Black mothers. The bill funds implicit bias training
programs for health professionals.
As Nina Martin describes in her investigative series ``Lost
Mothers,'' African-American mothers repeatedly report being
devalued and disrespected by medical providers who did not take
their medical concerns seriously.
I'll conclude as I began. The United States is the most
dangerous place in the developed world to deliver a baby.
I believe a high maternal death rate is a reflection of how
much a society values women. As the first chairwoman of the
Health Subcommittee, I think it's time we reverse this by
making a healthcare system that better cares for women.
I yield the remainder of my time to Representative Engel,
the author of H.R. 1551, the Quality Care for Moms and Babies
Act.
Ms. Eshoo. I now would like to yield the remainder of my
time to Representative Engel, the author of H.R. 1551, the
Quality Care for Moms and Babies Act. Oh, he is not here. All
right.
Well, the Chair will now recognize Dr. Burgess, the ranking
member of our subcommittee, for 5 minutes for his opening
statement.
OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF TEXAS
Mr. Burgess. Thank you, Chairwoman Eshoo. Thanks for the
recognition.
And I certainly appreciate that our Health Subcommittee is
revisiting the issue of maternal mortality. Certainly we
addressed this last year when we held the hearing on Jaime
Herrera Beutler's H.R. 1318, the Preventing Maternal Deaths
Act, which was signed into law last December. And whether the
people realize it or not--I don't know how many people do
realize it--unusual for the House of Representatives to pass a
stand-alone bill dealing with maternal mortality, but it did
indeed happen in the last Congress.
And now we are here today to see if we can build on that
success, build on that progress, utilize the data that is going
to become available because of getting H.R. 1318 across the
finish line.
By authorizing grants and allowing States to establish
Maternal Mortality Review Committees, such as the one that
Texas established back in 2013, States will be able to clearly
identify the causes of maternal mortality and use that data to
inform solutions. Given the robust bipartisan discussions that
occurred last year, we do want to continue those robust
bipartisan discussions. Unfortunately, today the bills that we
have before us are all on the majority side. Our staffs have
spent some time in preparation for this hearing. So it is
unfortunate that that could not have been a little more
expansive. Dr. Bucshon on this committee and Representative
Andre Carson, a member of the majority, introduced a bipartisan
bill, H.R. 4215, the Excellence in Maternal Health Act, along
with a number of Energy and Commerce members, and I believe
that a version of this language could become law and be signed
by the President, and we should discuss the merits of such a
policy at this hearing.
I think it is worthwhile to have a productive dialogue
about the ideas put forth in all of the bills before us today,
but there certainly are some questions about how implementation
would occur and whether the bills would actually make a
difference.
I in my former life did practice obstetrics and gynecology.
Now as a Member of Congress, I want you know that addressing
maternal mortality is one of my top priorities. And that is why
I advocated, along with Representative Herrera Beutler last
year, for the passage of H.R. 1318. Over the course of this
year, I have been carefully looking at the right next step to
build on the success we had last year. I have engaged with the
Congressional Budget Office on several policy options related
to Medicaid coverage of pregnancy, and I am committed to
finding a way to address this issue, but we do need to be
tactful and inclusive in this approach.
As we move through the discussion of these bills, I have
some questions that I would like our witnesses to have in mind.
First, what is the Centers for Disease Control and
Prevention already doing to aid States process data through
Maternal Mortality Review Committees? And do these bills we
have before us today, are they additive or are they simply
duplicative of existing efforts?
Secondly, more than 40 percent of the births in the United
States are covered by Medicaid. What tools do States need to
address the unique needs of their own Medicaid populations?
Thirdly, some States are already submitting 1115 waivers to
expand Medicaid coverage for 1 year postpartum without any
intervening Federal legislation. How would these existing State
efforts be impacted by a Federal law, and is there any danger
of hampering State innovation?
Fourthly, how can we support hospitals' existing efforts to
coordinate care and maintain access to physicians throughout
the delivery?
Fifth, are any States employing innovative maternity care
models in Medicaid that would be worthy of exploring at a
demonstration at a Federal level?
And then, finally, what are the main barriers to women
receiving pre- and postnatal care? And what are the best
practices that can be deployed to address maternal mortality
and severe morbidity, the so-called near misses that occur when
someone actually survives but has a very untoward event?
Now, I do want to spend a moment and give a special thanks
and a special Texas welcome to Dr. David Nelson, the chief of
obstetrics at Parkland Hospital.
Chairwoman, you said, quoting from USA Today, that the
United States is the most dangerous place in the world to have
a baby. I would submit that Parkland Hospital is probably the
safest place in the world to have a baby. It is because of the
tremendous leadership, the clinical staff, and the dedicated
staff of UT Southwestern and the residents and house officers
and the nurses who all provide care to the medically indigent
in Dallas County, Texas.
So, as a former Parkland resident, I am looking forward to
hearing about the practices that your team employs to ensure
safe delivery for both mothers and babies in Dallas, down in
Texas.
And I yield back my time.
[The prepared statement of Mr. Burgess follows:]
Prepared Statement of Hon. Michael C. Burgess
Thank you, Chairwoman Eshoo. I appreciate that our Health
Subcommittee is revisiting the issue of maternal mortality, one
that we addressed last year when we held a hearing on Rep.
Jaime Herrera Beutler's H.R. 1318, the Preventing Maternal
Deaths Act, which President Trump signed into law in December.
It was critical that we work in a bipartisan fashion to get
H.R. 1318 across the finish line because stakeholders continued
to tell us that there was a lack of data about why these
maternal deaths were occurring, and that it is difficult to
address problems that have yet to be clearly identified.
By authorizing grants allowing States to establish maternal
mortality review committees, such as the one that Texas
established in 2013, States will be able to clearly identify
the causes of maternal mortality, eventually using that data to
inform solutions.
Given the robust bipartisan discussions that occurred last
year, I am frustrated that the majority did not collaborate
with us much in preparation of this hearing. For example, our
staffs had spoken months ago about building upon language
included in the bipartisan Senate HELP Committee's healthcare
costs package to continue this subcommittee's commitment to
addressing the issue of maternal mortality. Unfortunately, you
decided you did not want to move forward on this language
together. In fact, you even tried to add a bill at the last
minute on Friday afternoon and still refused to include the
HELP language as introduced by Dr. Bucshon.
Dr. Bucshon and Rep. Andre Carson introduced a bipartisan
bill, H.R. 4215, the Excellence in Maternal Health Act of 2019,
along with me and a number of other Energy and Commerce
members. I believe that a version of this language could become
law, and that we should discuss the merits of such a policy at
this hearing. I think it is worthwhile to have a productive
dialogue about the ideas put forth in the four bills before us
today, but I have a lot of questions about how these policies
would be implemented and if they would actually make a
difference.
As an OB/GYN and a Member of Congress, addressing maternal
mortality is one of my top priorities, which is why I advocated
alongside Rep. Herrera Beutler last year for passage of H.R.
1318. Over the course of this year, I have been carefully
looking for the right next step to build on the successes of
H.R. 1318. I have engaged with CBO on several policy options
related to Medicaid coverage of pregnancy, and I am committed
to finding a way to address this issue, but we must be tactful
in our approach. I do wish that this hearing had been planned
in advance such that agencies that would be on the front lines
of implementing the policies before us today.
As we move through our discussion of these bills, I have
some questions that I would like our witnesses and other
Members to have in mind.
1. What is the Center for Disease Control and Prevention
already doing to aid States process data through maternal
mortality review committees as a result of H.R. 1318, and do
these other bills duplicate existing efforts?
2. More than 40 percent of births in the United States are
covered by Medicaid. What tools do States need to address the
unique needs within their own Medicaid populations?
3. States are already submitting 1115 waivers to expand
Medicaid coverage to one-year post partum without Federal
legislation. How would these existing State efforts be impacted
by a Federal law and would State innovation be hampered?
4. How can we support hospitals' existing efforts to
coordinate care and maintain access to physicians throughout
delivery?
5. Are any States employing innovative maternity care
models in Medicaid that would be worthy exploring in a
demonstration or at a Federal level?
6. What are the main barriers to women receiving pre- and
post-natal care, and what are best practices that can be
deployed to address maternal morbidity and mortality?
I would like to give a special Texas welcome to Dr. David
Nelson, the Chief of Obstetrics at Parkland Hospital. As a
former Parkland resident, I look forward to hearing more about
the practices he and his team employ to ensure safe delivery
for both mothers and babies in Dallas.
Thank you, and I yield back.
Ms. Eshoo. The Chair thanks the ranking member for his
comments. Let me just add something to them. The committee is
hearing four bills today, and together they contain all of the
provisions in the Senate health bill and Representative
Bucshon's bill, but they also go beyond those provisions to
include extending Medicaid coverage for post partum women. So I
wanted to add that to the conversation.
The Chair is now pleased to recognize the chairman of the
full committee, Mr. Pallone, for his 5 minutes for his opening
statement.
OPENING STATEMENT OF HON. FRANK PALLONE, Jr., A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NEW JERSEY
Mr. Palllone. Thank you, Madam Chair.
Today, we are examining the often tragic reality of the
maternal health system in our Nation and a number of policies
that could dramatically improve health outcomes for new mothers
and their children. Every year, about 700 women die here in the
United States from a pregnancy-related condition, and thousands
more face severe maternal morbidity. That is simply
disgraceful. And when you compare these outcomes to other
countries around the world, the United States is near the
bottom. We are also the only industrialized country in the
world with a rising maternal death rate.
In a nation as wealthy as ours, these statistics are simply
shocking and inexcusable, but I am hopeful that we can begin to
turn the tide to improve maternal health. The Centers for
Disease Control and Prevention estimates that 60 percent of
maternal deaths in the U.S. are preventable, and the
legislation we are discussing today is a strong step forward.
Now, a number of the bills that we have today will
strengthen prevention efforts that already exist, including
policies that follow up on the Preventing Maternal Deaths Act,
which was enacted last year. This new law improved data
collection and helped to expand Maternal Mortality Review
Committees to all 50 States. The legislation also authorizes
and strengthens the Alliance for Innovation on Maternal Health
and Safety, or the AIM program. This program helps physicians
and health systems implement evidence-based practices that have
been shown to improve patient outcomes when performed in a
healthcare setting but have not yet been implemented
nationwide.
Maternal mortality and morbidity are problems that affect
women throughout our country, but especially in African-
American and Native American communities, where women are three
times as likely to die due to pregnancy-related conditions as
White women. The bills also offer a number of proposals to
reduce health disparities along racial, ethnic, and cultural
lines.
We are also going to be looking at ways to improve health
coverage for new mothers. According to the CDC, one-third of
all pregnancy-related deaths occur between 1 week and 1 year
post partum. And while Medicaid and the Children's Health
Insurance Program cover more than half of all births in the
U.S., coverage for some new mothers ends just 60 days after
delivery. That is why I am glad we will be reviewing additional
proposals to extend that coverage to 1 year after delivery,
extending access to regular physician checkups and other health
services that help women and their healthcare providers detect
and treat health issues such as high blood pressure and heart
disease, two of the most common causes of pregnancy-related
deaths. It is my sincere hope to work with our Republican
colleagues to enact a bipartisan proposal to extend this vital
health coverage for new mothers.
Our witnesses today offer views from diverse backgrounds,
and I am confident that their experiences and expertise will
help us all learn more about the problems we are facing and the
solutions that will make a real difference. I thank them all
for being here.
And I also want to recognize the leadership of so many
bipartisan Members of the House who testified on this important
topic at our recent Member Day hearing, including several
members of the Congressional Caucus on Maternity Care and the
Black Maternal Health Caucus.
So I have a couple of minutes left. I would like to yield
that to the woman from Chicago, Ms. Kelly, the author of the
H.R. 1897, the MOMMA's Act.
[The prepared statement of Mr. Pallone follows:]
Prepared Statement of Hon. Frank Pallone, Jr.
Today we are examining the often tragic reality of the
maternal health system in our Nation, and a number of policies
that could dramatically improve health outcomes for new mothers
and their children.
Every year, about 700 women die here in the United States
from a pregnancy-related condition, and thousands more face
severe maternal morbidity. That's simply disgraceful. And when
you compare these outcomes to other countries around the world,
the United States is near the bottom. We are also the only
industrialized country in the world with a rising maternal
death rate.
In a nation as wealthy as ours, these statistics are simply
shocking and inexcusable, but I am hopeful that we can begin to
turn the tide to improve maternal health. The Centers for
Disease Control and Prevention (CDC) estimates that 60 percent
of maternal deaths in the United States are preventable, and
the legislation that we are discussing today is a strong step
forward.
A number of the bills will strengthen prevention efforts
that already exist, including policies that follow up on the
Preventing Maternal Deaths Act, which was enacted last year.
This new law improved data collection and helped to expand
Maternal Mortality Review Committees to all 50 States. The
legislation also authorizes and strengthens the Alliance for
Innovation in Maternal Health and Safety, or the AIM program.
This program helps physicians and health systems implement
evidence-based practices that have been shown to improve
patient outcomes when performed in a healthcare setting but
have not yet been implemented nationwide.
Maternal mortality and morbidity are problems that affect
women throughout our country, but especially in African-
American and Native American communities, where women are three
times as likely to die due to pregnancy-related conditions as
White women. The bills also offer a number of proposals to
reduce health disparities along racial, ethnic, and cultural
lines.
We are also going to be looking at ways to improve health
coverage for new mothers. According to the CDC, one-third of
all pregnancy-related deaths occur between one week and one
year postpartum. While Medicaid and the Children's Health
Insurance Program cover more than half of all births in the
United States, coverage for some new mothers ends just 60 days
after delivery. That is why I am glad we will be reviewing
additional proposals to extend that coverage to one year after
delivery. Extending access to regular physician checkups and
other health services could help women and their healthcare
providers detect and treat health issues such as high blood
pressure and heart disease, two of the most common causes of
pregnancy-related death. It is my sincere hope to work with our
Republican colleagues to enact a bipartisan proposal to extend
this vital healthcare coverage for new mothers.
Our witnesses today offer views from diverse backgrounds
and I am confident that their experiences and expertise will
help all of us learn more about the problems we are facing and
the solutions that will make a real difference. I thank them
all for being here.
I also want to recognize the leadership of so many
bipartisan Members of the House who testified on this important
topic at our recent Member Day hearing, including several
members of the Congressional Caucus on Maternity Care and the
Black Maternal Health Caucus.
I'd now like to yield the remainder of my time to
Representative Kelly, the author of H.R. 1897, the MOMMA's Act.
Ms. Kelly. Thank you, Mr. Chair.
Chairman Pallone, Chairwoman Eshoo, and Ranking Member
Burgess, thank you for allowing me to make this brief opening
statement.
Like you, I am shocked by our Nation's growing maternal
mortality crisis. While losing 700 to 900 new moms each year is
devastating, this crisis, like too many others, takes a
disproportionate toll on communities of color. Nationwide,
Black mothers die three to four times the rate of White
mothers. In my home State of Illinois, that disparity climbs to
six times. In the State of Washington, American Indian moms die
eight times the rate of their White counterparts.
It is clear that race is playing a role in these deaths.
That is why my proposal, the MOMMA's Act, which I will discuss
in depth later, includes provisions to ensure cultural
competency training to ensure all moms and families are
listened to during their childbirth journey.
However, this provision will only take us so far. It is
imperative that we continue investing in diversifying the
provider pipeline. The racial disparities underlying the
shocking maternal mortality statistics make an already tragic
situation more tragic. However, these challenges are not
insurmountable. Today's hearing and the commitment from this
subcommittee give me great hope for a future where all mamas
get the chance to be mamas. I thank the chairwoman for the time
and appreciate your efforts in addressing the crisis.
I yield back.
Ms. Eshoo. We thank the gentlewoman for her work on her
important legislation.
I now would like to recognize the ranking member of the
full committee, my friend Mr. Walden, for his 5 minutes for an
opening statement.
OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF OREGON
Mr. Walden. Thank you, Madam Chair. And thanks for having
this very important hearing.
I appreciate all the witnesses who are here to share your
stories and to comment on the legislation before us.
This critical issue of maternity morbidity and mortality,
it is an issue that is quite literally a matter of life and
death and for all women across the country. It is a difficult
topic. It is one that is close to my heart.
Despite massive innovation in healthcare and advancements
in technology, recent reports have indicated that the number of
women dying due to pregnancy complications has increased in
recent years. The effects of such a tragedy on any family are
impossible to comprehend.
This hearing builds off the important work of our committee
in the last Congress under the leadership of Dr. Burgess and
the Health Subcommittee. Last year, as you have heard, the
President signed into law H.R. 1318, the Preventing Maternal
Deaths Act. This important law, led by Representative Jaime
Herrera Beutler of Washington State and Diana DeGette of
Colorado, seeks to improve data collection reporting around
maternal mortality and develop systems at the local, State, and
national levels in order to better understand the burden of
maternal complications.
These efforts include identifying the reasons for disparity
in maternal care, health risks that contribute to maternal
mortality, and clinical practices that would improve health
outcomes for moms and babies.
We have continued to lead the way this Congress as well--
and on a bipartisan basis, I would add--sending letters earlier
this year to six Health and Human Service agencies where we
asked for the latest information on what they are doing to
combat maternal mortality. I hope we finish the briefings
requested in those letters very soon.
Unfortunately, I do have to say I am dismayed at the way
that this legislative hearing today came together. For an issue
that is absolutely bipartisan, I am just disappointed the
majority would not allow consideration of Dr. Bucshon's bill,
H.R. 4215, the Excellence in Maternal Health Act. It is a
bipartisan bill. It is led by Dr. Bucshon. It serves as the
House companion to the maternal mortality provisions in Senator
Alexander and Senator Murray's bipartisan Senate legislation,
Lowering Health Care Costs Act.
So I strongly support the bipartisan language in this bill
as it demonstrates our commitment to further addressing
maternal mortality, just as we did in a bipartisan way last
Congress. The bill authorizes grants to identify, develop, and
disseminate maternal health quality best practices, supports
training at health profession schools to reduce and prevent
discrimination and implicit biases, enhances Federal efforts to
establish or support perinatal quality collaboratives, and
authorizes grants for establishing and/or operating innovative
evidence-informed programs that deliver integrated services to
pregnant and post partum women.
The language in this bill passed the United States Senate
Committee on Health, Education, Labor, and Pensions as part of
Senator Alexander and Senator Murray's bipartisan package, and
so I truly don't understand why we wouldn't have had that on
the docket today for consideration as well. I just hope we
will. I hope there will be another hearing where we can hear
from Dr. Bucshon on his legislation.
Some of today's bills would expand Medicaid and CHIP
coverage for pregnant and postpartum women from 60 days to 1
year. This is a significant policy change and one, of course,
we need to carefully consider before we advance such a policy
through the committee. Importantly, several States have already
undertaken such initiatives. And we should gain a greater
understanding about the State experiences, as that will be
critical as we move forward.
Given the huge impact some of these bills will have on HHS,
I would also note that HHS is not here before us today to
discuss what they are already doing to address maternal
mortality--we would benefit from hearing from them--nor to
provide their thoughts on the incomplete list of bills before
us today.
Given this absence, I call on the majority to schedule a
second legislative hearing before moving to a markup. And I
strongly urge the majority to include H.R. 4215 in such a
hearing. It is a good-faith, bipartisan bill with Senate
support that deserves consideration in the House.
Despite my concerns about this process, I have no concerns
about our distinguished witnesses today and our panel of
experts. I want to thank you all again for being here today to
talk about the bills before us, to share your stories and your
expertise. I know we will learn much about the landscape of
maternal mortality and care and what more we can do to improve
the health outcomes in expectant and new mothers across the
country. That is a goal we all share. So thank you for being
here.
Madam Chair, with that, I yield back.
[The prepared statement of Mr. Walden follows:]
Prepared Statement of Hon. Greg Walden
The critical issue of maternal morbidity and mortality--an
issue that is literally a matter of life and death for women
all across the country--is a difficult topic, and one that is
close to my heart.
Despite massive innovation in healthcare and advancements
in technology, recent reports have indicated that the number of
women dying due to pregnancy complications has increased in
recent years. The effects of such a tragedy on any family are
impossible to comprehend.
This hearing builds off the important work of our committee
in the last Congress under the leadership of Dr. Burgess and
the Health Subcommittee. Last year, the President signed into
law H.R. 1318, the Preventing Maternal Deaths Act. This
important law, led by Representatives Jaime Herrera Beutler (R-
WA) and Diana DeGette (D-CO) seeks to improve data collection
and reporting around maternal mortality, and develop systems at
the local, State, and national level in order to better
understand the burden of maternal complications. These efforts
include identifying the reasons for disparities in maternal
care, health risks that contribute to maternal mortality, and
clinical practices that improve health outcomes for moms and
babies.
We have continued to lead the way this Congress as well--
and on a bipartisan basis, I might add--sending letters earlier
this year to six HHS agencies asking for the latest information
on what they are doing to combat maternal mortality. I hope
that we finish the briefings requested in those letters soon.
Unfortunately, I'm dismayed at the way the majority handled
our legislative process to get to this hearing. For an issue
that is absolutely bipartisan, I'm disappointed that the
majority would not allow consideration of H.R. 4215, the
Excellence in Maternal Health Act, a bipartisan bill led by Dr.
Bucshon that serves as the House companion to the maternal
mortality provisions in Senator Alexander and Senator Murray's
bipartisan Lowering Health Care Costs Act. I strongly support
the bipartisan language in this bill as it demonstrates our
commitment to further addressing maternal mortality. The bill
authorizes grants to identify, develop, and disseminate
maternal health quality best practices, supports training at
health professions schools to reduce and prevent discrimination
and implicit biases, enhances Federal efforts to establish or
support perinatal quality collaboratives, and authorizes grants
for establishing and/or operating innovative evidence-informed
programs that deliver integrated services to pregnant and post
partum women. The language in this bill passed the U.S. Senate
Committee on Health, Education, Labor, and Pensions as a part
of Senator Alexander and Senator Murray's bipartisan package. I
truly don't understand why the majority refused to include H.R.
4215 in today's hearing.
Regarding the four bills that we ARE reviewing today, only
one of the bills has a Republican cosponsor. I am also
concerned that despite coming off of a six week district work
period we didn't have witnesses agreed to until last Thursday
and Members weren't able to review testimony until yesterday.
Such a broken process is disrespectful of this important issue.
Some of today's bills would expand Medicaid and CHIP
coverage for pregnant and post partum women from 60 days to one
year. This would be a significant policy change and one we need
to carefully consider before we advance such a policy through
the committee. Importantly, several States have already
undertaken such initiatives and understanding that State
experience will be critical as we move forward.
Given the huge impact that some of these bills will have on
HHS, I would also note that HHS is not here today to discuss
what they have already been doing to address maternal
mortality, nor to provide their thoughts on the incomplete list
of bills before us today. Given this absence, I call on the
majority to schedule a second legislative hearing before moving
to a markup. And I strongly urge the majority to include H.R.
4215 in such a hearing. It's a good faith, bipartisan bill that
deserves consideration, too.
Despite my concerns about this process, I have no concerns
about our distinguished witnesses here today. I'd like thank
our witnesses for being here and sharing your stories and
expertise. I know we will learn much about the landscape of
maternity care and what more we can do to improve the health
outcomes in expectant or new mothers across the country.
Ms. Eshoo. The gentleman yields back.
It is always a pleasure to be joined by former Members of
Congress, and this morning former Congressman Phil Gingrey is
with us. So welcome, and thank you for being here.
I want to remind Members that, pursuant to committee rules,
all Members' written opening statements will be made part of
the record.
I now would like to introduce the witnesses for today's
hearing, beginning with Ms. Wanda Irving, the mother of Shalon
Irving. Thank you very much for being here. Your very moving
piece in ProPublica--anyone that has read that, I think you are
really not the same person after you read it. So thank you very
much for being here today.
Dr. Patrice Harris is president of the Board of Trustees of
the American Medical Association. Thank you to you for being
here.
Dr. Elizabeth Howell, director of the Blavatnik Family
Women's Health Research Institute at the Icahn School of
Medicine at Mount Sinai, welcome to you and thank you.
Dr. David Nelson, assistant professor of obstetrics and
gynecology at the University of Texas Southwestern Medical
Center, thank you to you for being here.
And Ms. Usha Ranji, the associate director of women's
health policy at the Kaiser Family Foundation, our thanks to
you.
We are very grateful because this is--as the ranking member
of the full committee said--this is a very important hearing.
And we look forward to your testimony. So, at this time, the
Chair will recognize each witness for 5 minutes to provide
their opening statements. If you are not familiar with the
light system, green obviously is go. When you see that the
light has turned yellow, you will have 1 minutes remaining. And
guess what? When it turns red, your time is up.
So I will begin by recognizing the very distinguish Ms.
Wanda Irving for your 5 minutes of testimony.
You need to turn the mic on. That is it. And get close to
it. We don't want to miss a word. We have some very energetic
people outside of our hearing room. So get the microphone even
closer so we don't miss a word. Thank you.
STATEMENTS OF WANDA IRVING, MOTHER OF DR. SHALON IRVING;
PATRICE HARRIS, M.D., PRESIDENT, BOARD OF TRUSTEES, AMERICAN
MEDICAL ASSOCIATION; ELIZABETH A. HOWELL, M.D., DIRECTOR,
BLAVATNIK FAMILY WOMEN'S HEALTH RESEARCH INSTITUTE, ICAHN
SCHOOL OF MEDICINE AT MOUNT SINAI; DAVID NELSON, M.D., CHIEF OF
OBSTETRICS, PARKLAND HEALTH AND HOSPITAL SYSTEM; AND USHA
RANJI, ASSOCIATE DIRECTOR, WOMEN'S HEALTH POLICY, KAISER FAMILY
FOUNDATION
STATEMENT OF WANDA IRVING
Ms. Irving. Good morning, Chairwoman Eshoo, Ranking Member
Burgess, distinguished members of the committee. Thank you for
the opportunity to address you.
New data released from the CDC demonstrates that pregnancy-
related deaths for Black women with at least a college degree
are five times higher than that of a White woman with similar
education. Shalon MauRene Irving had a dual titled Ph.D. in
sociology and gerontology and a master of science, both summa
cum laude, from Purdue University and earned before the age of
25. By 26, she was a college professor at Hofstra University
but decided, after watching her older brother who suffered
numerous indignities during treatment for multiple sclerosis,
that she wanted to work on the front lines fighting for health
equity. She earned a master of public health from Johns
Hopkins, also summa cum laude, and became certified as a health
education specialist while being a weekend caregiver for her
brother, who was then in a wheelchair.
She started her public health career as a Kellogg Fellow,
working with pregnant women at Healthy Start in Baltimore. From
there, she was hired as a consultant to the CDC, working on
former First Lady Michelle Obama's Let's Move! Initiative. She
went on to be accepted into the globally renowned Epidemic
Intelligence Service and was quickly promoted to lieutenant
commander.
As a well-respected epidemiologist at the CDC, she made
major contributions to several scientific books written by
colleagues and wrote various articles published in scientific
and medical journals. She was dedicated and committed to racial
equality and health equity. On her Twitter profile, Shalon
said: ``I see inequity wherever it exists, call it by name, and
work hard to eliminate it. I vow to create a better Earth.''
She believed in action over words and launched a consulting
firm specializing in inclusivity training. This is the picture
of Shalon Irving the professional, but she was so much more
than that. She was my only daughter, born between two brothers
that she idolized. Shalon was every mother's prayer and the one
few of us are lucky enough to receive.
An unexpected pregnancy at 36 only added to the fullness of
her life. She was so excited to become a mother. On January
3rd, Shalon underwent a planned c-section and gave birth to a
beautiful baby girl she named Soleil Meena Daniele. Shalon
thought Soleil was her greatest accomplishment. The 3 weeks
that followed Soleil's birth should have been filled with joy
and happiness, but it wasn't.
Instead, Shalon's general state of health steadily
declined, while her blood pressure rose. She experienced leg
swelling, decreased urine output, weight gains, and headaches.
But despite repeated visits to her healthcare providers during
this period, her complaints were not adequately addressed.
Shalon suffered cardiac arrest at home on the night of
January 24th, 2017, 21 days after the birth of her daughter and
just a few hours after her last trip to her health provider. My
beautiful, vibrant, brilliant daughter was officially declared
brain dead on Thursday, January 26th. Believe me, there is
nothing more heart-wrenching than seeing your child connected
to life support. On January 28th, life support was removed.
After reading her medical directive, the handwritten last line
shattered my heart: ``Mommy, I will fight hard, but if there is
no hope, please let me go.''
Shalon fought hard. She did what she was supposed to do. It
was the medical profession that let her down. She was a 36-
year-old woman of color who went to healthcare workers again
and again in distress and was not properly treated. Imagine the
many gerontology breakthroughs, epidemiology victories, and
social advances that Shalon could have generated if only her
medical providers had listened to her and addressed her cries
for help.
Shalon's daughter, Soleil, is transitioning into a little
girl. She is 31 months old now with a smile every bit as
brilliant as her mother's. Soleil is fearless and determined
like her mother. She constantly amazes me with her rapidly
expanding vocabulary, her capacity for learning French, her
athleticism as a gymnast, and her love for art and ballet. But
there are no words in the English language to adequately
portray the pain I feel when Soleil looks up at me and asks,
``Where's my mommy, Nona? Why can't I see her?'' or cries, ``I
want my mommy'' while clutching a picture of Shalon.
The loss of my daughter has earned me the right to demand
the transformation of the healthcare system. I ask you--no, I
implore you--to take three points from my words today. Not
every maternal mortality is because of lack of insurance nor
access to care, poverty, or lack of education. The dialogue
needs to be reframed so it widens the lens to include the
insured, those with access, and the educated.
Most pregnancy-related deaths can be prevented. According
the latest CDC Morbidity and Mortality Weekly Report, further
identification and evaluation of factors contributing to racial
and ethnic disparities are crucial to inform and implement
prevention strategies that will effectively reduce disparities
in pregnancy-related mortality.
Quality of care plays a pivotal role in pregnancy-related
deaths and associated racial disparities. It is imperative that
more aggressive strategies to break down racial bias and
prejudice be deployed now. Sending medical folks to cultural
sensitivity or implicit bias training is not going to fix the
problem without a redesign of medical school curricula. Post
partum care must be redefined and optimized as well. Healthcare
professionals must be accountable.
The reduction of preventable maternal death among Black
women is a national disgrace and has become an urgent national
priority. To paraphrase a line from Abraham Lincoln, it is the
cause for which my daughter gave her last measure of devotion.
Thank you.
[The prepared statement of Ms. Irving follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Long. Madam Chair, Madam Chair, I don't know if I need
to ask for a point of personal privilege or what, but I am
going to say something.
I am a member of the Black Maternal Health Caucus, and I
care deeply about this issue, and I think it is repugnant that
we have to sit here and listen to whatever in the world is
going on out there in the hall. These women deserve better.
These women that passed away during and after childbirth. This
is a very serious hearing, and that--whatever they are
celebrating or complaining about out there in the hall, the
Capitol Hill Police need to put a stop to it. If you could ask
them to do it, I appreciate it.
I yield back.
Ms. Eshoo. I thank the gentleman.
Thank you, Ms. Irwin, for your--this is the first step to
the promise that you are asking us to keep. Thank you for being
here today.
Dr. Patrice Harris, you are recognized for your 5 minutes.
STATEMENT OF PATRICE HARRIS, M.D.
Dr. Harris. Good morning, Chairwoman Eshoo, Ranking Member
Burgess, and committee members.
The American Medical Association commends you for holding
today's legislative hearing. My name is Dr. Patrice Harris, and
I am president of the AMA. I am a practicing child and
adolescent psychiatrist from Atlanta, and I am adjunct faculty
at the Emory University School of Medicine and the Morehouse
School of Medicine. I thank you for the opportunity to testify.
The data on maternal mortality in the U.S. are deeply
alarming. The U.S. is only one of three countries in the world
where the rate of maternal deaths is rising. Moreover, there is
a large disparity in maternal deaths. As you have heard, a
recent CDC report found that Black women are three to four
times and Native American/Alaska Native women are two and a
half times more likely to die from pregnancy-related causes as
White women. And Black and Hispanic women are
disproportionately affected by severe maternal morbidity,
defined as life-threatening complications during or after
childbirth. Most alarmingly, 60 percent of pregnancy-related
deaths are preventable. This is simply unacceptable when we
know these inequities and disparities are avoidable. Inequities
and disparities do not have to exist, and we must collectively
increase our efforts to close the gap.
What is causing these deaths? And why is the rate so much
higher, particularly for Black and Native American women? Among
the factors that play a role are as follows: Millions of women
still lack insurance or have inadequate coverage prior to,
during, and after pregnancy. There is increased closures of
maternity units both in rural and urban communities and,
thereby, reduced access to quality maternal care. There is a
lack of appropriately trained interprofessional teams in best
practices, and that also impacts quality of care. There are
structural determinants of health, which include public
policies, laws, and racism. And those impact the social
determinants of health, which include education, employment,
housing, and transportation. Discrimination, racism, implicit
biases exacerbates stress, which negatively affects the body
and can result in hypertension, heart disease, and gestational
diabetes during pregnancy.
The evidence tells us that clinician and institutional
biases can lead to missed warning signs--can and do lead, I
must say, to missed warning signs and delayed diagnoses. Women
of color are not being heard.
So how do we move forward? Regarding specific solutions,
the AMA believes that ongoing surveillance and activities to
promote appropriate screening, referral, and treatment are
needed. I want to thank the House Energy and Commerce Committee
for advancing H.R. 1318. We continue to support the expansion
of State Maternal Mortality Review Committees and appreciate
continued funding to support prevention efforts.
We also support the MOMMA's Act to improve data collection,
spread that information from that data on effective
interventions, and expand access to healthcare and social
services for post partum women. And to ensure optimal health
for women at risk for medical or mental health conditions
leading to maternal death, additional insurance coverage is
required. And the AMA believes that Medicaid coverage should be
extended to cover women 1 year post partum.
And, finally, let me highlight what the AMA is doing in
this space internally in our own house. The medical community
absolutely has a role to play here. The AMA recently hired Dr.
Aletha Maybank as the AMA's first chief health equity officer,
and she is initiating our new and explicit path to advanced
health equity through the AMA Center for Health Equity and,
although our Center for Health Equity is just getting up and
running, there is great potential to partner with Congress to
expand implicit bias training and other structural competency
trainings in medical schools, residencies, and throughout the
physician's career.
So it will take all of us working in partnership, and the
AMA is committed to doing so, to build and continue on a path
forward to more holistically and effectively improve maternal
health and advance health equity.
Thank you.
[The prepared statement of Dr. Harris follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Ms. Eshoo. Thank you, Dr. Harris.
We now will call on Dr. Elizabeth Howell, director of the
Blavatnik Family Women's Health Research Institute at Mount
Sinai. You have 5 minutes for your testimony. Welcome and thank
you.
STATEMENT OF ELIZABETH A. HOWELL, M.D.
Dr. Howell. Chairwoman Eshoo, Ranking Member Burgess,
Representative Engel of New York, and members of the
Subcommittee on Health, thank you for inviting me to testify.
My name is Elizabeth Howell, and I am an obstetrician/
gynecologist and a researcher. I serve as a professor in the
Departments of Population Health Science and Policy and
Obstetrics, Gynecology, and Reproductive Science. I also direct
the Blavatnik Women's Family Health Research Institute at the
Icahn School of Medicine at Mount Sinai.
So we are here today because the United States is in a
maternal healthcare crisis. You have heard that every year in
our country around 700 women die from pregnancy-related causes.
Our maternal mortality rate is higher than all other high-
income countries. And our numbers, as you have heard, are far
worse for women of color. While leading causes of maternal
death include heart conditions, high blood pressure,
infections, blood clots, rates of maternal death from overdose
and suicide are rapidly climbing. And opioid-related deaths
have doubled over the last decade.
But a maternal death is just the tip of the iceberg. For
every death, over a hundred women experience a life-threatening
complication related to pregnancy and childbirth. Severe
maternal morbidity impacts over 50,000 women every year in our
Nation. Every hour, six new moms will have a tragic event like
a stroke, a blood clot, or kidney failure. As you heard, the
good news is that over half of these tragic events, actually 60
percent, are preventable if we improve the quality of care
women receive before, during, and after pregnancy.
Quality of care includes women, no matter who they are and
where they live, having access to doctors and nurses who are
well-trained, prepared, and equipped with the right tools. It
also means having systems in place that make it easy for women
to receive evidence-based care. That means hospitals equipped
with adequate resources, policies, and practices, staffing, and
more. If we raised quality of care for pregnant women, we could
lower the rates of these tragic events.
And quality of care differs for women of color. You have
heard that Black women are three to four times and American
Indian women are three times more likely to experience a
pregnancy-related death than are White women. In New York City,
Black women are 8 to 12 times more likely to experience a
maternal death than are White women.
Although many want to think that income differences drive
these disparities, it goes beyond class. A Black woman with a
college education is nearly twice as likely to die as a White
woman with less than a high school education, and she is nearly
three times more likely to experience a severe maternal
morbidity.
There is a growing recognition that social determinants of
health, like racism and segregated housing, contribute to these
disparities, and the powerful story you heard from Ms. Irving
about her daughter highlights an additional underlying cause:
quality of care, lack of standards, and post partum care. Her
daughter was seen multiple times by clinicians after her
delivery, but she still died.
Reasons for Black/White differences highlight the need to
adequately resource programs that enhance quality of care.
Research by our team and others has shown that, for a variety
of reasons, Black women tend to deliver in a specific set of
hospitals. And those hospitals have higher rates of severe
maternal morbidity for both Black and White moms, regardless of
patient risk factors. This is true overall in the United
States, where about three-quarters of all Black women deliver
in these hospitals but less than one-fifth of White women do.
In New York City, a woman's risk of having a life-
threatening complication during her delivery in one hospital
can be six times higher than in another hospital. Black and
Latina mothers are more likely to deliver in hospitals with
worse outcomes. In fact, differences in delivery hospital
explain nearly one-half of the Black/White disparity in severe
maternal morbidity in New York City.
But it does not have to be this way. We can come up with
simple and effective ways to measure and improve quality of
care for childbearing women, whether they are Black or White,
rich or poor, rural or urban. I am pleased today to provide
testimony in strong support of a number of elements discussed
in the bills.
First, development of maternal health quality measures that
are patient-centered and address disparities; authorization of
the Alliance for Innovation in Maternal Health, the AIM
program, which is a national partnership that works to reduce
maternal mortality and morbidity by implementing standardized
care practices across hospitals and health systems; extension
of Medicaid for 12 months post partum to ensure access to
needed care; development and expansion of State perinatal care
quality collaboratives to improve quality of care for moms and
infants; support for healthcare professional training to
address implicit bias. I would expand this to include training
on patient-centered communication, shared decisionmaking, and
actions to address both implicit and explicit bias. And, last,
I would echo efforts that are already started, but we need more
to build a better infrastructure to support data collection and
measurement.
I would like to end my testimony by saying that we have to
value pregnant women from every community. We can and must do
better. I thank you for this opportunity to provide testimony,
and I look forward to your questions.
[The prepared statement of Dr. Howell follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Ms. Eshoo. Thank you, Dr. Howell.
Members may notice that I am allowing witnesses to go past
their 5 minutes, but I think every word that they have to be
instructive to us is really essential.
Dr. David Nelson, it is your turn to testify. You have 5
minutes, and thank you again for being here.
STATEMENT OF DAVID NELSON, M.D.
Dr. Nelson. Chairwoman Eshoo, Chairman Pallone, Ranking
Member Walden, Ranking Member Burgess, and members of the
Energy and Commerce Subcommittee on Health, thank you for
inviting me today. I am an obstetrician and gynecologist with
fellowship training in maternal-fetal medicine. I am the chief
of obstetrics at Parkland Hospital in Dallas, Texas. Parkland
is one of the largest single public maternity services in the
country. Last year, we delivered 12,671 women. This is more
deliveries than 10 States in our country.
As the medical director of this service, I would like to
share my appreciation of this committee for their efforts and
celebrate the Preventing Maternal Deaths Act that encourages
State programs to establish Maternal Mortality Review
Committees. However, as you know, our work is not done. A
single preventable pregnancy-related death is one too many. Mr.
Johnson's testimony last year to this committee and Shalon's
mother's testimony today emphasized this issue.
So what are the next meaningful steps? To answer this
question, I offer two themes: 1, access to prenatal care, and
2, use of relevant quality data. The significance of access to
care depends on how the issue of maternal mortality is framed.
The findings of the Texas Maternal Mortality Review Committee
from last year were that the majority of the pregnancy-related
deaths could be prevented. Similar to other reports, there was
a significant racial disparity. Women of color were
significantly more likely to die when compared to non-Hispanic
White woman, and the majority of these deaths under review were
Medicaid-funded at delivery.
So how can we address pregnancy-related deaths that are
potentially preventable among women of color and receiving
Medicaid funding? I offer our experiences from Parkland
Hospital as one strategy. Parkland is unique. It represents a
public hospital serving almost exclusively medically indigent
women. Of the more than 12,000 women delivered last year, 90
percent were Medicaid funded. At Parkland, there has been a
concerted effort to improve access to prenatal care. And today
there are 10 clinics located throughout Dallas County. These
clinics are in the neighborhoods where our patients live and
are often colocated with pediatric services to enhance patient
use.
Of the more than 12,000 women delivered in 2018, 97 percent
accessed prenatal care. These clinics also serve as the medical
home for our patients with important followup for services like
blood pressure surveillance and depression screening after
delivery. The system has administrative and medical oversight
that is seamless. The same protocols are used by nurse
practitioners at all 10 sites, and this guarantees consistent
care that is standardized for referrals of high-risk women to a
centrally located clinic.
Not all complications, though, can be identified before
delivery. At the hospital a multidisciplinary team of nurses
and providers work together according to standardized
protocols. Individualized care is stratified based upon medical
acuity and risk for complications. For example, we have
standardized management strategies for response to obstetric
emergencies like hypertension and hemorrhage. This emphasizes a
culture of safety with continuous quality improvement.
Recently, we have implemented an urgent request to the bedside
function with our nursing partners to electronically track and
monitor a timeliness to a patient's bedside for immediate care.
These efforts dovetail Parkland's participation in the
newly formed regionalization program known as Maternal Levels
of Care, as well as the Alliance for Innovation in Maternal
Health. These initiatives share similar principles with
California Maternal Quality Care Collaborative. Putting this
together, access to prenatal care is considered one component
of a comprehensive public healthcare system. It is community-
based and extends to the inpatient care setting for a
standardized approach.
An example of how access to prenatal care translates to
improved outcomes, the maternal mortality rate during pregnancy
and that delivery for the 3 percent of women that did not
access prenatal care is more than 25-fold higher than those
that had prenatal care access at our hospital.
Moving to the second theme, how do we measure quality? An
obvious method is to track rates of maternal mortality. This
unfortunately is easier said than done, and our hope is the
recent passing of the 2018 legislation is a key step forward in
this effort.
Another method of assessing quality is measuring rates of
severe maternal morbidity, or SMM rates. These are unexpected
outcomes that result in significant consequences to a woman's
health like hysterectomy or transfusion. These rates are almost
universally derived from hospital billing codes simply because
no other data sources are available. We must consider the
potential unintended consequences of tracking such metrics,
especially transfusion, because this can become a perverse
surrogate of quality. If a provider hesitates or, worse,
withholds a transfusion of blood, then a patient may have a
risk of mortality. It is critical we use relevant data to guide
our policies.
Thank you again for this opportunity to share our
experiences from Parkland and our efforts to establish access
to care. Also thank you for your understanding of the
importance of the relevant quality data. Ultimately these
efforts can lead to safer deliveries of mothers and their
infants for the future generations of our country.
Thank you.
[The prepared statement of Dr. Nelson follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Ms. Eshoo. I thank you, Doctor.
Usha Ranji, you are recognized for your 5 minutes of
testimony. You can proceed, and thank you.
STATEMENT OF USHA RANJI
Ms. Ranji. Good morning, Chairwoman Eshoo, Ranking Member
Burgess, and members of the committee. I am Usha Ranji,
Associate Director of Women's Health Policy at the Kaiser
Family Foundation, a nonprofit, nonpartisan organization that
provides health policy analysis.
Thank you for inviting me to testify about the role of
Medicaid coverage for pregnant and post partum women. I will
highlight three main areas: research on the importance of
health coverage for babies and mothers; the role of State
policy decisions on access to care during and after pregnancy;
and some of the current efforts to close gaps in post partum
coverage.
Medicaid is the primary source of health coverage for low-
income women and the major financier of maternity care. In the
mid-1980s in response to rising rates of infant mortality,
Congress and States saw an opportunity to use Medicaid to
improve birth outcomes by expanding the program to more low-
income pregnant women and children. Today, the program finances
more than 4 in 10 births nationally and more than half in many
States.
Research shows that women with Medicaid coverage
consistently fare better than uninsured women on several
measures of access, including greater use of timely prenatal
care. More recent research suggests that Medicaid expansion is
associated with a narrowing in racial and ethnic disparities in
infant outcomes. Our work at KFF finds that low-income women
with Medicaid use care at rates that are comparable to their
privately insured counterparts, and there is broad agreement
that access to care before and after a pregnancy is essential
for prevention, early detection, and treatment of some of the
conditions that raise a woman's risk for pregnancy
complications.
Medicaid plays a critical role in promoting access to that
care. Maternity care is one of the benefits that all States
must cover under Medicaid. Eligibility for Medicaid is based on
decisions that States make within Federal guidelines. Federal
law requires that all States cover pregnant women with incomes
up to 138 percent of the Federal poverty level, which is just
under $30,000 a year for a family of three, but most States
cover pregnant women with higher incomes, recognizing the
importance of coverage during the perinatal period.
Yet after a woman gives birth, there is no requirement to
continue Medicaid coverage beyond 60 days post partum.
Historically many women would become uninsured in the months
following pregnancy as a result. But policymakers have
opportunities to improve coverage for post partum women and
their families. States across the country have made different
decisions about whether to expand Medicaid under the ACA.
In the 14 States that have not changed their Medicaid
program eligibility levels, post partum women cannot stay on
the program unless they requalify as parents. However, in these
States eligibility for parents is much stricter than for
pregnant women. For example, in some States, a new mother would
lose Medicaid coverage 2 months after giving birth if she and
her partner have income above $4,000 a year.
Federal subsidies are available to help----
Ms. Eshoo. Can you say that one more time?
Ms. Ranji. Sure. When we look at the eligibility criteria
for parents, it is much lower than it is for pregnancy under
Medicaid, and it is State-determined, and in all States, it is
actually lower for pregnancy, and in some States, it is as low
as $4,000 a year for a family of three.
Ms. Eshoo. Wow.
Ms. Ranji. Federal subsidies are available to help some
lower-income mothers purchase private marketplace insurance.
But when a mother's income falls between her State's Medicaid
level for parents and the poverty line, she does not qualify
for either Medicaid or private insurance subsidies.
Today, a handful of States are exploring options to improve
Medicaid coverage for women after pregnancy. All States can set
and raise the income eligibility levels for parents, and that
is without adopting the Medicaid expansion.
Earlier this year, Illinois approved extension of post
partum coverage under Medicaid to 1 year. Policymakers in
Missouri and California have also proposed extending coverage
for mothers in need of substance abuse treatment and mental
healthcare, respectively. These are a few examples of efforts
to enhance care and coverage for low-income moms.
Madam Chair, members of the committee, the research is
clear. Having health coverage before, during, and after
pregnancy promotes access to care. And lack of coverage is
associated with poor health outcomes. Furthermore, our
understanding of the health needs of women shows that the post
partum period has evolved beyond one visit, yet in more than a
dozen States, Medicaid coverage ends 2 months after childbirth,
even though for a mom, her need for care does not end then.
In short, there is strong empirical evidence to support
what families across the country already know and experience on
a daily basis, that a mother's ability to care for her own
health and well-being is integral to her ability to do the same
for her children.
Thank you.
[The prepared statement of Ms. Ranji follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Ms. Eshoo. Thank you, Ms. Ranji.
Those are some startling numbers, that it sounds like you
have a child and then the system becomes punitive.
The witnesses have now concluded their opening statements.
We are going to move to Member questions. Members each have 5
minutes to ask questions of our witnesses, and I will start by
recognizing myself for 5 minutes.
There are many layers to this, but I want to go back to
where we began with Ms. Irwin and many of the things that she
said in her testimony to us. She said that we need to hold
healthcare professionals accountable for improving the quality
of care and ensuring equity.
Her daughter has had, I think, more education as one person
than most Members sitting on this dais. So she was not low
income. She was not uneducated. And it seems to me that racial
bias is alive and well in this area of giving birth and what
happens post partum.
Let me ask Dr. Harris: What is the AMA doing about this? I
mean, it seems to me that you can track the hospitals where
women of color frequent those hospitals than others. I think
the statistics are really very clear. This is not a foggy
picture. We heard Dr. Nelson talk about their very purposeful
training.
So what is the AMA doing before you came to the witness
table? Have you targeted the hospitals? Is it red light and
siren to do something that addresses this? Maybe you can just
briefly explain to us what the AMA is doing, and if you are
not, what you plan to do, to be fair.
Dr. Harris. Thank you, Chairwoman.
From the AMA's standpoint, we would see our audience as
impacting the physician community. Certainly, I heard from Dr.
Howell, though, that there is value in hospitals developing
standards. And it would be the recommendation that those
standards include some metrics for evaluation.
Ms. Eshoo. That hasn't before begun yet, in terms of AMA
partnering with hospitals and doctors?
Dr. Harris. No, we have not worked with hospitals to
develop any specific metrics. But we are starting internally,
as I mentioned earlier. We have just hired Dr. Aletha Maybank.
She is our first----
Ms. Eshoo. That is a first step. It's a first step.
Dr. Harris [continuing]. Chief health equity officer.
And that is building on the work that we already have been
working on from our Commission to End Disparities.
Ms. Eshoo. Thank you.
Obviously, the causes of pregnancy-related deaths differ.
The doctors on the panel, what I want you to instruct us about,
because we know heart disease and stroke cause most of the
deaths overall. Obstetrics emergencies, severe bleeding,
amniotic fluid, embolism cause the most deaths at delivery, but
severe bleeding, high blood pressure, and infections are the
leading causes in the week after delivery, and weakened heart
muscle is the leading cause of deaths 1 week to 1 year post
partum.
This is in our memorandum from the committee staff.
How best do you recommend to us to pursue each one of these
categories? And for the life of me, I don't understand why the
doctors that are trained in this--I mean, this is a specialty,
as our ranking member is--that these deaths are a result of
these areas, and, as you said, Dr. Howell, they are
preventable. Where have we gone wrong? Have they forgotten what
they learned? Is their training not up to snuff?
Can you be instructive to us on that, Dr. Howell?
Dr. Howell. Sure. Sure. So you bring up a really important
point, which is what we are pushing for through ACOG and the
Alliance for Innovation on Maternal Health. We need
standardized care practices based on evidence-based medicine--
--
Ms. Eshoo. And that is not the case now?
Dr. Howell. Well, we do. So AIM has started a few years
ago. And it is growing in numbers. It now reaches 27 States,
and these are partnerships with hospitals and health systems,
departments of health, caregivers to try to work together to
improve quality and safety. And we don't just target the most
preventable causes like hypertension, you know, blood clots, et
cetera. We also target additional things.
We have come up with an AIM bundle on how we might address
reducing disparities in hospitals and health systems with some
key steps that we recommend. We also have, as part of this
effort--it is very much a data-driven effort--so we have
quality--we have measures and metrics that we are trying to use
to utilize and examine how hospitals are doing, which we think
is a very important part. So we can't only implement, but we
have to evaluate to make sure what we are doing is the most
meaningful way.
So that is one big effort that has been going on for about,
I believe AIM started in about 2015, and it is very much a
partnership.
Ms. Eshoo. Well, thank you very much.
My time is up, but I also think the American Hospital
Association has to lean in on this as well because the
statistics can be traced right back to where women of color,
what hospitals they go to, and the number of deaths there or
the tremendous complications that follow. But my time is up.
So the Chair will now recognize the distinguished Dr.
Burgess, the ranking member of our subcommittee, for his 5
minutes of questions.
Mr. Burgess. Thank you.
Dr. Nelson, you look like you wanted to say something. Can
I give you a moment to respond to previous discussion?
Dr. Nelson. I agree with Dr. Howell that part of the issue
is our view. We have not had the full view that we need to see.
There are the issues surrounding pregnancy, delivery, and the
now subsequently post partum. One of the issues we need to
recognize is the process measures that need to be in place,
meaning our response that is consistent to emergencies like
hypertension and hemorrhage, things like a massive transfusion
protocol where we directly get blood to the patient's bedside
that needs help, processes like simulation to train our team
members in a safe environment. And then we need performance
measures that are meaningful to track data and identify quality
and sincere efforts to improve that space. That, I think, is a
major step forward for us collectively that we are trying to
see.
Mr. Burgess. And since you are talking about it--and, once
again, I want to thank you. You were very kind to show me
around the new unit at Parkland Hospital. They have just moved
in to new facilities, and so it is different from what it was
back in the 1970s when I was there, but I was impressed that
there are some of the things that I learned in the 1970s that
are still appropriate today, but you have also made things
different in a number of ways. And one of the ways that really
impressed me was the availability of, I guess, an emergency
bleeding cart that would be just footsteps away--and you had
several of them strategically positioned throughout the labor
and delivery units so that the response time could be
significantly reduced. Dr. Howell in her written testimony
talks about coming into a scene where somebody is
exsanguinating an hour after delivery. We had a hearing last
year--Mr. Johnson, whose wife had a bleeding complication after
cesarean section--can you speak to that and how the urgency
with which the situation is responded to has helped you in
managing this crisis?
Dr. Nelson. Yes, sir. And Dr. Howell is absolutely right.
Time is of the essence in these emergencies. Our labor and
delivery suite is over the size of a football field. There are
44 labor and delivery rooms, and in partnership with the
Maternal Levels of Care Program for Texas and in alignment with
the AIM program, we have four hemorrhage carts on our unit.
These are carts that contain specific resources, specific
instrumentation, and needs that a nursing team or physician
team might need to immediately respond to a hemorrhage event.
We debrief after every time we utilize a massive transfusion
protocol, meaning every time we activate a massive resource
allocation to a patient, we debrief with the team to understand
if there are opportunities to learn from the nurses or
physicians. We use multidisciplinary simulation where we train
in an environment with nursing--nurse midwives,
anesthesiologists, and team members. We formalized a checklist
that is consistent with the AIM platform. We have the
hemorrhage cart that we mentioned. We also perform daily
huddles for every scheduled surgery that we have performed, and
because our service deals with a fair number of women with what
is called placenta accreta spectrum disorder, or morbidity--
placentas, we actually have a dedicated team of maternal-fetal
medicine faculty and public surgeons for those cases.
Mr. Burgess. For people who don't know, that can be one of
the scariest situations you can encounter. So let me ask you
this, and one of your predecessors, Dr. Norman Gant, who was
the chairman of OB/GYN when I was a resident back in the 1970s,
I forget what he was haranguing us about one day, but he was
famous for doing that, and he was giving us the business about
how he was worried that his residents were giving care without
caring, and he wanted us to be sure to delve into the
interpersonal part of the relationship with the patient and
being certain we listened to the patient and heard the patient.
Some of that strikes me as--when Mr. Johnson was here last year
and gave his testimony about the problems his wife had after a
cesarean section and when we listened to Ms. Irving talk about
her daughter's problems, I mean, there were some significant
things that happened, and I don't want to say there were care
lapses, but I am sorry, a diastolic blood pressure of 118
millimeters of mercury, that is not an appointment to clinic
tomorrow. I mean, that is something that needs--something needs
to be acted upon. So are we empowering people to make the
decisions that need to be made when they encountered these
points?
And either Dr. Howell or Dr. Nelson, since you are the
clinical specialists.
Dr. Nelson. I absolutely agree accountability is critical,
and tracking that accountability is one issue. The urgent
requested bedside function we actually have in place to track
time from the blood pressure to when a response was seen. To
add on to the comments from Dr. Howell and some of our other
panelists, there is absolutely an issue of racial disparity in
our services. At Parkland alone, we have a diversity inclusion
officer. We have an instructor-led course once a month on this
issue, and every new hire has to go through that because of our
environment served. That is a commitment that we have at our
organization.
Mr. Burgess. And I would just stress that, because of the
environment served, you are basically what would be described
as an inner-city hospital, and you deal primarily with the
indigent population of Dallas County, Texas?
Dr. Nelson. Yes, sir.
Mr. Burgess. Thank you for being here today. Thanks all of
you for your testimony. It has all been very enlightening.
I will yield back.
Ms. Eshoo. The gentleman yields back.
I now would--let's see. Where is--a pleasure to recognize
the gentlewoman from California, Ms. Matsui, for her 5 minutes
of questioning of the witnesses.
Ms. Matsui. Thank you very much, Chairwoman Eshoo and
Ranking Member Burgess, for holding this very important
hearing. Like our witnesses here today, I am deeply concerned
about the rates of maternal death and severe maternal morbidity
in this country that is supposed to be one of the most
developed countries in the world. And a special thank you to
Ms. Irving for sharing your family's loss. I am so sorry.
Keeping our mothers and babies safe and healthy is vital.
As a cosponsor of last year's Preventing Maternal Deaths Act, I
am pleased that we are building on this effort to address
outstanding racial and ethnic disparities that exacerbate poor
maternal health. Extending Medicaid coverage for maternal
health services across continuum of care is a critical next
step, and strengthening the quality measures and training
programs will help protect our mothers and babies when care is
delivered. I thank the committee for prioritizing the hearing
on this issue. Several of you pointed out in your testimony the
uncomfortable truth that a significant portion of severe
maternal disease and death is preventable. It is clear how
critical Medicaid coverage is to ensure access to care and
avoid preventable maternal health complications.
Dr. Howell, you touched upon how quality of care pertains
to both clinician practice and system policies. In your
holistic view, what is the link between coverage and quality of
care?
Dr. Howell. So coverage is essential, and I think we heard
from Ms. Ranji about how important coverage is, you know,
preconception, antenatal, during delivery, and post partum, and
the growing awareness that a third of these deaths are
happening in the post partum way-out period. We are talking
about cardiomyopathies. We are talking about suicides. We are
talking about women dying from things that we could do
something about, but we have not been giving adequate access to
care. So it is instrumental, and it is a key link.
Ms. Matsui. OK. In Sacramento, we have been looking at,
through a Black Child Legacy Campaign since 2015, on this whole
area of maternal death, prenatal, post partum activity, and we
have come across quite a lot of activities that have really
increased our chances here in Sacramento County, and we are
really pleased to see that most of the country is sort of
looking at how we are doing it too.
In Sacramento, we also have cultural brokers at one of our
FQACs, the WellSpace Health, that helped to engage and support
pregnant women by integrating medical care, parental education,
and community resources for housing and transportation into a
prenatal program for families. It has to be all-inclusive, as
you know. This comprehensive model has led to rates of
premature and low birth rate that are significantly below the
national average.
Dr. Harris, it sounds like the AMA is doing some
interesting work around social determinants. Can you elaborate
on how you envision health plans integrating social and
environmental health data--environmental data to better address
a mother's unique needs, and how will this lead to healthier
babies?
Dr. Harris. Absolutely, and thank you. And the structural
and social determinants of health are critical as we understand
how to address this issue and actually other healthcare crises.
We have to look at transportation. Is there access to get to
prenatal visits? We have to look at other social supports to
make sure that our pregnant moms get to their prenatal visits.
For moms who are pregnant and diagnosed with depression, we
have to make sure that they have access to psychiatric care and
care for therapy, and so addressing housing and education and
employment are all critical as we address actually this issue,
but really all health issues.
Ms. Matsui. Sure. Both you and Ms. Ranji made it clear that
mental healthcare throughout the pregnancy is paramount to
improving the health of mothers and their babies. Would you
both expand on the transmaternal mortality with regards to
mental health? What is the link between depression and
pregnancy and maternal outcomes? You want to take this one, Ms.
Ranji?
Ms. Ranji. Thank you. I will let Dr. Harris and my
colleagues comment on the clinical aspects, but I will say what
we have heard from all the other witnesses is that maternal
mental health is a very serious issue. It is a contributor to
the maternal mortality and morbidity rates that we have been
seeing, and that that is--what we know is that is an issue that
does not resolve in perhaps 2 months' time, that that is an
ongoing chronic condition that could require various levels of
care depending on a woman's individual situation. And so access
to care and services is likely needed for an extended period of
time.
Ms. Matsui. OK. I wanted to follow up. Dr. Nelson, what
mental healthcare services are offered to women through your
clinic's healthcare home model, and why is mental healthcare
both before and after birth so vital?
Dr. Nelson. I appreciate you asking that. Mental health is
critically important. In Texas, in our maternal mortality
reviews from 2012 to 2015, there were 33 suicides, and 85
percent were post partum. In 2013, I published a paper
screening 17,000 women with post partum depression. We
identified rates consistent with other populations served. Only
22 percent made it to a psychiatrist that were identified to
screen positive. From that our service identified an
opportunity. We now have mental health counselors placed
strategically in all 10 clinics similar to the home you
described. Recently, we have actually exercised telehealth and
telemedicine with virtual visits. Last year, 1,100 phone calls
were made by those mental health counselors to the patients at
their home and at their work for those that can't access the
clinic directly.
Ms. Matsui. Oh, that is wonderful. Thank you very much, and
I know I have run out of time.
I yield back.
Ms. Eshoo. The gentlewoman yields back.
Pleasure to recognize the ranking member of the full
committee, Mr. Walden, for his 5 minutes of questions.
Mr. Walden. Thank you, Madam Chairwoman.
And, again, thanks to all our witnesses for your testimony.
Dr. Howell, as I mentioned in my testimony, we have more to
do on maternal mortality and morbidity, but we took a good
first step, I think, in the last Congress with H.R. 1318, the
Preventing Maternal Deaths Act, which, as you know, became law.
That bill reauthorized key CDC programs to improve data
collection reporting around maternal mortality. That will help
support State review committees like the ones set up in my home
State of Oregon to study these issues.
Dr. Howell, you are set up in New York, as I understand it,
but your organization does national research. How has the work
of the State review committees informed Alliance for Innovation
on Maternal Health maternal safety and quality improvement
initiatives?
Dr. Howell. So the maternal mortality reviews around the
country are key and essential to the program for AIM because
they teach us about each death and where are the preventable
moments, what are the things we really need to work on to
prevent a death. And then that information is brought to the
perinatal collaboratives using some of the tools that AIM has
brought together, and that is the way we can implement. We
learn from the deaths. We take data and information. And then
we act on it. And I think that is why these partnerships with
the CDC/AIM are so important, but we need all States to have
Maternal Mortality Review Committees. We need them all to
review their deaths. We need them to submit them to the CDC so
that they can have a central system for monitoring. And so we
still need to continue to improve our data acquisition and
management.
Mr. Walden. But it is fair to say where it does exist, it
is working? You are seeing the information flow which allows
then a positive response?
Dr. Howell. So I think it is mixed in the sense that, yes,
there are places that it is really working and you are seeing a
lot of movement and you see a lot of positive energy around
this. Sometimes the resources are not fully there yet, and so
some places are not able to actually do as well as others.
Mr. Walden. OK. Good. Dr. Harris, it is important to look
at every factor related to maternal mortality and morbidity,
but one piece I am worried about is the mental health, as has
been discussed here already. And in your testimony, you
mentioned that depression in pregnancy is associated with poor
maternal outcomes, including maternal death. We have tried to
take the lead in this committee on reforming America's mental
health laws, but we all know there is more work to be done,
especially for mothers with post partum depression. And I must
say as a footnote, I was deeply disappointed in my own State.
The Governor and the legislature actually cut mental health
support funding in my State, and why I cannot imagine, but I,
in town halls and other meetings I had this August, I learned
the legislature just did that, and it is stunning. You say it
occurs in nearly 15 percent of births. That is staggering,
especially considering some of the dire outcomes we now know
about. Are the State Maternal Mortality Review Committees
capturing these outcomes, and are there ways that we can do
better?
Dr. Harris. Actually, I will have to defer to my colleagues
who are obstetricians to maybe talk more about whether or not
that data is captured, but I will say, if it is not captured,
that is certainly an opportunity gap. We have, as you notice, I
think, from the last 30 years or so had a mental health system,
no infrastructure, severely underfunded, and we certainly need
to catch up, if we can, overall but particularly in this issue.
You heard Dr. Howell talk about suicide. I think for many years
there was a misperception that depression was normal after the
birth of the baby, that it was the baby blues. And so it is
critical that we end--there are some emotional swings that do
occur, but those are not what we are all talking about with the
diagnosis of a major depression, and we have to make sure that
the major depression is treated if it is identified within the
first visit.
Depression is a chronic disease, and it will need treatment
as sometimes for a lifetime, but certainly it is not just a
take a pill and your depression will be cured. So this is a
huge issue, and we certainly have a long way to go. Funding for
mental health overall, and certainly as regards to post partum
moms.
I will say one more thing, and there is some great
research--I don't have time, but I think we provided this to
the committee staff from the Center on the Developing Child at
Harvard University. It talks about the importance--of course,
we all know the importance of brain development in the first 2
to 3 years, but moms who are depressed are perhaps not
interacting with their children in a way, and it may impact
even the architecture of their brain development. And, of
course, later there are all sorts of negative impacts from
that. So many nuances to the importance of mental healthcare
for pregnant moms.
Mr. Walden. That is a really important point that could
easily be overlooked, is that in relationship. Thank you.
Thank you all for your testimony, and we will keep you in
our hearts. Thank you.
Ms. Eshoo. The gentleman yields back. Thank you.
I now have the pleasure of recognizing the gentleman from
Massachusetts, Mr. Kennedy, for his 5 minutes of questions.
Mr. Kennedy. Thank you, Madam Chair. Thank you for calling
this important hearing. Thank you to all of the witnesses for
being here for the work you do every day and for lifting up the
voices that need to be heard. It is easy to study the stats to
hear some of these stories, to learn about the inequities and
implicit bias, to look into the eyes of a spouse, a parent,
child, and to talk to a survivor and become, candidly, a bit
dejected, to begin to question why we can't in this Nation
protect mothers like the rest of the world can, to ask why
nearly a thousand American women die from pregnancy and
childbirth every year, and why do another 65,000 nearly die or
bear those scars for a lifetime?
The tragic truth is that we already know the answer to
these questions: a long and pernicious history of racism
calcified in our institutions, including our healthcare sector;
economic inequality that leaves entire communities relying on
unfunded, unprepared hospitals already stretched too thin; and
the politically motivated decision by many States to reject
Medicaid expansion that leaves thousands of women uninsured
less than 2 months after giving birth.
So, to begin with, Ms. Irving, words will never suffice,
and there is nothing we can say or do that will make up for the
preventable loss of your daughter. Please know that we will
carry her story with all of us. In your testimony, you told us
about implicit bias training and that it isn't enough, and you
are absolutely right. What systematic reforms would you like to
see in our healthcare system beyond that mandatory training?
Ms. Irving. I would really like to see some type of a
program/policy standardized--what would you call them--I guess,
standardized policies that are tied to either accreditation or
funding. That is, I think, the only way you are going to get
people to move off the dime. The implicit bias training is
great, but you need to have some kind of evaluation on whether
or not that is making a difference in the lives of patients,
mothers who are coming there. And if it is not, if it is
going--if it is causing harm, then they need to be held
responsible, whether it is funding cuts, whether it is
accreditation that is withheld, or however you want to put it,
but there has to be an incentive for folks to do the right
thing.
Mr. Kennedy. Thank you.
Ms. Ranji, nearly half American counties do not have a
single practicing OB/GYN, and there are stark divides across
access to care within cities like Washington or Boston. Would
adding doula services as a covered benefit under Medicaid--as,
by the way, a bill introduced by my colleague Ayanna Pressley,
the Healthy MOMMIES Act, would do, with increased access to
care and reduced rates of preventable maternal deaths or
complications?
Ms. Ranji. Thank you for the question. Currently, you raise
the issue of doula services. Currently, doula services is
covered under in, as far as I know, two States, Oregon as well
as Minnesota, under Medicaid. It is a benefit that is not
available to many women covered by Medicaid across the country.
It is an area that has been of interest in many States. New
York is also piloting a program, and several other States have
considered recently adding doula services. Doula services are
an important--could be an important source of support for
pregnant and post partum women. Doula services expanded beyond
just labor and delivery. I am not familiar with the research
necessarily tying it to rates of maternal mortality or
morbidity or the effect of that, but there is a lot of
research, particularly the Listening to Mothers Survey, that
has looked at women's perceptions around doula care and have
found it very useful. And perhaps some of my clinician
colleagues here could speak to working with doulas.
Mr. Kennedy. Thank you, and just very briefly here,
question for each witness, if I can. Can any of you tell me how
many post partum women die annually from suicides or accidental
overdoses?
Dr. Nelson. I can speak to the Texas maternal mortality
review. From 2012 to 2015, overdose was the number one cause,
and from 2012 to 2015 in Texas, there were 33 suicides.
Mr. Kennedy. No national figures, though?
Dr. Nelson. I do not have that, no.
Mr. Kennedy. Nobody? And to be clear, we do not have any
idea how many women die in this country after giving birth from
suicides or accidental overdoses because it has never been
studied, and it is not reported. So we can't address something
we don't know to be a crisis if we don't even know how big a
crisis that it is, yet I think we can all acknowledge that it
certainly is one, Doctor, given the statistics that you
indicate. But we also can't wait for years for these studies to
take place before we act, and that is why we need to have
perinatal mental health providers in these conversations and
why we need to have guaranteed Medicaid coverage for a full
year after birth.
Grateful to all of you for being here today. Thank you for
your attention to a critical health crisis in our country.
I yield back.
Ms. Eshoo. The gentleman yields back, and thank him for his
questions.
I gave birth to two children, in 1969 and 1971, which means
they are both older than I am now, but when I complained to my
doctor post partum after each birth how depressed I felt, I was
told that is just the way it is. So I just place that on the
table for everyone to think about, and now I would like to
recognize the gentleman from Michigan, Mr. Upton, who served as
the chairman of our full committee and with special leadership
qualities.
Mr. Upton. Thank you, Madam Chair. I know that we all
appreciate today's hearing. I want to do what we can,
particularly on a bipartisan basis, to resolve this.
Every one of our districts is different. All of our States
are different. My district has a central city of Kalamazoo,
hundred-some thousand people and some rural counties as well.
In the past, we have had some counties without hospital to help
so people literally had to go out of their county that they
reside in if they were going to deliver at a hospital, and,
obviously, that happens. Michigan has got pretty rural areas,
particularly in the UP, and we had pretty high death rate,
maternal, in Kalamazoo back in the 1990s. And we worked very
closely with HHS and got some special money to grant to really
target Kalamazoo to see what we could do to alleviate some of
those terrible statistics that are there, which go right along
with what you have been saying. Women of color, Hispanics,
Medicaid births at our hospitals generally are over 50 percent
and have been for some time, whether it be either in an urban
setting or maybe a rural hospital as well. And I am--Dr.
Nelson, I have heard of Parkland Hospital. I don't know how
many hospitals are in Dallas, and it seems like you have done a
remarkable job trying to really reach out with the satellites
and others.
I guess the question is a little bit of a followup to
Chairwoman Eshoo to Dr. Harris. So, when you see these
statistics that are out of sorts, bad, things that none of us
would accept, what efforts--what collaborative efforts--and I
guess, Dr. Howell, I ask you to be part of this since you are
with Mount Sinai, so thinking about the hospital situation--
what efforts are you taking on yourself to say, ``What can we
work with?'' How do we work with the AMA and others to try and
duplicate a success that we have seen--I would call it a
success--of what we have seen at Parkland? Maybe if the three
of you could chat a little bit about that.
I have got one last question for Ms. Ranji at the end as
well, but if you could just expand on that a little bit.
Because we see these statistics, what are you going to do? What
is happening? Where is the leadership to try and get it done?
Dr. Howell. So, in New York, we have had a lot of work
around this for the last 4 to 5 years when we recognized that
we were doing so poorly as a State and the significant racial
and ethnic disparities that existed. So, at the State level, we
have had a collaborative across all the States trying to
implement some of the AIM bundles, three of those bundles in
hospitals across the State. And in New York City, the
Department of Health had a lot of efforts trying to work on
quality improvement, implicit bias training to do so.
At my own institution, we have done a lot of similar things
that Dr. Nelson has mentioned in terms of trying to standardize
care, building a culture of safety and equity. We have had
implicit bias trainings and required it of our obstetricians,
gynecologists. We have had all sorts of different things.
But one other point I would just like to quickly raise is,
a lot of the research that I have done has really been looking
at New York City hospitals, and part of the story here is some
hospitals don't have the resources, have the know-how to be
able to implement these bundles and do these things. It takes
resources. You need protected time because you need a
partnership between physicians and nurses, a physician and
nurse leader to champion these efforts. And so, while it is in
part healthcare professionals in the way that they treat
patients, another big part of this story is the place matters,
and where you deliver matters. And the resources, the staffing,
some of the basic bread and butter of high-quality, efficient
hospitals is just not there, and that is something else we need
to be thinking about.
Mr. Upton. So, just to comment. So all of us here support
community health centers, all of us, everyone on this
committee. It has been a great bipartisan effort for many, many
years. And I know I have been to all of my community health
centers. I am going to be meeting with some of my folks from
Michigan this afternoon. I am going to follow up with questions
based on this hearing. I know that they are very active, and I
applaud what they are doing, and we are going to push them
hard. And I would just--my remaining time, Dr. Harris, if you
can help, particularly in your leadership role now, I think
that would be terrific.
My last question, Dr. Ranji, so one of the things that has
come up, some States have that 1115 waiver to extend the time
beyond 60 days that a woman might be able to be able to get
some care under Medicaid. Some States have it, some States
don't. A couple of the bills that we are talking about today,
in fact, have that coverage, which I think is good. I think it
is very good.
What is the impact on the States, because, again, Medicaid
is run by the States, so they have to make the application. So
what is the reaction of the States going to be if, in fact, we
do this thing that I think most of us could support?
Ms. Ranji. Well, Federal legislation would allow uniformity
for----
Mr. Upton. So they wouldn't have to apply for the waiver?
They would automatically--if they want do it, they do it.
Ms. Ranji. Right. Allow availability of coverage across the
country.
Mr. Upton. So my time is expired, but let me just say, so
how many States you think right away would--how many States
have it now, and how many States would say, ``Sign us up''?
Ms. Ranji. I can't tell you how many States would say,
``Sign us up.'' I should say Illinois earlier this year did
approve that policy and is, in fact, seeking a Federal waiver
to secure Federal financing, but again, if it was written into
Federal legislation that would allow--that would be uniform
across the country.
Mr. Upton. Thank you, and all my time is expired.
I yield back.
Ms. Eshoo. I thank the gentleman, and he yields back. It is
now a pleasure to recognize the author of the MOMMA's Act,
Congresswoman Robin Kelly, for her 5 minutes of questioning.
Ms. Kelly. Thank you, Madam Chair. Again, good morning, and
thank you all for being here to share your expertise, your
insights, your experiences surrounding this critical issue of
maternal health.
Ms. Irving, thank you so very much. It can't be easy, but I
just want to thank you over and over again.
And Dr. Harris, thanks for all of your support. We could
not have written the bill without the expertise and support of
the AMA, ACOG. We really appreciate everybody.
In recent years, as you have heard today, the number of
American moms dying from pregnancy and childbirth has climbed
drastically while globally the rate has declined. New American
moms are twice as likely to die today than in 1985, and it is
very scary to me. My husband and I have four children between
us, three girls, only one has had a baby yet, and it is
interesting or scary to think that it was safer for me to have
a baby than my next two daughters, who I think are going to
give me grandchildren.
After almost 35 years--never know--the situation should be
getting better, not worse. As with nearly all health
disparities, women of color, especially Black and Native
American moms, as we have heard, bear the burden of this crisis
and continue to die at much higher rates. In some places that
disparity grows even larger, such as my State of Illinois. One
of these mothers was Kira Johnson, the daughter-in-law of TV's
Judge Glenda Hatchett. Kira raced cars, flew planes, spoke five
languages. She died soon after giving birth to her second son,
Langston.
While each death is tragic, the reality of the situation
foretells more tragedy. According to ACOG's research, more than
half of all maternal deaths are preventable. In Illinois, it
said 75 percent of them are. It is clear that we can and must
do more to protect mothers' lives. Conditions like hemorrhaging
and preeclampsia can and should be prevented. We must
understand the need to listen to women and their health
concerns. Just last month, I held a field inquiry in Chicago on
maternal mortality. Over and over again I heard the same
problem: Women are not being listened to, especially women of
color.
The hard truth is that no law can legislate away racism. No
laws can change the hearts and minds of people who operate on,
deliver care to, or just look at people of color from the lens
of unconscious bias. But our laws can change how care is
delivered within our hospitals by equipping our providers with
standardized emergency obstetrical protocols. Our laws can
support providers across their training continuum with tools
that help them become more reflexive about how their own biases
play out in the care they provide to women of color. Our laws
can extend care to mothers who are Medicaid beneficiaries
throughout the entire post partum period. Our laws can support
full collection of consistent data about who dies on the way to
motherhood and why.
Knowing this, I introduce the MOMMA Act, which builds on
recent successes and data standardization and protocol
development to prevent deaths and also establishes a National
Maternity Mortality Review Committee, expands Medicaid coverage
for new moms to a full year, and seeks to address the racial
disparities in maternal mortality.
As chairwoman of the Congressional Black Caucus Health
Braintrust and cochair of the Congressional Caucus on Black
Women and Girls, a prime importance to me is equitable
healthcare access and delivery and the healthcare system's
impact on those who, before the ACA, historically experienced
barriers to care, whether due to cost, geographic isolation,
insurance coverage, and especially due to forms of exclusion,
such as race and the residuals of racism.
The time has come for action. We have already lost too many
mothers to this crisis, and there are too many kids growing up
without mothers because of preventable maternal deaths, and I
think that is something this committee needs to look at: How
long do we postpone? How long do we keep talking about this as
mothers continue to die? It is incumbent upon us to honor their
lives with action, action that will prevent another mother from
needlessly dying or another family from being torn apart. We
see the inequity. We are calling it out, and we are here to
eliminate it.
I would also like to enter into the record a statement from
Stacey Stewart, president and CEO of March of Dimes, and from
Advocate Aurora Health. Thank you, again.
And I yield back.
Ms. Eshoo. The gentlewoman yields back.
It is a pleasure to recognize the gentleman from Illinois,
Mr. Shimkus. I didn't like the news that went out with your
name attached to it, but we have, let's see, 16 months left to
work with you, so take it away. You are recognized for 5
minutes.
Mr. Shimkus. Thank you, Madam Chairman. I appreciate that.
I like the news. My wife likes the news. So I have been on the
ballot since 1988 for every 2 years. So it is time to not be on
the ballot. So thank you for those kind words, and we will get
the chance to work together more.
Ms. Irving, we grieve with your loss. Thank you for being
here.
I am encouraged that this committee is continuing its
efforts to understand and address underlying causes of our
Nation's maternal mortality challenges. As we have mentioned a
couple times today, the President signed H.R. 1318, which is
Preventing Maternal Deaths by our colleagues Herrera Beutler
and Diana DeGette from the full committee. This legislation
enhanced Federal efforts to support State Maternal Mortality
Review Committees to improve data collection. I am going to
talk about why that is important. I am glad my colleague,
Congresswoman Kelly, is here from Illinois because these are
most recent stats based upon having started to gather more and
better information.
In fact, in October last year, October 2018, Illinois
Department of Public Health released its first maternal
morbidity and mortality report, which found that, during 2014
and 2016, there were 231 pregnancy-associated deaths, with the
pregnancy-associated mortality ratio being highest for women
living in rural counties and in the city of Chicago, 60 to 56,
respectively. You know, obviously, we mourn every death, and
one is too high, but that is just the stats that now we can now
dig into and figure out what is going on.
Understanding that this issue affects a broad and diverse
population, it is important to make sure any Federal
legislation considers the unique needs of States and the
localities as opposed to a one-size-fits-all solution. For
example, Illinois has a waiver to cover mothers up to 200
percent of the Federal poverty limit. And the ACA exchange
coverage begins at 100 percent of the Federal poverty limit,
and this is due--Ms. Ranji, are you concerned that additional
Federal legislation affecting patients at these income levels
could complicate State efforts, or worse, end up punishing
States for having made such investments by simply bolstering
States and dedicating their resources elsewhere?
Ms. Ranji. Thank you. You know, the Federal legislation or
a Federal--as I said before, would add a uniformity to the
policy and make it----
Mr. Shimkus. Yes, that is exactly why I am asking the
question, because if the State of Illinois is better than the
Federal legislation, then you are penalizing Illinois for what
it is trying to do internally to address these concerns.
Ms. Ranji. Well, States would still retain the option and
flexibility that they have now----
Mr. Shimkus. We have to make sure that that is available in
the legislation. We can't assume that that is going to be the
way the legislation comes out. We have to--that is part of the
package.
Ms. Ranji. Certainly that would have to be part of the
terms if that was----
Mr. Shimkus. Right, and that is our concern.
Ms. Ranji. I would just add that, you know, I think what we
have talked about today is that coverage is one part of this
whole conversation, and that is one area that States have been
making efforts in, as has been discussed. You know, States as
well as providers and you alluded to differences in provider
availability in different regions. Provider States all have a
role in this.
Mr. Shimkus. And States follow the money, just like anybody
else, and so the FMAP does drive decisions by States, and I
think we have to understand that and make sure that these kind
of contradictory, sometimes competing messages are direct into
the way in which we want them to perform.
Let me go to Dr. Howell real quick. In your testimony, you
mentioned specific elements of legislation to combat maternal
mortality, specifically those elements pertaining to data
collection and support for implicit bias training for health
professionals.
As a member of the Communications and Technology
Subcommittee, we discuss the potential benefits of using Big
Data and machine learning, algorithms and such, but also note
that the data we often rely upon to inform decisions is
inherently biased. You know, that old garbage-in/garbage-out
debate that we have all the time. I am curious if you or others
on the panel could expand on or offer examples of effective
ways to limit the negative impact this bias has on patient
care.
Dr. Howell. I think you bring up a really good point about
data quality, and I want to echo that if you just use vital
statistics alone to figure out the maternal deaths, you are
going to miss a lot of the mental health and the--you know, the
late deaths because it was not a reliable system. The pregnancy
check box, which was introduced in 2003, was introduced
differently across all the different States, and so, again, you
are not dealing with apples-to-apples comparisons.
That is why Maternal Mortality Review Committees are so
essential, because we are really collecting data from multiple
sources on each death. So we really understand what is the
underlying cause, what were the contributing factors. And then
now we have the CDC trying to have the MMWR program, which is
surveillance, 33 States are part of it, to actually collect
this information from the MMRCs so that there is now a national
understanding of what is going on. We need to get that all the
way up to 50 States, but that is the way to have better quality
data around maternal deaths.
Mr. Shimkus. Thank you, Chairman.
Ms. Eshoo. I thank the gentleman. Excellent questions and
highly instructive answers.
I now would like to recognize Dr. Ruiz from California for
his 5 minutes of questioning.
Mr. Ruiz. Thank you. While it is stating the obvious, I
would be remiss not to say that is abhorrent that the United
States of America is one of only three countries where maternal
mortality is on the rise, along with Afghanistan and Sudan, and
it is unacceptable that 60 percent of pregnancy-related deaths
are actually preventable. Even worse is the fact that the CDC
found that Black women were three to four times more likely to
die from a pregnancy-related cause than White women. This is
one of the reasons that I have been working on legislation to
address health disparities in women's health equity. The
Women's Health Equity Act will create a centralized,
independent interagency council in the executive branch to
facilitate coordination between Federal agencies on women's
health issues.
The problem is that you have different agencies working in
silos, and they are not communicating being efficient in what
they are doing, and they are not opening up the resources as
well as they could be with efficiency between all the different
governmental agencies addressing this issue. This will enhance
coordination and communication between the agencies when
addressing women's health issues and health disparities.
The interagency council would focus on collecting and
analyzing programs currently in place and give recommendations
on how to better coordinate their efforts. The council would
also be responsible for monitoring, evaluating, and providing
recommendations to address women's health equity and health
disparities. It would also streamline programs and activities
within Federal agencies that are working towards the same
goals.
Dr. Harris, do you agree that the lack of coordination on
the Federal level is hampering efforts to truly address health
disparities?
Dr. Harris. Well, what I would say is you bring up a great
point about the importance of getting out of our silos, and
interagency coordinating councils are a proven method to do
that in other disease and public health crises. And so I would
say that any opportunity where folks get out of their silos and
work together and agencies coordinate their efforts better is a
step in the right direction. I would say, from the AMA's
standpoint, we would hope that there would be physician input
into any of that agency coordination.
Mr. Ruiz. Well, just to let you know, AMA has been very
active in contributing their input into this legislation. Dr.
Howell, what are your thoughts on that?
Dr. Howell. I agree with what Dr. Harris said, that, you
know, us working together, collaborating, and sort of figuring
out the next steps, having the voices of many parties,
including physicians, in this discussion is really important.
Mr. Ruiz. Excellent. So, you know, I grew up in a
farmworker community where residents were largely poor, with
English as a second language. And as a kid growing up and later
as a doctor who practiced medicine there, I saw firsthand how
critical cultural competence is to delivering effective, high-
quality care, and it is not just understanding terms from a
different culture; it is a cultural sensitivity where you can
understand the practice of truly trying to understand a
person's background in order to provide the best therapy and
increase compliance and increase success of those
recommendations. The Giving Voice to Mothers study released
this summer surveyed women in the United States in an effort to
learn more about mistreatment during birth and found that 17.3
percent of women experience one or more types of mistreatment,
including but not limited to privacy violations, being shouted
at or scolded by healthcare providers, or having treatment
withheld.
Women of color were more likely to report an experience of
mistreatment, with 33 percent of indigenous women, 25 percent
of Hispanic women, 22 percent of Black women reporting an
experience of, at least, one form of mistreatment. We have
heard on our panel today about at least one terrible example of
what can happen when a patient doesn't receive the care she is
saying that she needs. These experiences further perpetuate
mistrust in healthcare systems and influence women's desires to
access care.
Dr. Harris, in your experience, how can we imbed improving
the experience of care in efforts to improve the quality of
care?
Dr. Harris. Another important topic, and thanks to the
committee members for raising this. There is this whole
universe of how we understand and work with others, so you
mentioned two terms: cultural competency, cultural sensitivity.
I even use the term cultural humility. So we have to appreciate
all of these issues in the context. Several of the committee
members have mentioned implicit bias, unconscious bias, another
part of that universe.
What we know is all of us have unconscious and implicit
biases and how should we--but unfortunately there is no gold
standard at this point, and one of the things that AMA wants to
do is look at not necessarily developing a gold standard, but
what might be the components of a great program to get it all.
Mr. Ruiz. I would love to work with you on that. Just in
closing, Chairwoman, we can't look at maternal mortality
disparities if we don't look at the overall health disparities
in our system, because a pregnant woman doesn't exist only when
she is pregnant, right? So you have to look at her health and
her experience with her health, because that is one of the
leading factors of health outcome, is her health prior to being
pregnant. And just recently, for example, as an example of how
we have these inherent biases, September 6th, JAMA Open Network
published an article that showed that, out of over 800,000
women and men under Medicare, they found that Black and
Hispanic women were diverted from EMS, from the emergency
department designated for them, took a longer trip to send them
to the safety net hospital elsewhere----
Ms. Eshoo. Thank you, Doctor, your time has expired.
Mr. Ruiz [continuing]. Which, you know, has dire
consequences.
Ms. Eshoo. The gentleman yields back.
I would like to recognize Mr. Guthrie of Kentucky for his 5
minutes of questioning.
Mr. Guthrie. Thank you, Madam Chair. I appreciate it very
much.
And thanks, Ms. Irving, for telling your story. We had a
hearing on this for some bills that we did pass and signed into
law. There was a husband in your seat, and he was talking about
his wife, and he made the same arguments that you made. He said
his wife--I think it was either a business consultant or
private equity. His wife I think was a Ph.D., athlete, UCLA, if
I remember--delivered at UCLA Hospital--and then had
complications and went back. I don't know how many days it was.
It was several days, and she was just dismissed with ``you are
exaggerating'' or whatever.
And so what we are saying here--I know we are implicit
bias, cultural bias, and we are using those terms, and they are
absolutely accurate. But what we are saying is--you said it
wasn't lack of education, it wasn't lack of insurance, it
wasn't lack of access. I think Dr. Howell said that, if you
control for education, insured, African-American women or women
of color are treated different than less educated and within
coverage for Whites, so what we are saying is, African-American
women or women of color are showing up in front of healthcare
professionals, and healthcare professionals are treating them
differently. We need to do--if it is commission, if it is the
agencies, if it is cross-referencing that we can do in
Washington, we need to do that to make sure that this is taken
care of.
Dr. Harris, you are the only one here representing
healthcare profession. What is going on? Is the AMA trying to
address this internally? I know we are here in Washington
trying to address it, but we know there is a problem. We know
it is lack of--there is bias, and what do you think it is, and
what is AMA trying to do to address that?
Dr. Harris. I think we are trying to find the answers to
those questions, and as I mentioned earlier with our new work
and, by the way, this is building upon work for many years that
the AMA, our commission to end health disparities--again, I
just talked to Dr. Aletha Maybank this morning, and we talked
about the possibilities. Now we are just getting our center up
and running, but this is one of the areas where we want to
focus on, we want to understand why, and then what are the
solutions that physicians can implement.
Of course, as you know, I am a psychiatrist by training, so
I am trained to listen maybe in a different way, but, as I said
in my testimony, for whatever reason, many of them are racism,
discrimination, implicit/unconscious biases, women are not
being heard, particularly African-American women are not being
heard. So the fact that we are talking about that is the first
step, and I know at the AMA that we are going to move forward
and try to find solutions and spread that to the medical
community. Of course, our partners at ACOG are here, and we
will work closely with them.
Mr. Guthrie. I want to correct the record. I think she was
a UCLA athlete. She was--Cedars-Sinai was the hospital. So I
want to make sure I have that corrected, the previous witness,
it was her--so Parkland, though, you have 90 percent Medicaid,
and you have this extensive program, and so I think what Dr.
Howell said, in New York City, you have hospitals--and I
understand that. It is absolutely a fact: You have hospitals
that have better outcomes, and hospitals, others. And you are
saying it is more women of color go to their--they are kind of
divided up in where they go to get their service. But what I
don't understand--getting back to the healthcare professionals,
why aren't they just showing up--are they showing up at your
hospital, Dr. Nelson, saying, ``What are you doing? How can we
replicate it and move forward?''
It looks like we are here doing a mandate from Congress,
and if Congress needs to mandate it, we need to mandate it. But
it seems like within the healthcare profession, they would be
flooding to what you are doing, or in New York, some of the
hospitals go into the hospitals having better outcomes, and
just, what are you doing different? Because when we did the
bill last year, we found that, in high-risk pregnancy, some
hospitals didn't even have high-risk kits available when they
were doing high-risk deliveries, just the basic stuff. And it
is hard for us to fix--when they are not even doing the basic
stuff--from Washington.
So, Dr. Nelson or Dr. Howell, whoever wants to talk about
that, it is disturbing that the healthcare profession is not
addressing this better than they are? Not saying you are not.
Dr. Nelson. Well, I think, to speak first, you are
absolutely correct and that the first issue that Dr. Harris
mentioned is we have to recognize we have a problem, and
collectively we have to agree that we have a problem and this
includes issues within high-resource settings and low-resource
settings. And one of the steps forward that I am proud of is
the regionalization of care that we have provided in Texas, and
that is not to say we are closing hospitals in rural
communities. We support that. It is really to identify women
with prenatal care that have a high-risk condition, identify
their needs, and get them to a facility that has resources----
Mr. Guthrie. I understand what you are doing, but are other
hospitals flocking to you from other cities and trying to
understand what you are doing and replicate it?
Dr. Nelson. That model is one of the opportunities, and it
dovetails AIM, and it dovetails the California initiative.
These are standardized practices that we can all collectively
agree to in the medical community to say----
Mr. Guthrie. Because you being 90 percent Medicaid, you are
not at the top of the chain in terms of financing?
Dr. Nelson. But the principles----
Mr. Guthrie. It can be replicated.
Dr. Nelson. The principles of care are the same, and that
is emergent response to emergent conditions, and time is key.
Mr. Guthrie. Right. Thank you.
My time has expired, and I yield back.
Ms. Eshoo. I thank the gentleman, and he yields back.
Pleasure to recognize the gentleman from North Carolina,
Mr. Butterfield, for his 5 minutes of questioning.
Mr. Butterfield. Thank you very much, Madam Chair.
Thank you to all of the witnesses for your testimony today.
Let me begin with you, Ms. Ranji. Thank you for coming
today, and thank you for your words.
As you pointed out in your testimony, research shows that
health coverage before, during, and after pregnancy is
important to support healthy pregnancies and positive outcomes.
Medicaid, that favorite word that we all talk about, Medicaid,
I wish it was available in every State in the Union with
respect to its expansion, but Medicaid is a vital program for
many families in my district and all of our districts. I am
glad the committee is looking at bills that would extend
Medicaid eligibility for pregnant women to 1 year post partum.
A maternal-fetal medicine specialist at Duke University in my
district shared with my staff recently that extending Medicaid
coverage to 1 year post partum would be life-altering and
potentially lifesaving for her patients, many of whom have not
had regular care until finding out that they were pregnant.
Extending Medicaid coverage for new moms is a vital step to
ensure these women can continue to be cornerstones of our
families.
Ms. Ranji, simply put, healthy moms lead to healthy babies.
Is that an overstatement?
Ms. Ranji. There are certainly a lot of research that
connects the health of moms with the health of their children
and as well as coverage that access to coverage for moms also
connects to access to coverage for children.
Mr. Butterfield. Could you describe for me the long-term
positive benefits that 1-year post partum Medicaid coverage
would have on moms and their children?
Ms. Ranji. Well, like I said, in several States now, women
do lose coverage after 2 months, and so extending to 1 year
would provide access--seamless access so that women could
continue to see the same providers and follow up on many of the
issues that--clinical issues that my colleagues have talked
about today. Cardiac-related health, maternal mental health,
and again, coverage provides access to a provider and being
able to continue and follow up on all of those issues that,
again, that we know don't resolve within 2 months usually.
Mr. Butterfield. Thank you. Many of the witnesses, Madam
Chair, today have commented on the disgraceful and disturbing
fact that African-American women are three to four times more
likely to die from a pregnancy-related cause than their
counterparts. Black women are also more likely to have
complicating conditions, like uterine fibroids and
hypertension, among others, which can cause severe maternal
morbidity and have potentially life-threatening and lifelong
consequences.
There have been countless stories of women dying or
becoming ill because their symptoms were ignored or treatments
were not offered. What should we do--and let's try you, Dr.
Howell, on this if we can. I just looked at your bio. It looks
like you are well suited to handle this. What should we do to
educate providers about conditions like these that
disproportionately impact women of color and how to identify
and treat them?
Dr. Howell. So, again, a very important point about risk
status for women when they enter our healthcare system,
antenatally as well as on labor and delivery. So risk
stratification is an important part, and it is something that
we use also in our AIM bundles to understand who is most at
risk and to make sure those people are getting what they need
and when they need it. So I think in addition to just pure
clinical care and thinking about the best way to optimize care
for individual patients, we also need to think about some of
these other issues around communication strategies,
decisionmaking, shared decisionmaking, listening to patients to
better understand their story, and recognizing and teaching
healthcare providers that there is a bias not to listen to
women in general, which we have heard in our own focus groups
across race and ethnicity, but it is more pronounced for women
of color. So I think those are some of the steps that we need
to take.
Mr. Butterfield. Thank you. Thank you very much.
Madam Chair, since Dr. Ruiz went over 1 minute, I will go
under 1 minute, and maybe we can cancel each other out. Thank
you.
I yield back.
Ms. Eshoo. I always knew you were a good man, always.
Mr. Butterfield. Yes. He is my friend.
Ms. Eshoo. Yes. Well, you are both my friends.
The gentleman yields back, and now it is a pleasure to
recognize the gentleman from Virginia, Mr. Griffith, for his 5
minutes of questioning.
Mr. Griffith. Thank you very much, Madam Chair.
And clearly somebody said it earlier, we have to identify
that we have a problem, and clearly that has been identified,
and we heard the testimony last year of Mr. Johnson. We heard
your testimony today, Ms. Irving, and those losses where the
mothers were just--they just weren't paid attention to. And
that clearly is a concern.
But I was struck, Dr. Howell, by one paragraph in your
testimony, and I am going to repeat that paragraph because I
think it is helpful, and then I am going to ask you a question.
Quoting your testimony: ``Research by our team and others
has shown that, for a variety of reasons, Black women tend to
deliver in a specific set of hospitals, and those hospitals
have worse outcomes for both Black and White moms regardless of
patient risk factors. This is true in the United States overall
where three quarters of all Black women deliver in a specific
set of hospitals while less than one-fifth of White women
deliver in those same hospitals. Both Black and White women
have worse outcomes in those hospitals. In New York City, a
woman's risk of having a life-threatening complication in one
hospital can be six or seven times higher than in another
hospital. Black and Latino mothers are more likely to deliver
in hospitals with worse outcomes. In fact, differences in
delivery hospital explain nearly one-half of the Black/White
disparity and one-third of the Latina/White disparity in severe
maternal morbidity.''
So here is my question, with their choosing a specific set
of hospitals, how do we fix those hospitals, and should we have
some way of getting the information out if we can't fix those
hospitals that these hospitals are far more dangerous? Doesn't
solve all the problems, but your testimony indicates that one-
half of the disparity is because of specific hospitals. Nothing
else that we are doing here at the Federal level or the State
level, but the specific hospitals they are choosing? How do we
fix them?
Dr. Howell. So I think what is interesting about the work
we have done in New York City is that it is not the traditional
hospital characteristics, so it is not percent Medicaid. The
median percent Medicaid in New York City hospitals is like 80
percent, so we are talking about a highly--60 percent of our
deliveries are covered by Medicaid. So it is not volume. It is
much more--we don't really understand why there is such a
variation, other than having to go in and talk to hospitals,
and that is what our research team is doing. So we are going
into hospitals who have low rates and hospitals that have high
rates to try to understand what the differences are. And what
we are finding is that it is things like staffing. It is things
like culture--the culture of the institution and the way that
they treat adverse events. It is things like communication and
the emphasis. It is quality and safety on labor and deliveries
and the use of evidence-based practices, but it is also whether
there is any focus on equity and diversity and how they think
about it.
So more work needs to be done to understand these
variations, especially in large urban centers where you have
high volume, but that is one key, important piece because, in
certain hospitals, regardless of what you look like, your risk
is higher to have one of these severe complications, and that
is an important part of the story we are talking about today.
Mr. Griffith. And so, while we look at these bills--and I
think this was the same point that Mr. Guthrie was making just
a minute or two ago, and he and I hadn't talked about what we
were going to discuss, but he started hitting some of that same
testimony.
While we are working on this legislation, that is an area
we need to focus on. And right now, while there is some studies
in these bills, I don't think the bills are really focused on
that area, and maybe we need to give some more money to the NIH
to focus in on that so that we can figure out what the problem
is. Maybe they need to be doing what Dr. Nelson is doing in
Texas, but maybe that doesn't work in New York City because
what works in Texas might not work in New York City, but we
still need to figure out, if that is half of the problem, then
it ought to be addressed in some of our bills as more than just
a casual line in a study.
Would you not agree, Dr. Howell?
Dr. Howell. I think that it is one important part of
something that needs to be addressed. So, yes, I do agree that
it is one more element that we need to look at and a very
important one in New York City.
Mr. Griffith. And, Dr. Nelson, you would be more than happy
to talk with anybody who wants to figure what you are doing
right. Is that correct?
Dr. Nelson. Yes, sir.
Mr. Griffith. And you would be willing to work with these
hospitals that in the testimony are just listed as--and I am
not asking for names today--a specific set.
Dr. Howell, real quick. I just have a few seconds left.
Should we identify for the public those specific set of
hospitals where your risk is higher?
Dr. Howell. So I think that, Dr. Nelson, I think we both
agree that measurement is a key. Quality measures that are
important and that women can use to help choose hospitals I
think is an important measure, but we have to be very careful
about the development of appropriate risk-adjusted quality
measures so we do not penalize the hospitals that take care of
the sickest and the hardest cases, and I think that is a really
important part of doing really well-done, quality measure
development in maternal health that focuses on both the
patients--patient-centered, thinking about experience--as well
as on disparities.
Mr. Griffith. Thank you.
I am out of time. If the chairlady would like to give you
time, Dr. Nelson, she can. But I am out.
I have to yield back.
Ms. Eshoo. Well, the gentleman yields back, but I think
that his question to you is really very, very important. All of
the collection of the data is essential so that you have
something that is foundational, but we already know where women
of color deliver and die. So there has to be--I think there
needs to be a red-light-and-siren team that gets into these
hospitals, and I also think that we should consider the
accreditation of that hospital based on the morbidity rates.
So I don't know if that is what the--where the gentleman
was going, but it certainly is my sentiment.
Mr. Burgess. Would Dr. Nelson respond to that?
Ms. Eshoo. Certainly.
Dr. Nelson. So one of the comments of sharing, in all
seriousness, sharing our experiences and what we do as
practices is actually part of the outreach and one of the
things that we actually stress as part of the regionalization
of care. We actually have an outreach team going to lower-level
facilities to talk about emergent response to hypertension and
labor management. So that actually is one of the existing
programs we currently are using right now.
Ms. Eshoo. I mean, I don't know if El Camino Hospital in
Mountain View, California, knows what you are doing. And I am
not saying that they have a problem. It is marvelous what you
are doing, but this needs to be under a national umbrella, and
I don't think anyone is arguing with that.
It is a pleasure to recognize the gentlewoman from
California, Ms. Barragan, for her 5 minutes of questioning.
Ms. Barragan. Thank you, Madam Chairwoman.
And thank you all for being here today, for sharing your
stories. The statistics are quite tragic, completely
unacceptable in a country like ours.
I first learned about the issue of racial health
disparities when I was in the White House. I was an intern, and
the New England Journal of Medicine came out with a study. It
showed that they had sent an African-American woman, a White
woman, a Latina woman to similar doctors, same doctors,
complaining of the same symptoms, and they were all treated
differently, and that is when I first learned of it.
And I think one of the points made by my colleague Dr. Ruiz
is critically important. It is certainly overall health and
making sure we are all getting access to equal care, but that
we are being listened to.
And, Ms. Irving, I want to thank you for coming and sharing
your story of your daughter, and the testimony that you
provided is something that we all needed to hear. And that is
why I am glad we are having this hearing today to kind of look
at these bills and see what can be done.
It sounds to me there is not one fix. It sounds like there
is going to be a series of things that need to be done to be
fixed, to fix this issue and to make this wrong right.
And so I thank you all for coming.
Dr. Howell, two of the bills that we are being presented
with and are looking at are H.R. 1898, the MOMMA's bill that my
colleague Ms. Kelly has, and H.R. 2902, which is a bill that my
colleague Alma Adams has. Have you had a chance to look at
those bills? I would like to know if you believe those bills
might help eliminate some of the implicit bias among the
medical professionals.
Dr. Howell. So I did get a chance to look at those bills. I
don't have my notes. Could you just repeat the names of the two
you wanted me to talk about real quickly?
Ms. Barragan. Sure. The MOMMA's Act.
Dr. Howell. Yes.
Ms. Barragan. And the other one is the Maternal Care Access
and Reducing Emergencies Act.
Dr. Howell. Got it. So, yes, I did have chance to look at
all of the bills, which, again, I think there are elements that
are key for this issue.
The MOMMA'S Act, authorizing the AIM program, which I told
you is the key to having standardized care practices
implemented in hospitals and health systems across the United
States currently reaching 27 States, so potential to reach more
than 50 percent of all U.S. births, very important. We need to
authorize that.
Second, Perinatal Quality Collaboratives, Maternal and
Infant Health Quality Collaboratives are so important as a tool
to improve quality of care. And these are partnerships with
hospitals and health systems and Department of Health.
As you have heard from my colleague, very important to
extend Medicaid for 12 months post partum. You know, there are
so many cases of women who have gestational diabetes. They go
on to have a risk. They are seven times more likely to have
type 2 diabetes, but if we don't capture them in that post
partum period, they could go on and be much sicker the next
time they get pregnant, as well as cardiovascular complications
that are so important.
Then, finally, the Regional Centers of Excellence to
address implicit bias and culturally competent care, which we
have had a discussion about, which I think is a really
important piece, again, I would expand it to think about
patient-centered communication, shared communication. It is not
just bias. That is the problem. But we are not doing a good
enough listening to our patients, communicating with our
patients, and understanding their perspectives. So having
centers of excellence that really focus more broadly with a
focus on explicit and implicit bias, I think, are important.
And I think that the Maternal CARE Act has very similar
themes to it. The Maternal CARE Act, though, does talk a fair
amount about care coordination and its importance to target
social determinants of health, which I think is an important
piece. It calls for a medical home demonstration project, which
I think is of interest.
My one thought I would just share is that CMMI Innovation
project looked at group prenatal care versus birth centers,
which is predominantly midwifery care, versus maternity home
care for prenatal services to see if we could lower adverse
birth outcomes, lower costs, and improve satisfaction. And the
other two models performed better than the maternity home
model.
So that is evidence that I think we have to include in
these discussions. There is no question that care coordination
in general seems to really do a good job targeting disparities,
and it may need to be a piece, but we need more evidence to
make sure, because this early evidence is not telling us it may
be the best step forward.
Ms. Barragan. Thank you, Dr. Howell.
I also want to mention I think another component is making
sure that we get more people of color into the medical
profession that are there to listen, that are there to
understand. I am proud to have Charles Drew University Medical
School in my district, which is a historically Black graduate
institute that is a district that is 88 percent Latino/African
American, that is bringing more and more people into the fold,
into these professions and certainly, if I had more time, would
ask about your opinion, but I wanted to certainly say that I
think this is another angle we can certainly improve in as
well.
Thank you very much, and I yield back.
Ms. Eshoo. The gentlewoman yields back.
It is a pleasure to recognize the gentleman from Florida,
Mr. Bilirakis, for his 5 minutes of questions.
Mr. Bilirakis. Thank you, Madam Chair. I appreciate it so
much.
And thank you to the witnesses here who are testifying.
Very informative.
Dr. Howell, we can't solve what we don't understand. That
is why, last Congress, this committee passed bipartisan
legislation, the Preventing Maternal Deaths Act, which provides
funding through the CDC for States and other entities to
develop Maternal Mortality Review Committees so we can start
collectively understanding and reducing our rate of maternal
mortality.
CDC recently announced it is funding the first round. It is
funding the first round of grants to support 25 States, their
efforts to combat maternal mortality through the creation of
Maternal Mortality Review Committees. As States prepare their
implementation efforts, what should this committee be paying
the most attention to?
Dr. Howell. Well, I think it is wonderful that the CDC is
now sponsoring 25 perinatal quality collaboratives. I think the
data is at a key point.
I also want to say one thing, though. You are absolutely
right. What we don't understand, we can't really address, but
there are models of success. We have heard a lot about Parkland
today. If we look at California Collaborative and what they
have done, by using Maternal Mortality Review Committees,
gathering the information around deaths, then using that
information to drive quality improvement. And they have done a
number of the bundles, the same bundles we are talking about
for AIM. They started--hemorrhage, hypertension, venous
thromboembolic disease--and they have actually lowered deaths
in hospitals that adopted these bundles by, like, 21 percent
for the hemorrhage-related deaths and their mortality rate,
while the rest of the United States has been going up, theirs
has been going down. So we have evidence that, when we tie data
to quality and improvement, we can really make a difference.
The important lesson about California, though, is--an
additionally important lesson--is that their disparities,
however, did not decrease. So they lowered mortality for White
women and they lowered it for Black women, but that gap is
still there. And now they are trying to target a lot of the
things that the rest of us are trying to target around health
equity, combining quality improvement, what the data tells us
with cultural humility, and sort of trying to understand
communities, getting them involved to help tackle this problem,
which is something that the AIM bundle also tries to do. The
ACOG partners with community organizations to get their input
about how best we implement these bundles not only in hospitals
and health systems, but we get communities on board as well.
Mr. Bilirakis. Thank you.
Are there concerns within the research community regarding
the integrity of the data being collected in States, and if so,
what are those concerns, and how might they be addressed? Are
there any concerns with regard to the integrity of the data?
Dr. Howell. Well, there are certainly concerns with the use
of what I had mentioned about if you only base maternal
mortality rates on vital statistics data only that you are only
getting a slice of the picture, and it is not a great way of
monitoring our trends across the Nation. The CDC now uses vital
stats. It combines it with State discharge abstract data, which
gives a better estimate, but still the best estimates are the
data from the Maternal Mortality Review Committees that
actually get multiple sources of data to figure out how this
death occurred, what were the contributing causes, and then
feeding that back up to the CDC through their MMWR program is
probably the best way for us to get data on this that we can
use for improvement.
Mr. Bilirakis. Very good.
Thank you. Last week, the CDC released a report titled
``Racial and Ethnic Disparity in Pregnancy-Related Deaths.'' In
the report, CDC suggested that steps still need to be taken in
order to better integrate care delivery between hospital and
pre- and postcare services for mothers and their newborns, as
well as better management of high-risk patients.
How might this committee consider addressing these specific
challenges highlighted by the report? And can you highlight any
States or entities that can be looked at as models--again, best
practices in these areas?
Dr. Nelson. So I think that I would echo. Much of what Dr.
Howell just mentioned, I think, is reflective in that effort.
California has been a model for a lot of the programs, but the
same principles are true within the AIM domain. Parkland
Hospital publishes Williams Obstetrics as a textbook. It is the
most popular textbook worldwide. We have 17 authors on our
faculty, including myself, and these principles are the same.
The important part of this is disseminating that level of
scholarship and information to the community centers, to the
communities at large, and the providers in those communities.
Mr. Bilirakis. Well, thank you very much.
And I yield back, Madam Chair. Thank you.
Ms. Eshoo. The gentleman yields back.
It is a pleasure to recognize the gentlewoman from Florida,
Congresswoman Castor, for her 5 minutes of questioning.
Ms. Castor. Well, thank you.
And, Chairwoman Eshoo, I want to thank you very much for
organizing this hearing here today on the maternal health
crisis in America.
It is good to see so much engagement by the committee this
morning, right, our first committee meeting back after the
district work period.
First off, I want to say I am really proud to be a
cosponsor of Representative Kelly's MOMMA's Act. And I am so
glad that she joined the committee this year. She is a champion
on this issue, and her voice is vital to this discussion, and
it is needed. It is just horrendous what is happening with
disparities when it comes to maternal health in the United
States of America.
And I want to thank the witnesses for being here and for
providing your expertise. Already I have seen Members making
long lists of how we can improve the bills that are before us
today.
Ms. Irving, I thank you very much for sharing the story of
your daughter. You are very brave to do so, and I know she
would be very proud to know that you are carrying on her work.
I am also grateful to the advocates across America who
engage every single day, whether it is the March of Dimes or it
is the American College of Obstetricians and Gynecologists or
Every Mother Counts, the folks in the trenches, making sure
that--whether they might be Healthy Start--making sure that
women and families have every opportunity to have healthy
children.
In the Tampa Bay area, I am very fortunate. We have a
terrific Healthy Start REACHUP initiative led by Lo Berry. They
are one of the national leaders. But what they tell me is,
while they have years of experience and they are making
progress, they are not able to reach everyone. We are still not
able, after so many years, to ensure that women of childbearing
age get the services, get the support that they need. I mean,
in America, it is so disjointed, Medicaid and maybe private
health insurance and maybe you are uninsured and you are trying
to find a community health center, but that community health
center doesn't provide care. It is still not enough.
And I was really taken by the comments of Dr. Ruiz and
Representative Butterfield, who highlighted this really is a
continuum of care that is in crisis, and add on top of it the
disparities, the racism that continues, the social stigma
probably in many different groups. We have got to do so much
more. So I will look forward to as we get into the markups on
these bills how we can really tackle this continuum of care.
I am also fortunate, back in Tampa, we are home to the
University of South Florida. Dr. Judette Louis is the chair of
the College of Medicine's Obstetrics and Gynecology Department.
She shared, again, the sobering statistics. In Florida, Black
women are nearly three times more likely to die from pregnancy-
related causes than White women. She said that, yes, the
Maternal Mortality Review Committees and the perinatal quality
collaboratives are helping, but so much needs to be done.
I want to start my questions with Ms. Irving. You have
listened. These folks are very smart. Members of Congress have
had some insightful questions. What would your daughter want to
highlight after listening to everyone here today? What would
your daughter say, ``Boy, that is absolutely right''? What
would she have wanted to highlight to this?
Ms. Irving. I wish I knew. My daughter was a brilliant
person. I think the most, what she might say or start off
saying is, this is not a new phenomenon. This has been going on
for decades. Why can't we get it right? There are things that
can be done but are not being done. I think she would probably
say that behind every one of these statistics, there is a woman
who is loved, who is missed. And look at the domino effect.
Look at the families. Look at the children that are suffering
because we can't get it right.
She would want us to look at making sure that there are the
standard care policies and procedures in place, and there is
some accountability behind it so that we can make sure that
folks are being listened to.
I listened to all of your talk and things about people come
in, and it is the hospitals, and there are certain hospitals
where you can't go or where you won't get the same amount of
care. That wasn't the case for Shalon. The case was that she
wasn't heard. She came in. She presented with the symptoms. It
wasn't that she was making it up. She came in with swollen
legs. She wasn't voiding. She was gaining weight. She gained 7
pounds in one week, and she was there three times that week.
Her blood pressure was off the chart. She was not only not
listened to, she wasn't--her symptoms were not addressed. She
was there. She was in a very, very good hospital. She had great
doctors in that hospital. She had gold-plated insurance. She
was not an ignorant woman. She knew what was wrong, and she
kept saying it: ``I don't feel well. This is not--this is not
me. There is something going on here.''
But she was dismissed with the ``Oh, it is fine. You just
had a baby. Give it time. Don't worry about it.''
I think my daughter was just so tired at that point. She
didn't stand up and say, ``Look, I am going to the emergency
room, or I am going to call another doctor, or I am going to
another hospital or whatever until somebody listens to me.''
With a newborn baby with colic, with respiratory distress,
she just was tired. And she needed someone to advocate for her.
She needed someone to realize that they had to take care of her
at that time, and so I think she would just be off the chart
right now because that is not happening.
Ms. Castor. Well, let that be a lesson for all of us as we
move these bills. Thank you.
Ms. Eshoo. The gentlewoman yields back.
I now would like to recognize the gentleman from Missouri,
Mr. Long, for his 5 minutes of questioning.
Mr. Long. Thank you, Madam Chairwoman.
In this final round of Jeopardy! today, we only have one
category left, and that is ``Who said it?'' So in the category
of ``Who said it?'' for $1,000:
``After delivering another perfect baby, I was sitting next
to Kira by her bedside in the recovery room. That is when I
first noticed blood in her catheter. I notified staff
immediately. A series of tests were ordered, along with a CT
scan to be performed stat. I understood `stat' to mean the CT
scan would be performed immediately.
``Hours passed, and Kira's systems escalated throughout the
rest of the afternoon into the evening. We were told by the
medical staff at Cedars-Sinai Kira was not a priority, and we
waited for the CT scan to be done. We waited for the hospital
to act so she could have her recovery. Kira kept telling me,
`Charles, I am so cold. Charles, I don't feel right.' She
repeated these same words to me for several hours. After more
than 10 hours of waiting and watching my wife's condition
deteriorate, after 10 hours of watching Kira suffer in
excruciating pain needlessly and begging and pleading them to
help her, the medical staff at Cedars-Sinai finally took
action.
``As they prepared Kira for surgery, I was holding her hand
as we walked down the hall to the operating room. Kira looked
at me and said, `Baby, I am scared.' I told her without doubt
everything would be fine. The doctor told me I would see her in
15 minutes. Kira was wheeled into surgery, and it was
discovered that she had massive internal bleeding caused by a
horrible medical negligence that occurred during her routine c-
section. She had approximately three liters of blood in her
abdomen. Kira died at 12:22 a.m., April 17th, 2016. Langston
was 11 years old.
``As someone who experienced firsthand what it was like to
have your spouse die in front of you, I do not have the words
to describe the loss my family has suffered. My boys no longer
have their mother. Kira was the most amazing role model and
mother any boy could ever wish to have. I no longer have the
love of my life, my best friend.''
Of course, those were the words of Charles Johnson IV, who
I believe was of means. Kira was of means. It wasn't someone
that didn't have good prenatal care. It wasn't someone that
had--didn't have a--it was a preplanned c-section.
We are talking here today, and I hear a lot of people
talking about access to prenatal care, which of course is
vitally important, but cases like this, cases like Ms.
Irving's, all I want to do is come down there and hug your
neck. I can tell you that.
But I am the only Missouri Member that is on Energy and
Commerce. So, consequently, I am the only Missouri Member that
is on the healthcare subcommittee. So I feel an obligation to
travel the State for healthcare issues. I visited just during
this break a week ago--it may have been a week ago today, I am
not sure of the timing--but Kansas City Children's Mercy
hospital. Went through the neonatal. Went--you know, and I do
that quite often. I go to St. Louis Children's up there.
Our oldest daughter is a pediatrician, and I know when she
does her rounds at the hospital that, you know, all that she
wants to do and you think all any doctor would want to do is
love these babies and make sure they get a good start and love
the mothers, and so whatever we can do on this committee.
I mentioned earlier in my little outburst when we had the
outburst in the hall--which I apologize to you all that that
went on for any length of time during your testimony--I am a
member of the Black Maternal Health Caucus. And I deeply care
about this issue. The timing didn't work out to bring up H.R.
4215 today, the Excellence in Maternal Health Act. Nobody's
fault, just the timing didn't work out.
But I am an original cosponsor of that, and I just want to
thank you all for being here today and your heartfelt
testimony. I have said a lot of words today, but there is no
words to say, to express what an unbelievable issue this is and
the things that happen, but if your testimony here today,
Charles' testimony back in September of 2018, I believe it was,
we have had a lot of important, lot of big hearings, a lot of
memorable hearings in Energy and Commerce. Mark Zuckerberg from
Facebook is an example of--Dorsey, Jack Dorsey of Twitter, you
know, the rooms were packed, a lot, you know, but no hearing
ever moved me like Charles Johnson's testimony that day, and
your testimony here today is right along there with it.
So God bless you and thank you for being here, and thank
all of you for being here, and if there is anything that me, my
staff, the committee can do, please keep us apprised, any
suggestions, ideas. We will be honored and glad to work with
you.
I yield back.
Ms. Eshoo. The gentleman yields back.
It is now a pleasure to recognize the gentlewoman from
Delaware, Ms. Blunt Rochester, for her 5 minutes of questions.
Ms. Blunt Rochester. Thank you, Madam Chairwoman.
And thank you so much to the witnesses for your testimony.
I especially want to acknowledge Representative Kelly for her
leadership in this important issue.
I held a townhall meeting in the past month over the
recess, and a midwife stood up and shared her perspective on
the role that she plays. And one of the things that she focused
on was the social determinants of health, particularly in
maternal mortality. And she said that she was caring for a
soon-to-be mother, many of which are told go out and get some
exercise, but they don't feel safe walking around their
neighborhoods, or who are being told to eat nutritious diets
but don't live within blocks of a grocery store selling fresh
fruits and vegetables.
And as we transition our health system, you know, I think
it is critical that we think about the social determinants of
health and all those things that surround it.
And so my first question is to Dr. Harris. Can you talk
about the social determinants of health and how we can address
this challenge of maternal mortality by dealing with the social
determinants of health?
Dr. Harris. Thank you.
And I can. I can say that the AMA is very committed to
addressing these issues because, if you look at that circle of
care and you look at the fact that maybe health outcomes are
impacted, and we know they are impacted some by physicians and
hospitals, but we see a huge impact related to the social
determinants of health: transportation, housing, whether or not
you have a job. You mentioned whether or not you live in a food
desert, and I know now and my colleagues can talk about whether
or not you live in a maternity care desert.
So those are all pieces that we plan to focus on as we
build out the work of our Center for Health Equity, but I will
say we have current policies that raise the importance of
social determinants of health. So, wherever we go, I mention
that and, in my own work, that it is not enough for us to say
to exercise. Physicians should say that, but we have to make
sure there are equitable opportunities for exercise, to access
healthy, nutritious foods. So that work will be included in the
work of our Center for Health Equity.
Ms. Blunt Rochester. Thank you.
This questions is for the panel, and it is one that has
plagued me for a long time.
And, Ms. Irving, first of all, thank you so much for
sharing your testimony and for sharing your daughter's story.
And it is at the heart of my question. I don't understand why.
I can talk about the social determinants of health and
understand that there is a disconnect sometimes between access
to healthcare or the kind of healthcare, but your daughter, you
know, smart, understood health.
I watched a Jon Stewart piece last night about maternal
mortality, which is interesting, and he said that--they showed
a clip of a father, an African-American man, who said his wife
died because he was afraid to be perceived as the angry Black
man if he spoke up for her.
So I am curious. Can you explain to me for those African-
American women that are experiencing this and it is not an
issue of access to healthcare, education, a doctor, can the
panel, can someone help me understand? What is it? What is
going on?
Ms. Irving. I will start off and then turn it over, but I
had the same issue, and I suffer now from regret that I wasn't
that angry Black woman, and I think my daughter kept me from
doing that because she would say, ``Mom, just calm down. Just
let them handle it. It is going to be OK.''
But it wasn't OK, and I wish now that I had stood up and
said, ``Look, you are going to do something right now.''
But I think it might have had the negative effect, because
then I would have pushed them away, and it might--well, it
would have--I can't see how it would have turned out any worse
than it did, but that is what a lot of Black women or Black men
face when you are coming in because you are looked at as a
threat. Then, if you start getting loud, the next thing you
know, you could be put out of the hospital because you are not
communicating in a way that is acceptable.
Ms. Blunt Rochester. Doctor.
Dr. Harris. So that is an important part. I would say that
is the other end of folks examining their own implicit biases.
I have not had a child, but I have often been the only African-
American woman in a room, and I think people of color,
particularly African-American women, because there are issues
around discrimination based on gender and race, end up self-
editing sometimes and being extra careful so that we are not
the angry Black woman or the angry Black man.
And I think as we have this conversation, we have to talk
about that more. It only comes, I think, with some practice and
some experience and, frankly, some privilege that you feel more
comfortable raising issues. And that should not be the case.
Ms. Blunt Rochester. You are right.
Dr. Harris. And so I will say that was part of our
discussion, will be part of our discussion at the AMA. But it
really needs to be part of this society's discussion to look
at, I think, the biases and the racism and discrimination in
all contexts.
Ms. Blunt Rochester. I know I am out of time, and it is
just something that has plagued me. I know people like Serena
Williams, Beyonce have gone through this, and it is not even--
it is beyond privilege.
Thank so you much for having this hearing, and I will send
questions in writing. Thank you.
Ms. Eshoo. The gentlewoman yields back, and you ask a very
heavy question, but a necessary one.
It is a pleasure to recognize the gentlewoman from Indiana,
Ms. Brooks, for her 5 minutes of questioning.
Mrs. Brooks. Thank you so much, Madam Chairwoman.
And I also want to thank the ranking member because this is
something that we have been focused on for a couple of
Congresses, and we must do more. We rarely in this body, I
think, have an opportunity like we have now to educate those
medical providers of the future.
And one thing that you mentioned, Ms. Irving--and I want to
thank you so much for sharing your horrible, very, very sad
story, but the power of your testimony, the power of your
written testimony, which I read this morning and was quite
moved this morning, even before you spoke--you mentioned
something that I don't think that we have talked about enough,
although Dr. Burgess mentioned it. In his medical training, he
had a doctor who talked about care, about caring, and you
mentioned med schools.
And I think the hearing we had last Congress and the
hearing we are having this Congress from all of the incredible
professionals here that are studying it, that are working on
it, that are trying to improve--Indiana has the third-highest
rate of maternal mortality. Now, yes, we just instituted that
review committee. Luckily our new, or fairly new, head of State
Department of Health is an OB/GYN, and this is a top priority,
Dr. Kristina Box, top priority now for our State, but we have
got to start earlier. The review committees are after the fact.
We have got to study the data. We have to collect the data to
understand the problem.
But what would you all like to see our med schools do, our
nursing programs do, our--we haven't really talked. That is one
aspect we haven't really talked about.
Maybe starting with you, Ms. Irving.
Ms. Irving. I think the training that we have talked about
before as far as the implicit bias training, et cetera, is good
to start early. They must recognize that every patient should
be treated as an individual. Even though we have standards of
care, you look at the patient as a whole. And I haven't been to
medical school. So I don't know what the training is, but you
have to have that ``it could be my mother, it could be my wife,
it could be my daughter'' and look at each patient through
those lenses and work on it from that point.
Mrs. Brooks. Thank you.
Dr. Harris, how do we take what Ms. Irving is hoping and
praying that folks like you all implement?
Dr. Harris. I think that is critical, and the AMA 5 years
ago looked at the issue of training the next generation of
physicians, and we awarded 11 $1 million grants and have since
then developed a consortium of other medical schools that can
share best practices, and I will say a couple of those medical
schools are specifically focused from our grant, although they
were already working in these areas, on two issues that have
been raised.
One is the social determinants of health. So we have
medical students now getting trained and understanding and
appreciating the importance of social determinants of health.
And we have a couple of other medical schools that are talking
about health disparities, making sure that the future workforce
is a diverse workforce so that the faces of our physicians
match the faces of our patients, and then, of course, from
those learnings we are spreading that out to the consortium of
medical schools, and then hopefully that will be spread out to
the entire medical school community.
So we are committed and do agree that we need to raise
these issues early in training of physicians.
Mrs. Brooks. Dr. Nelson, I want to commend Parkland.
And thank you, Dr. Harris.
Has the med school community reached out, and are they
studying your model in Parkland, and how do we do a better job
getting--because it is not just doctors. It is nurses. I am
sure there were many nurses that didn't listen to your
daughter's needs, not just doctors--doctors, nurses, others.
How about the medical training? I don't just mean med schools.
Dr. Nelson. Correct. That is what I was going to build
upon. So I am a faculty at the University of Texas Southwestern
Medical Center. And we are one of the largest obstetrics and
gynecology programs in the country. We have 72 residents in our
current existing program. And part of our responsibility is to
talk about and begin the training that you heard here. It also
extends to the training that we have within our nurse midwives,
our advanced practice providers with nurse practitioners, and
nursing students who are responsible for training the next
generation.
And this is the part that becomes really difficult, is
translating the importance and advocacy that we are hearing
that we need to share in fighting for our patients and hearing
their voice, is something that is our responsibility to carry
forward.
Mrs. Brooks. Thank you all. My time is up, but I certainly
hope that our med schools take the opportunity to actually
listen to your testimony, to read it and to listen to it. I
think it would be incredibly instructive.
With that, I yield back.
Ms. Eshoo. The gentlewoman yields back.
I now would like to recognize the gentleman from Maryland,
Mr. Sarbanes, for his 5 minutes of questioning.
Mr. Sarbanes. Thank you, Madam Chair.
I want to thank our witnesses for your testimony today.
Extremely compelling and in certain instances certainly heart-
wrenching. So thank you for being here.
Ms. Ranji, I wanted to talk a little bit more about the
situation that women can find themselves in when they have to
make a switch to different coverage because of the expiration
of Medicaid coverage, and we have heard from many of you and it
is well documented that the Medicaid, current Medicaid
pregnancy coverage only covers women for 60 days after they
give birth, and then, at that point, what happens can range
from losing coverage completely, potentially being able to
enroll through a marketplace plan on one of the exchanges, et
cetera.
Obviously, getting some coverage after that 60 days is
better than having no coverage. But I think it is important to
recognize that forcing women to change plans during what is a
very, very critical time can also generate negative
consequences. So I would just like to ask you a few questions
about that phenomenon, which is referred to in shorthand as
churning.
If a woman gains Medicaid coverage as a result of her
pregnancy, what are the coverage options after that coverage
ends 60 days post partum? What is the range of things that
could happen there?
Ms. Ranji. Right. Well, it really depends where you live.
And this is what, when it comes to post partum coverage, there
is a lot more variation across the States for low-income women.
So, like you said, some women are able to continue on Medicaid.
Some may be able to get subsidies to purchase private
insurance. Some may be uninsured. But the phenomenon that you
refer to, churning, certainly has an impact.
We know that disruptions in conversation are relatively
frequent for low-income women around the time of delivery, and
we know that churning can negatively affect access to care. It
can really result in delays in care, having to switch
providers, identifying a new provider network. And down the
road that can lead to delays in things like preventive services
like cancer screenings, et cetera.
So churning is relatively common among this population when
you have to switch plans.
Mr. Sarbanes. I mean, in fact, that is exactly the moment
in time when someone's condition might change in a way where,
if there was a continuous perspective because the coverage was
lasting for a longer duration, that change would be captured in
terms of the care plan for that particular individual. But
because there is a transition happening to a different
coverage, potentially involving different providers, involving
a different set of benefits as to what is covered and what is
not covered, the system will miss the opportunity to identify
the kind of care that should be delivered. Then you can end up
having drastic consequences from that. Is that correct?
Ms. Ranji. Well, and being able to stay with the same
coverage plan can allow you to stay with the same provider and
provide that continuity of care from a relationship that a
woman may have formed with--during the prenatal period--with
the provider, being able to continue with that provider or with
that group of providers could streamline her access to follow
up on conditions and obtain preventive services.
Mr. Sarbanes. I would also imagine that it's going to be
easier to deploy strategies for more sensitivity to the patient
population, and we have heard testimony about the importance of
that today. If the coverage situation is not one that is in
flux, it is just better if you have got a longer period of time
in which to deploy these strategies to get out in front of some
of the biases, discriminatory practices, and other things that
we have heard testimony about today.
So, clearly, there are strong arguments in favor of
extending the Medicaid coverage period substantially. And that
is at the heart of a number of the proposals that we are
hearing about today.
Thank you all for your testimony. I appreciate it, and I
yield back.
Ms. Eshoo. The gentleman yields back.
It is a pleasure to recognize the gentleman from Montana,
Mr. Gianforte.
Mr. Gianforte. Thank you, Madam Chair.
Ms. Irving, I just want to say I am sorry for the loss of
your daughter. And I want to thank you for being here to tell
your story. Unfortunately, Montana has a higher maternal death
rate than the national average, and our State faces unique
challenges in this space.
Dr. Howell, in your testimony you state that maternal
deaths from substance use disorders and mental health are
climbing. Unfortunately, methamphetamine use is an epidemic in
Montana. How does drug addiction impact maternal deaths, and
what changes can we make to help mothers who are facing a drug
addiction?
Dr. Howell. So, just as substance-use disorders are growing
across our country and we are having an opiate crisis, that
also affects maternal deaths, as well as from other areas. And,
although this is not my area of expertise, I will just share
that I think that the risk factors and some of the issues are
lack of treatment centers for opiate abuse and also lack of
access to opiate replacement therapies.
Mr. Gianforte. So our specific problem is methamphetamine.
Dr. Howell. So that is not my area of expertise, but I
think some of the general things that we know about substance-
use disorder can be applied in the maternal healthcare setting
and that we don't recognize that there are other options, and
there are treatment alternatives and that there is not enough
being done. I would defer also to my colleague, if he has more
to add.
Mr. Gianforte. Dr. Nelson.
Dr. Nelson. So we have a robust perinatal intervention
programs that covers opioids as well as methamphetamine use.
This requires intense multidisciplinary care. It involves case
management, addiction medicine, obstetricians, and
pediatricians. And it has implications related to the care of
the mother during the pregnancy. It can also have implications
to the baby at delivery as well.
Mr. Gianforte. OK. Thank you.
Today is World Suicide Prevention Day, and unfortunately
Montana leads the Nation in suicide, number one. We understand
the impact that a lack of access to mental health services has
on our communities. To ensure that people have access to these
services they need in the face of this crisis, I recently
introduced a bipartisan bill to designate 988 as the National
Suicide Prevention Hotline. This is an essential resource for
anyone facing mental health crisis. I look forward to working
with my colleagues to get this bill through committee, and I
hope it will be available to help mothers that we are
discussing today.
Dr. Howell, again, if we could, can you describe what is
being done especially in rural areas to address the increase in
maternal deaths for mental health complications such as post
partum depression?
Dr. Howell. So I am not an expert on rural healthcare,
coming from New York City. But I can comment that I think a lot
of the things that you were hearing about--depression is a
major issue for pregnant women and post partum women. You have
heard rates of around 15 percent, and so it is a major issue,
not only for breastfeeding, maternal-infant bonding, but
everything you can think about for both the mother, the child,
and the family, and so we have to do a better job around mental
health.
Now, in rural areas, just like there are major access
issues in cities around mental health, as you have heard, but
there is also additional barriers, and so the use of
telemedicine, the use of new techniques around cognitive
behavioral therapy on, you know, internet platforms, sort of
thinking outside of the box is the way that we have to move
forward to sort of broaden our ability to reach patients from
everywhere around the country.
Mr. Gianforte. And that is really essential, particularly
in our rural communities. We are not going to have a specialist
in every discipline, in every community. Telehealth is one way
to do it. So I appreciate your comments there.
Dr. Harris, Montana has seven federally recognized American
Indian Tribal Governments. You mention in your testimony that
CDC recently released a report that American Indian women are
two to three times more likely to die from pregnancy-related
causes than White women.
Can you talk a little bit about the key drivers of this
disparity in our Native American population?
Dr. Harris. So I would imagine that it is about access, it
is about bias, all the issues that we have discussed today. We
want to make sure that we appreciate all of the issues faced by
those who are not of the same community. Again, that is why we
stress the importance of a more diverse physician workforce,
making sure that those in rural areas have access to
healthcare. You mentioned telemedicine. Making sure that
everyone, again, has affordable, meaningful coverage.
So I think all of those drivers are the same or similar.
They won't be absolutely the same for Native American women as
African-American women, and I appreciate your point on
methamphetamine being an issue in your State, and I think that
is why certainly we need to do all that we can to address
opioids, but I think there is an opportunity here to make sure
we have an infrastructure for substance abuse disorders in
general and not just regarding opioids.
Mr. Gianforte. Yes, thank you, Doctor.
And just in closing, Madam Chair, if I could, I want to
echo the comments of Ranking Member Walden in his call for
additional hearings, and I would just suggest that, if we do
that additional hearing, that we might include the Native
American voice at the table because the Tribal communities are
not represented here today and possibly IHS, Indian Health
Services, as well as we continue to look at these issues.
With that, I yield back.
Ms. Eshoo. I think that is an excellent suggestion from the
gentleman. And we have two Members of Congress, women Members
of Congress, for first time in the history of the Congress,
that are Native Americans. So, thank you.
Now I would like to recognize the gentleman from
California, Mr. Cardenas, for his 5 minutes of questioning.
Mr. Cardenas. Thank you so much, Madam Chairwoman.
And also I would like to thank Ranking Member Burgess for
having this important hearing on this very important and
heartbreaking issue.
I want to also thank all of the panelists for providing
your expertise, especially Ms. Irving. You are someone who
should have never had to learn so much about this issue and to
endure what you have had to endure. So thank you for coming in
and enlightening us.
Ms. Irving, I would like to thank you for sharing with us
today what you have been going through, and I know it is not
about you. It is about making sure that we do better for the
families and the women of today and tomorrow. So thank you for
enlightening us. As a parent and a grandparent, I can only
imagine the pain that you have gone through, and I certainly
agree with those who have been calling you very brave, but I
would also like to point out that I truly do believe that you
are an embodiment of what it is to have faith. And by being
here today, you are putting that faith into action.
And I believe that it is incumbent upon us on this side of
the room to act responsibly and to do whatever we can to make
sure that we pay heed to your advice and the wisdom of all of
you so that we can actually take action swiftly and accurately
so that less pain is endured by families going forward.
I do have a question for you. Could you please describe for
us what high-quality, fair, and respectful post partum care for
your daughter could or should have been, should she still be
with us?
Ms. Irving. I think for the first time what should have
happened is she should have been able to see her doctor within
a week after giving birth. Just like the baby went in 2 or 3
days after birth, there should be a mandatory 1 week, let's
come in, let's check you out, let's see how you are doing. She
should have been able to call up a doctor or go in and see the
doctor right there.
Instead, what she had was she saw a nurse practitioner a
couple of times, and that nurse practitioner left and said she
came back to see the doctor, but the doctor never showed up at
all. So I would think the doctors would follow their patients
and make sure that they see the patient and make sure that
their symptoms or concerns are addressed right then and there.
Mr. Cardenas. Thank you. What you just described is proper
standards of care in the moment, case-by-case, not just
theoretically. So thank you so much.
Dr. Howell, we have heard about some of the systematic
barriers to care that Black women face. And we know that
Hispanic women face many of the same obstacles, as do Native
Americans, et cetera. Yet reporting on the rates of maternal
mortality for Hispanic women has been inconsistent, and it is
difficult to find clarity on what it is telling us.
Can you speak to this issue and what the potential
consequences to this lack of data might be?
Dr. Howell. Yes. So a perfect example is the national
statistics do not suggest that Latina women have an elevated
rate. Our pregnancy mortality review done in New York City
revealed, when I said that they were 8 to 12 times higher for
Black women, for Latina women it was 3 times higher. And it
shows you that, when you get more granular data and when you
invest in maternal mortality reviews that actually collect data
from multiple sources, you can get better data on race and
ethnicity. You can get the causes. That allows to us actually
see a true story.
Without the data, you don't know. And that is what happens,
when you have a vital statistics system that doesn't collect
the stuff in a good way. That is why I think it was
underreported.
Mr. Cardenas. Thank you.
One of the things I would like to personally comment on
that I want to thank all the women who are here in this
committee room and also the men, but the women vastly outnumber
the men who are guests and experts apprising this important
committee on this very, very critical issue.
And I personally want to add to that, that I believe that
when this side of the room looks more like that side of the
room, I think that, especially when it comes to issues facing
women and families, we are going see much quicker, much more
accurate results out of what happens in the decisionmaking of
this elected body.
I am not casting aspersions on us men or what have you, but
what I am saying is, when there are women in the room, you
enlighten us in a way that I--and you think of things and
approach in a way that I just can't, and I just want to thank
you for doing that at every opportunity and certainly today.
Thank you very much. I yield back.
Ms. Eshoo. I thank the gentleman for most especially for
those comments, as well as the others.
It is a pleasure to recognize the gentleman from Georgia,
Mr. Carter, for his 5 minutes of questions.
Mr. Carter. Thank you, Madam Chair.
And I want to thank each and every one of you for being
here today. This is an extremely important subject.
And especially I want to thank you, Ms. Irving, for being
here. Yours is quite a compelling story, and we just cannot say
enough about your courage and your work, and we thank you very
much for that.
Ladies and gentlemen, I am from the State of Georgia. This
is obviously--maternal mortality is a national problem. There
is no question about that, but in the State of Georgia, it is a
serious problem. In fact, we have the unenviable, unenviable
position of being the number one State in the Nation in
maternal mortality, and for what reason we can't figure out.
But that is what really is driving us to try to do something
about this, and I have been doing it. I have been doing it in
my district. I have held many roundtable discussions with
different groups about why is this and how can we address this
situation and how can we make things better, because we all
want to make it better. Regardless of which side of the aisle
you are on, you want to make it better.
This is not a Republican, this is not a Democrat issue. It
does not discriminate against anyone, and we have to work
toward a solution, and I have to tell you that I am really
proud the last session that Representative Jamie Herrera
Beutler, her bill, Preventing Maternal Deaths Act, passed. And
that is good. It was signed into law. We need more bills like
that, and I am really proud of that.
I will have to tell you I am a little bit disappointed that
we don't have some Republican bills that we are talking about
here. In fact, we don't have even much Republican input in
these bills. And I hope that that is going to change for a
couple of reasons.
First of all, we have been out in our district for the past
5 weeks, and I have been proudly proclaiming that not only do I
serve on the oldest and the most diverse as far as subject
matter is concerned committee in Congress but also the most
bipartisan committee, and I consider it to be the most
bipartisan committee. So I am a little disappointed--I have to
express that to the chairperson--we don't have more Republican
bills.
Having said that, I do have to tell you I do have a bill I
am working on with Representative Katherine Clark of
Massachusetts that has to do with Medicaid. It is a Medicaid
demonstration project that tests how we might be able to
enhance access to care by better utilizing birth centers. All
throughout our testimony today, what we have heard about is
access to healthcare. That is extremely important in the
solution to this problem. We all understand that. And birth
centers, I think, are not being utilized to the point that they
could be, and I hope that it is something, and I thank Ms.
Clark for working with me on this, and it is something that I
want to work with her on.
Ms. Ranji, I will ask you first. Again, one of the things
that we have heard during this testimony has been access to
healthcare. And I would just ask you, is there a better place
or a place for a better use of birth centers, that we could
possibly use them in a potential solution or a partial solution
to this national health problem?
Ms. Ranji. Well, thank you for the question.
Just as Medicaid policies vary between States, it is a
similar situation with birth centers, and so while birth
centers themselves are not my area of expertise, I know the
availability and the certification and the licensing procedures
and practices vary between the States. I could certainly see
that there would be room for growth of presence in birth
centers and coverage under Medicaid, but, again, the
availability and access, those vary a lot between localities,
and the financing policies would then have to be worked out
with it on the State level.
Mr. Carter. One thing I will inform you about is that I
represent South Georgia. You know, there are two Georgias.
There is Atlanta and everywhere else, and I am in everywhere
else. So birthing centers are extremely important for us and
particularly in the rural areas. So that is why I look at that,
and I am excited this bipartisan bill that Representative Clark
and I are working on.
Dr. Nelson, I want to ask you. Currently I am the only
pharmacist serving in Congress. So I have a very--an interest
in opioid epidemic and a very strong interest in how it is
impacting maternal health.
And I just wanted to ask you, could you very quickly help
us to understand, when you have a mother who is going through
an opioid addiction, how they are handled and treated during
the pregnancy?
Dr. Nelson. So the problem of opioids is also a major
crisis for this country. In 2017 alone in Parkland, we
delivered 69 women with opioid disorder. In 2018, I personally
toured Dr. Giroir and Dr. Adams, the Assistant Secretary of
Health and the U.S. Surgeon General, through Parkland Hospital
to see our program. Our program is comprehensive, and the
challenges are both related to the maternal care, the risks to
mom, but also the neonatal opioid withdrawal syndrome risk to
the baby. And that is a chronic, life-changing opportunity for
us to have resources provided for a pregnant mother and her
unborn child.
Mr. Carter. Real quickly, just how do you get over the
stigma--or not stigma, but the obstacle of a mother who is
addicted that doesn't want that to be known, so she doesn't
reach out for care? I know that has got be a problem and
something we have got to address as well.
Dr. Nelson. I agree that stigma is important. Our service
as physicians is to be a healthcare home for those patients and
to provide them access, and that is a complex issue related to
interfacing the legality of some of those circumstances. But
our first and foremost effort should be providing access to
care to those women and getting them resources to potentially
even get better.
Mr. Carter. Great. Thank you all for being here. This is a
most important subject, especially for the State of Georgia and
for our country.
Thank you, and I yield back.
Ms. Eshoo. The gentleman yields back.
It is a pleasure to recognize Mr. Engel from New York, who
is the author of the Quality Care for Moms and Babies Act.
Thank you for your solid work, Mr. Engel. And you are
recognized for 5 minutes of questioning.
Mr. Engel. Thank you. Thank you, Madam Chair.
And thank you for holding this very, very important
hearing.
And thank you to all the panelists. Thank you so much. We
appreciate everything that you have done.
Ms. Irving, I want to single you out because what you are
doing today takes an enormous amount of courage, and so God
bless you and know that we support you, and what you are doing
today will save the lives of countless other people tomorrow.
So thank you for having the courage.
I want to thank the chairwoman and the--Chairman Pallone
for holding today's subcommittee hearing on the Nation's
maternal mortality crisis and which includes my bipartisan, as
the chairman said, bicameral legislation, the Quality Care for
Moms and Babies Act. The bill would bring together diverse
stakeholders to develop care quality benchmarks for women and
children, as well as to also find existing and new quality
collaboratives.
Quality collaboratives are on the front lines of the
efforts to end this crisis. The New York State Quality
Collaborative has developed resources to address the leading
causes of maternal deaths in New York, which include
hypertension and hemorrhaging. These resources were distributed
to over 126 birthing hospitals in New York.
So I urge Members on both sides of the aisle to support
this commonsense, bipartisan legislation. I would also like to
ask for unanimous consent to submit a letter of support from
many organizations, including March of Dimes, the American
College of Obstetricians and Gynecologists, in support of
Quality Care For Moms and Babies Act.
Dr. Howell, it is always good to see more New Yorkers in
Washington. I get lonely over here. So please come back, and
thank you for the great work that you do and that Mount Sinai
does as well. Mount Sinai, of course, is very well known in New
York and very well respected.
So I want to personally thank you, Dr. Howell, for your
service on the New York State Task Force of Maternal Mortality,
and it is my understanding that the task force issued a report
this past March in which it recommended expanding the New York
State Perinatal Quality Collaborative and as you know, as you
mentioned, which I appreciate you mentioning it, I am
sponsoring the Quality Care for Moms and Babies Act with my
friend, Congressman Steve Stivers. It is a bipartisan bill. Our
legislation authorizes funding for existing and new perinatal
quality collaboratives.
Let me ask, you Dr. Howell. Can you again share--I think it
is worth repeating--why developing and sustaining perinatal
quality collaboratives is an important tool for addressing
racial and ethnic disparities in maternal health outcomes?
Dr. Howell. It is a very important tool for us to use
across the United States, as well as in New York, because it
allows us to build--have partnerships with physicians and
nurses, with departments of health, hospitals, and health
systems to target specific processes based on the evidence that
we can target together to improve, and we have done it in a
number of different situations, not only in terms of the
bundles that you have heard about but in terms of trying to
lower our cesarean section rates, in terms of our elected
delivery rates. We have done it on the NICU side.
So it is these groups that can take the shared learning and
utilize that to help make improvements in hospitals, and your
bill supports that, and I think it is a really wonderful and
important part of this story that we need to advocate for.
Mr. Engel. Well, thank you, and I have high hopes that we
will pass the bill and pass it on the floor and hopefully get
it passed in the other body and have the President sign it into
law. So thank you for everything you are doing.
Dr. Harris, let me ask you. In your written testimony, you
note that the quality of maternal care can vary greatly by
provider and facility. Given that public health programs cover
most births in the U.S., with Medicaid alone covering 43
percent of them, I believe obviously these programs are
uniquely situated to improve maternal health.
To that end, the Quality Care for Moms and Babies Act would
direct the development of a core set of maternal and infant
health performance measures for Medicaid and CHIP that promote
best practices.
So let me ask you, Dr. Harris, how would the creation of
this measure core set affect the quality of care and reduce
maternal morbidity and mortality, especially for women of
color?
Dr. Harris. Mr. Engel, Congressman Engel, if you don't
mind, I would like to let Dr. Howell talk about the specifics
of that, of the core metrics, and how they would help. But from
sort of the 30,000-foot view, it is very important to have the
data. Data then informs. And that is, again, why the AMA is
very supportive of these review committees. You have heard a
lot today, but there is no sort of one-size-fits-all solution,
and patients are unique.
And as Dr. Howell mentioned earlier, California has done a
great job of reducing mortality but not African-American women.
So we still need to look at the data and why overall mortality
decreased but not African-American women.
So I think the opportunity there is to get that data, get
the data specifically for African-American women. And then,
once we get that data, it is important to have funding to
implement what we find in the data. So I would say that from a
100,000-foot view and let Dr. Howell talk about specific
measures that should be included to improve those disparities.
Mr. Engel. Well, thank you.
If the chairwoman will indulge, we will have Dr. Howell.
Dr. Howell. So, I think it is incredibly important that we
develop quality measures in maternal healthcare that are both
patient-centered and address disparities. We have done work
showing that hospital performance on primary, low-risk cesarean
or hospital performance on elective delivery is not correlated
with hospital performance on severe maternal morbidity.
So the current group of quality measures don't really
provide information to mothers about the different facilities
in terms of safety, and they weren't correlated either with
neonatal morbidity at term. We need better quality measures
that can serve and we can give to the public so that they can
better understand what is going on.
So your bill that advocates for quality measure development
I think is really instrumental and a very important piece. And
having quality measures also target disparities and address
disparities is another piece, because previous data shows that
the quality measures in obstetrics are not really doing that
either.
Mr. Engel. Thank you.
Thank you, Madam Chair, for your indulgence. And thank you
for all the great work you are doing.
Ms. Eshoo. Thank you for your work, Mr. Engel, and this
sounds like a resounding--we recognize endorsements, don't we,
when they occur? I think I just heard one.
I now would like to recognize the gentleman from Illinois,
Mr. Rush, who is--I am really pleased to be joining him in his
congressional district in a handful of weeks where he is
conducting a field hearing on this very issue.
And you are now recognized for 5 minutes for your
questions.
Mr. Rush. I want to thank you, Madam Chair, and I certainly
want to applaud you for holding this critically important
hearing.
Ms. Irving, I feel you. I understand some of what you are
going through. I am reminded just this very day that, some 10
years ago, this very same committee, subcommittee, had a
hearing on post partum depression. I had introduced a bill
entitled the Melanie Blocker-Stokes Postpartum Depression Act
of 2007, and her mother, Melanie Blocker-Stokes' mother, Ms.
Carol Blocker, sat at this very same table that you are sitting
at some 10 years ago.
Melanie was one of my constituents who had been seeing a
series of doctors post partum, and none of them diagnosed the
depression that she was going through. And she ultimately, on a
bright Saturday morning, spring Saturday morning, went up to a
hotel in Chicago, on near the north side of Chicago, and leaped
to her death from the 10th floor, and the cause of it was post
partum depression.
So here you are, another mother in a line of mothers who
are coming to this Congress asking and pleading and bringing
your pain to this--to our presence, to this table, asking us to
help, and I want you to know that some of us are determined to
provide the help that you are seeking and other mothers are
seeking.
My bill was--the language of my bill was included in the
ACA Act, in the Obamacare, and I was very pleased with that,
but we have such a long, long way to go in order to deal with
it. So I applaud you, and I commiserate with you, and I just--
you know, your pain is a pain that generations will remember
and will bear until we are able to solve this problem of
maternal mortality.
I want to move to questioning, if I have got a few moments
here. And I want to ask Dr. Ranji. Dr. Ranji, I am curious
about doulas and the effect on the healthcare system of doulas,
and can you explain to us why you think that doulas can improve
health outcomes, and also can you address what are some of the
cultural and economic variants to presenting a nationwide
system that would include doulas?
Ms. Ranji. Well, the research shows that women and moms
have expressed, in many surveys, have expressed interest in
having doulas care, more support during the prenatal, labor,
and delivery, and post partum periods. There is, you know, some
sense--we talked earlier, the panel was talking about the
ability to be able to, sometimes for patients being able to
challenge providers or ask for what they need, and there is
some research showing that women have said that maybe if they
had more support, for example, with assistance of a doula, that
that might be part of expanding her ability to be able to
recognize and sort of understand what her options are.
Currently, under Medicaid, only two States, as far as I
know, Oregon and Minnesota, include coverage for doulas, but
there are some other States that have certainly been
considering it, and New York is one that has a pilot program
going in certain parts of the State where they are also
considering, at least are doing for some women, expansion of
coverage for doulas.
Mr. Rush. So do you know of any--what are some of the
barriers that you see that we may face in terms of implementing
or creating a doula care system?
Ms. Ranji. Right. Well, some of the barriers include sort
of administrative and procedural barriers. Right now, you know,
Medicaid reimburses licensed medical practitioners, and the
sort of doula training standards and doula certification and
licensing is still an area that is in work. It is not an area
that I have focused on, but there is a lot of published
research out there that I certainly will also be able to share
with you, if that is of interest.
Mr. Rush. I want to thank you, Madam Chair.
I yield back.
Ms. Eshoo. I thank the gentleman for his work on this
issue, and I look forward to the hearing in your district.
Now I would like to recognize Ms. Schakowsky of Illinois,
who is a member of our full committee and is waiving onto the
Health Subcommittee today where she served for many years.
So you are recognized for your 5 minutes of questions.
Ms. Schakowsky. Thank you so much, Madam Chair, for
allowing me to waive onto today's hearing. And it is such an
important one.
I want to thank all the witnesses. And I want to give a
special thank you to my friend and colleague from Illinois,
Robin Kelly, who has been such a champion of this issue for our
State.
Illinois has been one of the most extreme pregnancy-related
death disparities in the Nation. According to data from our
Department of Public Health, Black women are six times more
likely to die of pregnancy-related conditions as White women.
It is just totally unacceptable.
And I want to say a really special thank you to Ms. Irving,
and I am so grateful that you have shared your daughter,
Shalon's, story with us today, and I just want to add when I
read the article that was given to us that this is the third
child and the last child that you have also buried. So I am so
sorry for that.
I fully believe the words of your testimony, that this
disparity, quote, ``has to do with the appallingly way Black
women are or aren't attended to or listened to,'' unquote. I am
complete--I am fully supportive of extending Medicaid coverage
for the post partum care up to--from 60 days to 1 year, as the
bill that we are considering today proposes, and though that
will make a transformative change, that is certainly not
enough.
Ms. Irving, I wanted to ask you a question. Here you have
such an educated daughter in the healthcare field. She is a
doctor herself. What did the physicians tell her as she
continued to suffer after the birth of her daughter that
somehow indicated that they must not have been hearing her?
Ms. Irving. Every time she went to the doctor's office--and
there were probably at least five times, three times I know of,
in 1 week--each time it was a dismissive ``You just had a baby,
give it time, you will feel better.''
Ms. Schakowsky. Did they do any of the tests that would
have indicated what the problems were?
Ms. Irving. On the last day that she went, which was the
24th, 5 hours before she collapsed, she went in, and they gave
her a test for preeclampsia, but since she didn't have any
blurriness of vision, they said, ``Well, we can rule that
out.''
And they gave her a test for blood clotting. She said, ``I
have had blood clots. I know what they feel like. This is not a
blood clot.''
And, of course, it wasn't a blood clot. But her blood
pressure was still off the roof. I think if I am correct it was
174 over 119, and she was sent home, and 5 hours later she
collapsed.
Ms. Schakowsky. You also said in your testimony that
essentially that no one is really immune, regardless of
education, et cetera.
Ms. Irving. No.
Ms. Schakowsky. And that the issue of racial disparities is
certainly a huge problem.
I wanted to ask Dr. Howell a question. I am interested in
the idea of holding hospitals accountable for maternal care,
maternity care through a value-based care model. Do you believe
that bundled payments for an entire episode of maternal care
could give health systems more incentives and greater control
to improve the pregnancy-related outcomes from beginning to
end, with regard to racial disparities in particular?
Dr. Howell. I think we need more work on alternative
payment models to think about maternity care and incentivize
clinicians and hospitals correctly. I do worry about unintended
consequences, specifically that certain hospitals will be
penalized if we don't do this right in terms of the fact that
they have the highest-risk patients and we are not recognizing
that. So I think there is a lot of work to be done in this
space. I don't have the perfect solution yet because I want to
make sure that we think about those unintended consequences as
we move forward.
Ms. Schakowsky. So do you think bundled payments may be one
thing that at least should be explored so that, from prenatal
care through the full year, maybe issues like post partum
depression be considered in a bundle of payments?
Dr. Howell. I think they should be explored. I think that
the measures that they would be accountable for would need to
be partnered with new quality measures that are really well
developed and so that we have the right things. Some of those
measures would also be targeting disparities. So, if you
measure the success based on those quality metrics that look at
patient-centeredness and disparities, it might be a promising
avenue, but, again, always remembering that we can't penalize
those hospitals that take care of the sickest patients. So we
have to make sure that we are accounting for that in our
models.
Ms. Schakowsky. We also want to make sure that diversity in
the workforce is there so that everyone is represented at every
level of care. Thank you so much.
And, again, Ms. Irving, thank you so much very much.
I yield back.
Ms. Eshoo. The gentlewoman yields back.
I want to, on behalf every member of the subcommittee, I
want to thank each witness.
Ms. Irving, there really aren't words. You are a source of
inspiration to us to move ahead in your daughter's name, in
your name, in your granddaughter's name, and I think that if--I
think as she is watching and listening from heaven, she is--you
can hear the ``Bravos'' from there. Thank you. Thank you.
You really have, you have touched all of us, and we are not
going to rest until we have solid legislation that addresses
this and that this statistic in the United States of America
piercing the conscience of our country, and I think it is a
combination of things, women being undervalued, women not being
listened to. In the history of humankind, no man has given
birth to a child, and so I remember the doctor saying to me,
``Well, they are the blues, but they will go away.'' So we have
a lot of work to do. Thank you.
Thank you to you, Dr. Harris, Dr. Howell, Dr. Nelson, Ms.
Ranji. This has been an outstanding hearing.
Mr. Rush. Madam Chair, if I just could for 10 seconds.
Ms. Eshoo. Sure.
Mr. Rush. Ms. Irving, I was just looking at some notes.
Melanie was also in the healthcare area. She was a
pharmaceutical sales manager. So she was very aware of health
issues with doctors. Her husband was a physician, and she had a
daughter, only child, and her name was Summer. So your
granddaughter's name is Soleil. So there are so many
similarities here.
I wanted to note that for the record.
Thank you, Madam Chair.
Ms. Eshoo. OK. I would like to remind Members that,
pursuant to committee rules, they have 10 business days to
submit additional questions for the record to be answered by
the witnesses.
And I know that you will all cooperate, give
straightforward, succinct answers. OK?
And I ask each witness to do so promptly to any questions
that you may receive.
I now want to ask unanimous consent to enter into the
record the following: a statement from the March of Dimes; a
statement from the American College of Obstetricians and
Gynecologists; a statement from the American Hospital
Association; a statement from America's Health Insurance Plans;
a report from the Center for American Progress on racial
disparities and maternal mortality; a coalition letter from the
American College of Nurse-Midwives, et al.; a statement from
the Premier Healthcare Alliance; a statement from Gauss
Surgical; a report from Premier Incorporated on maternal health
trends; a report from ProPublica and NPR on maternal mortality.
So I ask for unanimous consent.
Mr. Guthrie. No objection.
Ms. Eshoo. So ordered.
[The information is available at the conclusion of the
hearing.\1\]
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\1\ The Center for American Progress report has been retained in
committee files and also is available at https://docs.house.gov/
meetings/IF/IF14/20190910/109919/HHRG-116-IF14-20190910-SD006.pdf.
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Ms. Eshoo. And this will conclude our hearing today. The
subcommittee is adjourned.
[Whereupon, at 1:25 p.m., the subcommittee was adjourned.]
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