,,ii #aaeth ,,congress #ast ,session ,s4 #aaab ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,may #aa1 #bjag,ms4 ,heitkamp 7for herself and ,mrs4 ,capito7 introduced the following bill2 which was read twice and referred to the ,committee on ,health1 ,education1 ,labor1 and ,pensions ,a ,,bill ,to support ,states in their work to save and sustain the health of mothers during pregnancy1 childbirth1 and in the postpartum period1 to eliminate disparities in maternal health outcomes for pregnancy-related and pregnancy-associated deaths1 to identify solutions to improve health care quality and health outcomes for mothers1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,maternal ,health ,accountability ,act of #bjag4 #b4 ,findings2 purposes 7a7 ,findings ,congress finds the following3 7#a7 ,the ,united ,states is ranked #ejth globally for its maternal mortality rate1 and it is one of eight countries in which the maternal mortality rate has been on the rise4 7#b7 ,in recent studies1 the estimated maternal mortality rate in the ,united ,states increased by approximately #bf4f percent from #bjjj to #bjad1 with the rate increasing in nearly all ,states4 ,this reported increase1 along with no improvement in previous years1 remains a source of great concern for the ,centers for ,disease ,control and ,prevention 7,,cdc71 health care providers1 and patient advocates such as the ,american ,congress of ,obstetricians and ,gynecologists1 the ,association of ,women's ,health1 ,obstetric1 and ,neonatal ,nurses1 and the ,preeclampsia ,foundation4 7#c7 ,maternal deaths in the ,united ,states result from pregnancy-related causes such as hemorrhage1 hypertensive disease and preeclampsia1 embolic disease1 sepsis1 and substance use disorder and overdose1 and violent causes such as motor vehicle accidents1 homicide1 and suicide4 7#d7 ,as of #bjag1 less than #be ,states conduct systematic reviews of maternal deaths and_/or have standing maternal mortality review committees in order to develop the data needed to work toward management and solutions4 7#e7 ,review of pregnancy-related and pregnancy-associated deaths is essential to determining strategies for developing prevention efforts and quality improvement and quality control programs4 ,the ,united ,states must identify at-risk populations and understand how to support them to make pregnancy and the postpartum period safer4 7#f7 ,the most severe complications of pregnancy1 generally referred to as severe maternal morbidity 7,,smm71 affect more than #fe1jjj women in the ,united ,states every year4 ,the ,,cdc uses ,,icd-#i-;,,cm codes1 which indicate a potentially life-threatening maternal condition or complication1 to define ,,smm4 7#g7 ,data from the ,,cdc shows ,black women are three times more likely to die from complications of pregnancy or childbirth than ,white women3 #db4h ,black women per #ajj1jjj live births1 as opposed to #ab4e ,white women and #ag4c women of other races4 7#h7 ,the ,,cdc recommends that maternal deaths be investigated through ,state collaboratives4 ,these ,state collaboratives would bring together leaders in obstetric and neonatal health care from private1 academic1 and public health care settings to make recommendations for preventing pregnancy-related and pregnancy-associated deaths and health complications and identify ways to improve quality of care for women and infants4 7#i7 ,a few ,states1 including ,california1 have worked to develop and strengthen maternal morbidity and mortality review systems and utilize data to reduce maternal deaths and injuries to address leading issues such as maternal hemorrhage1 hypertension and preeclampsia1 and health and racial disparities4 7b7 ,purposes ,the purposes of this ,act are the following3 7#a7 ,to establish a shared responsibility between ,states and the ,federal ,government to identify opportunities for improvement in quality of care and system changes1 and to educate and inform health institutions and professionals1 women1 and families about preventing pregnancy-related and pregnancy-associated deaths and complications and reducing disparities4 7#b7 ,to develop a model for ,states and ,federally recognized ,indian tribes and tribal organizations to operate maternal mortality reviews and assess the various factors that may have contributed to maternal mortality1 including quality of care1 racial disparities1 and systemic problems in the delivery of health care1 and to develop appropriate interventions to reduce and prevent such deaths4 #c4 ,state maternal mortality review committees on pregnancy-related and pregnancy-associated deaths 7a7 ,program authorized 7#a7 ,in general ,the ,secretary of ,health and ,human ,services1 through the ,director of the ,centers for ,disease ,control and ,prevention1 shall establish a grant program under which the ,secretary may make grants to ,states1 and ,federally recognized ,indian tribes and tribal organizations1 for the purpose of-- 7,a7 carrying out the activities described in subsection 7b77#a72 7,b7 establishing and sustaining a ,state maternal mortality review committee1 in accordance with subsection 7b77#b72 7,c7 ensuring that the ,state department of health carries out the activities described in subsection 7b77#c72 7,d7 disseminating the case abstraction form developed under subsection 7c72 and 7,e7 providing for the public disclosure of information1 in accordance with subsection 7d74 7#b7 ,criteria ,the ,secretary shall establish criteria for determining eligibility for1 and the amount of a grant awarded to1 a ,state under paragraph 7#a74 ,such criteria shall provide that in the case of a ,state that receives a grant under paragraph 7#a7 for a fiscal year and is determined by the ,secretary to have not used such grant in accordance with this section1 such ,state may not be eligible for such a grant for any subsequent fiscal year4 7b7 ,use of funds 7#a7 ,review of pregnancy-related and pregnancy-associated deaths ,with respect to a ,state that receives a grant under subsection 7a77#a71 the following shall apply3 7,a7 ,process for mandatory reporting of pregnancy-related and pregnancy-associated deaths 7i7 ,in general ,the ,state1 through the ,state maternal mortality review committee established under subsection 7a77#a71 shall develop a process that provides for mandatory and confidential case reporting to the ,state department of health by individuals and entities described in clause 7ii7 with respect to pregnancy-related and pregnancy-associated deaths4 7ii7 ,individuals and entities described ,individuals and entities described in this clause include each of the following3 7,i7 ,health care professionals4 7,,ii7 ,medical examiners4 7,,iii7 ,medical coroners4 7,,iv7 ,hospitals4 7,v7 ,birth centers4 7,,vi7 ,other health care facilities4 7,,vii7 ,other individuals responsible for completing death records4 7,,viii7 ,other appropriate individuals or entities specified by the ,secretary4 7,b7 ,process for voluntary reporting of pregnancy-related and pregnancy-associated deaths ,the ,state1 through the ,state maternal mortality review committee established under subsection 7a77#a71 shall develop a process that provides for voluntary and confidential case reporting to the ,state department of health by family members of the deceased and other individuals on possible pregnancy-related and pregnancy-associated deaths4 ,such process shall include-- 7i7 making publicly available on the website of the ,state department of health a telephone number1 ,internet web link1 and email address for such reporting2 and 7ii7 publicizing to local professional organizations1 community organizations1 and social services agencies the availability of the telephone number1 ,internet web link1 and email address made available under clause 7i74 7,c7 ,identification of pregnancy-related and pregnancy-associated deaths by ,state vital statistics unit ,the ,state1 through the vital statistics unit of the ,state1 shall annually identify pregnancy-related and pregnancy-associated deaths occurring in such ,state in the year involved by-- 7i7 matching each death record of a woman in such year to a live birth certificate or an infant death record for the purpose of identifying deaths of women that occurred during pregnancy and within one year after the end of a pregnancy2 7ii7 identifying each death of a woman reported during such year as having an underlying or contributing cause of death related to pregnancy1 regardless of the time that has passed between the end of the pregnancy and the death2 7iii7 collecting data from medical examiner and coroner reports2 and 7iv7 using any other method the ,state may devise to identify maternal deaths such as reviewing a random sample of reported deaths of women to ascertain cases of pregnancy-related and pregnancy-associated deaths that are not discernable from a review of death records alone4 ,for purposes of effectively collecting and obtaining data on pregnancy-related and pregnancy-associated deaths1 the ,state shall adopt the most recent standardized birth and death records1 as issued by the ,national ,center for ,vital ,health ,statistics1 including the recommended checkbox section for pregnancy on each death record4 7,d7 ,case investigation and development of case summaries 7i7 ,in general ,following the receipt of reports by the ,state department of health pursuant to subparagraph 7,a7 or 7,b7 and the collection of cases of pregnancy-related and pregnancy-associated deaths by the vital statistics unit of the ,state under subparagraph 7,c71 the ,state1 through the ,state maternal mortality review committee established under subsection 7a77#a71 shall investigate each case1 using the case abstraction form described in subsection 7c71 and prepare a de-identified case summary for each case1 which shall be reviewed by the committee and included in applicable reports4 ,the ,state department of health or vital statistics unit of the ,state1 as the case may be1 shall provide the ,state maternal mortality review committee with access to the information collected pursuant to subparagraphs 7,a7 or 7,b71 or under subparagraph 7,c71 as necessary to carry out this subparagraph4 7ii7 ,mandatory data and information ,each case investigation under this subparagraph shall1 subject to availability1 include data and information obtained through-- 7,i7 medical examiner and autopsy reports of the woman involved2 7,,ii7 medical records of the woman1 including such records related to health care prior to pregnancy1 prenatal and postnatal care1 labor and delivery care1 emergency room care1 hospital discharge records1 and any care delivered up until the time of death of the woman2 7,,iii7 oral and written interviews of individuals directly involved in the maternal care of the woman during and immediately following the pregnancy of the woman1 including health care1 mental health1 and social service providers1 as applicable2 7,,iv7 socioeconomic and other relevant background information about the woman2 7,v7 any information collected under subparagraph 7,c77i72 and 7,,vi7 any other information on the cause of death of the woman1 such as social services and child welfare reports4 7iii7 ,discretionary data and information ,each case investigation under this subparagraph may include data and information obtained through oral or written interviews of the family of the woman4 7#b7 ,state maternal mortality review committees 7,a7 ,mandatory activities ,a ,state maternal mortality review committee established under subsection 7a77#a7 shall carry out the following activities3 7i7 ,develop the processes described in subparagraphs 7,a7 and 7,b7 of paragraph 7#a74 7ii7 ,review the data and information collected by the vital statistics unit of the ,state under paragraph 7#a77;,c7 regarding pregnancy-related and pregnancy-associated deaths to identify trends1 patterns1 and disparities in adverse outcomes and address medical1 non-medical1 and system-related factors that may have contributed to such pregnancy-related and pregnancy-associated deaths and disparities4 7iii7 ,carry out the activities described in paragraph 7#a77;,d74 7iv7 ,develop recommendations1 based on the case summaries prepared under paragraph 7#a77;,d7 and the data and information collected under paragraph 7#a77;,c71 to improve maternal care1 social and health services1 and public health policy and institutions1 including improving access to maternal care and social and health services and identifying disparities in maternal care and outcomes4 7,b7 ,discretionary activities 7i7 ,in general ,a ,state maternal mortality review committee established under subsection 7a77#a7 may1 while subject to confidentiality requirements1 present findings and recommendations based on the case summaries prepared under paragraph 7#a77;,d7 directly to a health care facility or its local or ,state professional organization for the purpose of-- 7,i7 instituting policy changes1 educational activities1 and improvements in the quality of care provided by the facility2 and 7,,ii7 exploring and forming regional collaborations4 7ii7 ,investigation of cases of ,severe ,maternal ,morbidity ,a ,state maternal mortality review committee may investigate cases of severe maternal morbidity and any such investigation may include data and information obtained through-- 7,i7 identified patient registries2 or 7,,ii7 oral or written interviews of the woman concerned and the family of such woman4 7,c7 ,composition of ,state maternal mortality review committees 7i7 ,in general ,a ,state maternal mortality review committee established under subsection 7a77#a7 shall be multidisciplinary and diverse4 ,membership on the ,state maternal mortality review committee shall be reviewed annually by the ,state department of health to ensure that membership representation requirements are being fulfilled in accordance with this subparagraph4 7ii7 ,required membership ,each ,state maternal mortality review committee shall include-- 7,i7 representatives from medical specialties providing care to pregnant and postpartum patients1 including obstetricians 7including generalists and maternal fetal medicine specialists7 and family practice physicians2 7,,ii7 certified nurse midwives1 certified midwives1 and advanced practice nurses2 7,,iii7 hospital-based registered nurses2 7,,iv7 representatives of the maternal and child health department of the ,state department of health2 7,v7 social service providers or social workers1 including those with experience working with communities diverse with respect to race1 ethnicity1 and limited ,english proficiency2 7,,vi7 chief medical examiners or designees2 7,,vii7 facility representatives1 such as from hospitals or birth centers2 7,,viii7 patient advocates1 community maternal health organizations1 and minority advocacy groups that represent those diverse racial and ethnic communities within the ,state that are the most affected by pregnancy-related or pregnancy-associated deaths and by a lack of access to maternal health care services2 and 7,,ix7 representatives of the departments of health or public health of major cities in the ,state4 7iii7 ,discretionary membership ,each ,state maternal mortality review committee may also include representatives from other relevant academic1 health1 social service1 or policy professions or community organizations on an ongoing basis1 or as needed1 as determined beneficial by the committee1 including-- 7,i7 anesthesiologists2 7,,ii7 emergency physicians2 7,,iii7 pathologists2 7,,iv7 epidemiologists2 7,v7 intensivists2 7,,vi7 nutritionists2 7,,vii7 mental health professionals2 7,,viii7 substance use disorder treatment specialists2 7,,ix7 representatives of relevant patient and provider advocacy groups2 7,x7 academics2 7,,xi7 paramedics2 7,,xii7 risk management specialists2 and 7,,xiii7 representatives of ,federally recognized ,indian tribes and tribal organizations4 7iv7 ,staff ,staff of each ,state maternal mortality review committee shall include-- 7,i7 vital health statisticians1 maternal child health statisticians1 or epidemiologists2 7,,ii7 a coordinator of the ,state maternal mortality review committee1 to be designated by the ,state2 and 7,,iii7 administrative staff4 7,d7 ,option for ,states to establish regional maternal mortality review committees ,states may choose to partner with one or more neighboring ,states to carry out the activities required of a ,state maternal mortality review committee under this section4 ,in such a case1 with respect to the ,states in such a partnership1 any requirement under this section relating to the reporting of information related to such activities shall be deemed to be fulfilled by each such ,state if a single such report is submitted for the partnership4 7,e7 ,treatment as public health authority for purposes of ,,hipaa ,for purposes of applying ,,hipaa privacy and security law 7as defined in section #cjji7;a77#b7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;jj-#ai771 each ,state maternal mortality review committee and regional maternal mortality review committee established under subsection 7a77#a7 or subsection 7b77#b77;,d71 as the case may be1 shall be deemed to be a public health authority described in section #afd4eja 7and referenced in section #afd4eab7;b77#a77;i77 of title #de1 ,code of ,federal ,regulations 7or any successor regulation71 carrying out public health activities and purposes described in such section #afd4eab7;b77#a77;i7 7or any such successor regulation74 7#c7 ,state department of health activities ,with respect to a ,state that receives a grant under subsection 7a77#a71 the ,state department of health shall-- 7,a7 in consultation with the ,state maternal mortality review committee and in conjunction with relevant professional organizations and patient advocacy organizations1 develop a plan for ongoing health care provider education1 based on the findings and recommendations of the committee1 in order to improve the quality of maternal care2 and 7,b7 take steps to widely disseminate the findings and recommendations of the ,state maternal mortality review committee and implement the recommendations of the committee4 7c7 ,case abstraction form 7#a7 ,dissemination ,the ,director of the ,centers for ,disease ,control and ,prevention shall disseminate a uniform case abstraction form to ,states and ,state maternal mortality review committees for the purpose of-- 7,a7 ensuring that the data and information collected and reviewed by such committees can be pooled for review by the ,department of ,health and ,human ,services and its agencies2 and 7,b7 preserving the uniformity of the information collected for ,federal public health purposes4 7#b7 ,permissible ,state modification ,each ,state may modify the form developed under paragraph 7#a7 for implementation and use by such ,state or by the ,state maternal mortality review committee of such ,state by including on such form additional information to be collected1 but may not alter the standard questions on such form1 in order to ensure that the information can be collected and reviewed centrally at the ,federal level4 7d7 ,public disclosure of information 7#a7 ,in general ,for fiscal year #bjah1 or a subsequent fiscal year1 each ,state receiving a grant under this section for such year shall1 subject to paragraph 7#c71 provide for the public disclosure1 and submission to the information clearinghouse established under paragraph 7#b71 of the information included in the report of the ,state under subsection 7f77#a7 for such year4 7#b7 ,information clearinghouse ,the ,secretary shall establish an information clearinghouse1 to be administered by the ,director of the ,centers for ,disease ,control and ,prevention1 that will maintain findings and recommendations submitted pursuant to paragraph 7#a7 and provide such findings and recommendations for public review and research purposes by ,state departments of health1 ,state maternal mortality review committees1 and health providers and institutions4 7#c7 ,confidentiality of information ,in no case may any individually identifiable health information be provided to the public1 or submitted to the information clearinghouse1 under this subsection4 7e7 ,confidentiality of proceedings of ,state maternal mortality review committees 7#a7 ,in general ,all proceedings and activities of a ,state maternal mortality review committee established under subsection 7a77#a71 opinions of members of such a committee formed as a result of such proceedings and activities1 and records obtained1 created1 or maintained pursuant to this section1 including records of interviews1 written reports1 and statements procured by the ,department of ,health and ,human ,services or by any other person1 agency1 or organization acting jointly with the ,department1 in connection with morbidity and mortality reviews under this section1 shall be confidential and may not be subject to discovery1 subpoena1 or introduction into evidence in any civil1 criminal1 legislative1 or other proceeding4 ,such records shall not be open to public inspection4 7#b7 ,testimony of members of committee 7,a7 ,in general ,members of a ,state maternal mortality review committee established under subsection 7a77#a7 may not be questioned in any civil1 criminal1 legislative1 or other proceeding regarding information presented in1 or opinions formed as a result of1 a meeting or communication of the committee4 7,b7 ,clarification ,nothing in this subsection may be construed to prevent a member of a ,state maternal mortality review committee established under subsection 7a77#a7 from testifying regarding information that was obtained independent of such member's participation on the committee1 or public information4 7#c7 ,availability of information for research purposes ,nothing in this subsection may prohibit a ,state maternal mortality review committee established under subsection 7a77#a7 or the ,department of ,health and ,human ,services from publishing statistical compilations and research reports that-- 7,a7 are based on confidential information1 relating to morbidity and mortality reviews under this section2 and 7,b7 do not contain identifying information or any other information that could be used to ultimately identify the individuals concerned4 7f7 ,reports 7#a7 ,state reports ,for fiscal year #bjah1 and each subsequent fiscal year1 each ,state maternal mortality review committee established under subsection 7a77#a7 and receiving a grant under this section for such year1 shall submit to the ,director of the ,centers for ,disease ,control and ,prevention a report on the findings and recommendations of such committee and information on the implementation of such recommendations during such year4 7#b7 ,annual reports to ,congress ,for fiscal year #bjah1 and each subsequent fiscal year1 the ,secretary of ,health and ,human ,services shall submit to ,congress a report on-- 7,a7 the findings1 recommendations1 and implementation information submitted by any ,state pursuant to paragraph 7#a72 and 7,b7 the status of pregnancy-related and pregnancy-associated deaths in the ,united ,states1 including recommendations on methods to prevent such deaths in the ,united ,states4 7g7 ,definitions ,in this section3 7#a7 ,the term pregnancy-associated death means the death of a woman while pregnant or during the one-year period following the date of the end of pregnancy1 irrespective of the cause of such death4 7#b7 ,the term pregnancy-related death means the death of a woman while pregnant or during the one-year period following the date of the end of pregnancy1 irrespective of the duration of the pregnancy1 from any cause related to1 or aggravated by1 the pregnancy or its management1 excluding any accidental or incidental cause4 7#c7 ,the term ,secretary means the ,secretary of ,health and ,human ,services4 7#d7 ,the term severe maternal morbidity means the physical and psychological conditions that result from1 or are aggravated by1 pregnancy and have an adverse effect on the health of a woman4 7#e7 ,the term ,state means each of the #ej ,states1 the ,district of ,columbia1 and each of the territories1 and shall include ,federally recognized ,indian tribes and tribal organizations that receive a grant under subsection 7a77#a74 ,such tribes and organizations shall meet the requirements applicable to ,states under this section as determined appropriate by the ,secretary4 7#f7 ,the term vital statistics unit means the entity that is responsible for maintaining vital records for a ,state1 including official records of live births1 deaths1 fetal deaths1 marriages1 divorces1 and annulments4 7h7 ,authorization of appropriations ,there is authorized to be appropriated to carry out this section #g1jjj1jjj for each of fiscal years #bjah through #bjbb4 #d4 ,eliminating disparities in maternity health outcomes ,part ,b of title ,,iii of the ,public ,health ,service ,act is amended by inserting after section #cag,t of such ,act 7#db ,u4,s4,c4 #bdg;b-#bb7 the following new section3 #cag,u4 ,eliminating disparities in maternal health outcomes 7a7 ,in general ,the ,secretary shall1 in consultation with relevant national stakeholder organizations1 such as national medical specialty organizations1 national maternal child health organizations1 national patient advocacy organizations1 and national health disparity organizations1 carry out the following activities to eliminate disparities in maternal health outcomes3 7#a7 ,conduct research into the determinants and the distribution of disparities in maternal care1 health risks1 and health outcomes1 and improve the capacity of the performance measurement infrastructure to measure such disparities4 7#b7 ,expand access to health care services1 resources1 and information that have been demonstrated to improve the quality and outcomes of maternity care for vulnerable populations4 7#c7 ,establish a demonstration project to compare the effectiveness of interventions to reduce disparities in maternity services and outcomes and to implement and assess effective interventions4 7b7 ,scope and selection of ,states for demonstration project ,the demonstration project under subsection 7a77#c7 shall be conducted in no more than #h ,states1 which shall be selected by the ,secretary based on-- 7#a7 applications submitted by ,states1 which specify which regions and populations the ,state involved will serve under the demonstration project2 7#b7 criteria designed by the ,secretary to ensure that1 as a whole1 the demonstration project is1 to the greatest extent possible1 representative of the demographic and geographic composition of communities most affected by disparities2 7#c7 criteria designed by the ,secretary to ensure that a variety of models are tested through the demonstration project and that such models include interventions that have an existing evidence base for effectiveness2 and 7#d7 criteria designed by the ,secretary to ensure that the demonstration projects and models will be carried out in consultation with local and regional provider organizations1 such as community health centers1 hospital systems1 and medical societies representing providers of maternity services4 7c7 ,duration of demonstration project ,the demonstration project under subsection 7a77#c7 shall begin on ,january #a1 #bjah1 and end on ,december #ca1 #bjba4 7d7 ,grants for evaluation and monitoring ,the ,secretary may make grants to ,states and health care providers participating in the demonstration project under subsection 7a77#c7 for the purpose of collecting data necessary for the evaluation and monitoring of such project4 7e7 ,reports 7#a7 ,state reports ,each ,state that participates in the demonstration project under subsection 7a77#c7 shall report to the ,secretary1 in a time1 form1 and manner specified by the ,secretary1 the data necessary to-- 7,a7 monitor the-- 7i7 outcomes of the project2 7ii7 costs of the project2 and 7iii7 quality of maternity care provided under the project2 and 7,b7 evaluate the rationale for the selection of the items and services included in any bundled payment made by the ,state under the project4 7#b7 ,final report ,not later than ,december #ca1 #bjbb1 the ,secretary shall submit to ,congress a report on the results of the demonstration project under subsection 7a77#c74 4