Sec. 2. Findings
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/bill/115/hr/5977/ih/section-2·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
Congress finds the following: Every year, across the United States, four million women give birth, about 700 women suffer fatal complications during pregnancy, while giving birth, or during the postpartum period, and 65,000 women suffer near-fatal, partum-related complications. The maternal mortality rate is often used as a proxy to measure the overall health of a population. While the infant mortality rate in the United States has reached its lowest point, the risk of death for women in the United States during pregnancy, childbirth, or the postpartum period is higher than such risk in any all other developed nations.
The estimated maternal mortality rate (per 100,000 live births) for the 48 contiguous States and Washington DC increased from 18.8 percent in 2000 to 23.8 percent in 2014 to 26.6 percent in 2018. This estimated rate is on par with such rate for underdeveloped nations such as Iraq and Afghanistan. International studies estimate the 2015 U.S. maternal mortality rate as 26.4 per 100,000 live births, which is almost twice the 2015 World Health Organization
(WHO)estimation of 14 per 100,000 live births. It is estimated that almost half of all maternal mortalities in the United States are preventable. African-American women experience maternal-related deaths at three to four times the rate of non-Hispanic White women. The findings described in paragraphs
(1)through
(5)are of major concern to researchers, academicians, and epidemiologists at the Centers for Disease Control and Prevention (CDC); providers across the obstetrical continuum represented by organizations such as the Preeclampsia Foundation; the American College of Obstetricians and Gynecologists; the Association of Women’s Health, Obstetric, and Neonatal Nurses; the California Maternal Quality Care Collaborative; Black Women’s Health Imperative; the National Birth Equity Collaborative; Black Mamas Matter Alliance; the National Association of Certified Professional Midwives; and the American College of Nurse Midwives. According to the CDC, the maternal mortality rate varies drastically for women by race and ethnicity. There are 12.7 deaths per 100,000 live births for White women, 43.5 deaths per 100,000 live births for African-American women, and 14.4 deaths per 100,000 live births for women of other ethnicities. While maternal mortality disparately impacts African-American women, the phenomenon traverses race, ethnicity, socioeconomic status, educational background, and geography. Hemorrhage, cardiovascular and coronary conditions, cardiomyopathy, infection, embolism, mental health conditions, preeclampsia and eclampsia, infection or sepsis, and anesthesia complications are the predominant causes of maternal-related deaths and complications. Such conditions are largely preventable or manageable. The United States has not been able to submit a formal maternal mortality rate to international data repositories since 2007. Thus, no official maternal mortality rate exists for the Nation. There can be no maternal mortality rate without streamlining maternal mortality-related data from the State level and extrapolating such data to the Federal level. In the United States, death reporting and analysis is a State function rather than a Federal process. States report all deaths—including maternal deaths—on a semi-voluntary basis, without standardization across States. While the CDC has the capacity and system for collecting death-related data based on death certificates, these data are not sufficiently reported by States in an organized and standard format across States such that the CDC is able to identify causes of maternal death and best practices for the prevention of such death. Vital registration systems often underestimate maternal mortality and are insufficient data sources from which to derive a full scope of medical and social determinant factors contributing to maternal deaths. While the addition of pregnancy checkboxes on death certificates since 2003 have likely improved States’ abilities to identify pregnancy-related deaths, they are not generally completed by obstetrical providers or persons trained to recognize pregnancy-related mortality. Thus, these vital forms may be missing information or may capture inconsistent data. Due to varying maternal mortality-related analyses, lack of reliability, and granularity in data, current maternal mortality informatics do not fully encapsulate the myriad medical and socially determinant factors that contribute to such high maternal mortality rates within the United States compared to other developed nations. Non-standardization of data and lack of data sharing across States and between Federal entities, health networks, and research institutions keep the Nation in the dark about ways to prevent maternal deaths. Having reliable and valid State data aggregated at the Federal level are critical to the Nation’s ability to quell surges in maternal death and imperative for researchers to identify long-lasting interventions. Leaders in maternal wellness highly recommend that maternal deaths be investigated at the State level first. Then, have data regarding maternal deaths be standardized across States, streamlined, de-identified, and sent once a year to a federally supervised database, managed by a Federal agency at the discretion of the Secretary of Health and Human Services. Such data standardization and collection would be similar in operation and effect to the National Program of Cancer Registries housed at the CDC and akin to the Confidential Enquiry in Maternal Deaths Programme in the United Kingdom. Such a maternal mortality and morbidities registry and surveillance would help providers, academicians, lawmakers, and the public to address questions concerning the types of, causes of, and best practices to thwart, pregnancy-related or pregnancy-associated mortalities and morbidities. The United Nations’ Millennium Development Goal 5a aimed to reduce by three quarters, between 1990 and 2015, the maternal mortality rate, yet this metric has not been achieved. In fact, the maternal mortality rate in the United States has been estimated to have more than doubled between 2000 and 2014. Yet, because national data are not fully available, the United States does not have an official maternal mortality rate. Many States have struggled to establish or maintain Maternal Mortality Review Committees (MMRC). On the State level, MMRCs have lagged because States have not had the resources to mount local reviews. State-level reviews are necessary as only the State departments of health have the authority to request medical records, autopsy reports, and police reports critical to the function of the MMRC. The United Kingdom regards maternal deaths as a health systems failure and a national committee of obstetrics experts review each maternal death or near-fatal childbirth complication. Such committee also establishes the predominant course of maternal-related deaths from conditions such as preeclampsia. Consequently, the United Kingdom has been able to reduce their incidences of preeclampsia to less than one in 10,000 women—its lowest rate since 1952. The United States has no comparable, coordinated Federal process by which to review cases of maternal mortality, systems failures, or best practices. Many States have active MMRCs and leverage their work to impact maternal wellness. For example, the State of California has worked extensively with their State health departments, health and hospital systems, and research collaborative organizations, including the California Maternal Quality Care Collaborative and the Alliance for Innovation on Maternal Health, to establish MMRCs, wherein they have determined the most prevalent causes of maternal mortality and recorded and shared data with providers and researchers, who have developed and implemented safety bundles and care protocols related to preeclampsia, maternal hemorrhage, and the like. In this way, the State of California has been able to leverage its maternal mortality review board system, generate data, and apply those data to effect changes in maternal care-related protocol. To date, the State of California has stymied its maternal mortality rate, which is now comparable to the low rates of the United Kingdom. Hospitals and health systems across the United States lack standardization of emergency obstetrical protocols before, during, and after delivery. Consequently, many providers are delayed in recognizing critical signs indicating maternal distress that quickly escalate into fatal or near-fatal incidences. Moreover, any attempt to address an obstetrical emergency that does not take into account both clinical and public health approaches falls woefully under the mark of excellent care delivery. State-based maternal quality collaborative organizations, including the Alliance for Innovation on Maternal Health
(AIMs)and California Maternal Quality Care Collaborative, have formed obstetrical protocols, tool kits, and other resources to improve system care and response as they relate to maternal complications and warning signs for such conditions as maternal hemorrhage, hypertension, and preeclampsia. State perinatal quality collaboratives are working to identify health care processes that need to be improved and use the best available methods to make those changes as quickly as possible, while the Alliance for Innovation on Maternal Health is working with States and health systems to align national, State, and hospital level quality improvement efforts through the creation and dissemination of maternal safety bundles to improve overall maternal health outcomes. The CDC reports that more than half of all maternal deaths occur in the immediate postpartum period—between 42 days up to a full year—whereas more than one-third of pregnancy-related or pregnancy-associated deaths occur while a person is still pregnant. Yet, for pregnant women, Medicaid coverage lapses at the end of the month on which the 60th postpartum day lands. A growing body of evidence-based research has shown the correlation between the stress associated with one’s race—the stress of racism—and one’s birthing outcomes. The stress of sex and race discrimination and institutional racism has been demonstrated to contribute to a higher risk of maternal mortality, irrespective of one’s gestational age, maternal age, socioeconomic status, or individual-level health risk factors, including poverty, limited access to prenatal care, and poor physical and mental health (although these are not nominal factors). African-American women remain the most at risk for pregnancy-associated or pregnancy-related causes of death. When it comes to preeclampsia, for example—which is related to obesity—African-American women of normal weight remain the most at risk of dying during the perinatal period compared to non-African-American obese women. The rising U.S. maternal mortality rate is predominantly driven by the disproportionately high rates of African-American maternal mortality. African-American women are three to four times more likely to die from pregnancy or maternal-related distress than are White women, yielding one of the greatest and most disconcerting racial disparities in public health. Compared to women from other racial and ethnic demographics, African-American women across the socioeconomic spectrum experience prolonged, unrelenting stress related to racial and gender discrimination, contributing to higher rates of maternal mortality, giving birth to low-weight babies, and experiencing pre-term birth. Racism is a risk-factor for these aforementioned experiences. This cumulative stress often extends across the life course and is situated in everyday spaces where African-American women establish livelihood. Structural barriers, lack of access to care, and genetic predispositions to health vulnerabilities exacerbate African-American women’s likelihood to experience poor or fatal birthing outcomes, but do not fully account for the great disparity. African-American women are twice as likely to experience postpartum depression, and disproportionately higher rates of preeclampsia compared to White women. Racism is deeply ingrained in United States systems, including in health care delivery systems between patients and providers, often resulting in disparate treatment for pain, irreverence for cultural norms with respect to health, and dismissiveness. Research has demonstrated that patients respond more warmly and adhere to medical treatment plans at a higher degree with providers of the same race or ethnicity or with providers with great ability to exercise empathy. However, the provider pool is not primed with many people of color, nor are providers (whether student-doctors in training or licensed practitioners) consistently required to undergo implicit bias, cultural competency, or empathy training on a consistent, on-going basis.