U.S. GOVERNMENT PUBLISHING OFFICE

36–730 WASHINGTON : 2019

BETTER DATA AND BETTER OUTCOMES: 

REDUCING MATERNAL MORTALITY IN THE U.S. 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON ENERGY AND 

COMMERCE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED FIFTEENTH CONGRESS 

SECOND SESSION 

SEPTEMBER 27, 2018 

Serial No. 115–169 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 

(II) 

COMMITTEE ON ENERGY AND COMMERCE 

GREG WALDEN, Oregon 

Chairman 

JOE BARTON, Texas 

Vice Chairman 

FRED UPTON, Michigan 

JOHN SHIMKUS, Illinois 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

STEVE SCALISE, Louisiana 

ROBERT E. LATTA, Ohio 

CATHY MCMORRIS RODGERS, Washington 

GREGG HARPER, Mississippi 

LEONARD LANCE, New Jersey 

BRETT GUTHRIE, Kentucky 

PETE OLSON, Texas 

DAVID B. MCKINLEY, West Virginia 

ADAM KINZINGER, Illinois 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILL JOHNSON, Ohio 

BILLY LONG, Missouri 

LARRY BUCSHON, Indiana 

BILL FLORES, Texas 

SUSAN W. BROOKS, Indiana 

MARKWAYNE MULLIN, Oklahoma 

RICHARD HUDSON, North Carolina 

CHRIS COLLINS, New York 

KEVIN CRAMER, North Dakota 

TIM WALBERG, Michigan 

MIMI WALTERS, California 

RYAN A. COSTELLO, Pennsylvania 

EARL L. ‘‘BUDDY’’ CARTER, Georgia 

JEFF DUNCAN, South Carolina 

FRANK PALLONE, JR., New Jersey 

Ranking Member 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

MICHAEL F. DOYLE, Pennsylvania 

JANICE D. SCHAKOWSKY, Illinois 

G.K. BUTTERFIELD, North Carolina 

DORIS O. MATSUI, California 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

JERRY MCNERNEY, California 

PETER WELCH, Vermont 

BEN RAY LUJA ́ N, New Mexico 

PAUL TONKO, New York 

YVETTE D. CLARKE, New York 

DAVID LOEBSACK, Iowa 

KURT SCHRADER, Oregon 

JOSEPH P. KENNEDY, III, Massachusetts 

TONY CA ́ RDENAS, California 

RAUL RUIZ, California 

SCOTT H. PETERS, California 

DEBBIE DINGELL, Michigan 

(III) 

SUBCOMMITTEE ON HEALTH

MICHAEL C. BURGESS, TEXAS

Chairman 

BRETT GUTHRIE, Kentucky 

Vice Chairman 

JOE BARTON, Texas 

FRED UPTON, Michigan 

JOHN SHIMKUS, Illinois 

MARSHA BLACKBURN, Tennessee 

ROBERT E. LATTA, Ohio 

CATHY MCMORRIS RODGERS, Washington 

LEONARD LANCE, New Jersey 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILLY LONG, Missouri 

LARRY BUCSHON, Indiana 

SUSAN W. BROOKS, Indiana 

MARKWAYNE MULLIN, Oklahoma 

RICHARD HUDSON, North Carolina 

CHRIS COLLINS, New York 

EARL L. ‘‘BUDDY’’ CARTER, Georgia 

GREG WALDEN, Oregon (ex officio) 

GENE GREEN, Texas 

Ranking Member 

ELIOT L. ENGEL, New York 

JANICE D. SCHAKOWSKY, Illinois 

G.K. BUTTERFIELD, North Carolina 

DORIS O. MATSUI, California 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

BEN RAY LUJA ́ N, New Mexico 

KURT SCHRADER, Oregon 

JOSEPH P. KENNEDY, III, Massachusetts 

TONY CA ́ RDENAS, California 

ANNA G. ESHOO, California 

DIANA DEGETTE, Colorado 

FRANK PALLONE, JR., New Jersey (ex 

officio) 

(V) 

C O N T E N T S 

Page 

Hon. Michael C. Burgess, a Representative in Congress from the State of 

Texas, opening statement .................................................................................... 1 

Prepared statement .......................................................................................... 3 

Hon. Gene Green, a Representative in Congress from the State of Texas, 

opening statement ................................................................................................ 4 

Hon. Greg Walden, a Representative in Congress from the State of Oregon, 

opening statement ................................................................................................ 6 

Hon. Frank Pallone, Jr., a Representative in Congress from the State of 

New Jersey, opening statement .......................................................................... 7 

WITNESSES

Jaime Herrera Beutler, a Representative in Congress from the State of Washington .................................................................................................................... 9 

Prepared statement .......................................................................................... 11 

Charles S. Johnson, IV, Founder, 4Kira4Moms .................................................... 14 

Prepared statement .......................................................................................... 17 

Stacey D. Stewart, President, March of Dimes ..................................................... 42 

Prepared statement .......................................................................................... 44 

Lynne Coslett-Charlton, M.D., Pennsylvania District Legislative Chair, the 

American College of Obstetricians and Gynecologists ...................................... 51 

Prepared statement .......................................................................................... 53 

Joia Crear Perry, M.D., Founder and President, National Birth Equity Collaborative .............................................................................................................. 58 

Prepared statement .......................................................................................... 60 

SUBMITTED MATERIAL

Statement of MomsRising.org, submitted by Mr. Burgess ................................... 95 

Statement of the Alexis Joy Foundation, submitted by Mr. Burgess .................. 97 

Statement of the Society for Maternal Fetal Medicine, submitted by Mr. 

Burgess ................................................................................................................. 105 

Report of the Maternal Mortality and Morbidity Task Force from the State 

of Texas, submitted by Mr. Burgess 1

Statement of Dr. Gary D.V. Hankins of UTMB Health, submitted by Mr. 

Burgess ................................................................................................................. 108 

Article entitled, ‘‘Obstetric Hemorrhage Toolkit Hospital Level Implementation Guide,’’ 2010, submitted by Mr. Burgess 2

Statement of March for Moms, submitted by Mr. Burgess .................................. 111 

Statement of Postpartum Support Virginia, 2010, submitted by Mr. Burgess .. 114 

Statement of the Association of Maternal & Child Health Programs, submitted by Mr. Burgess ......................................................................................... 116 

Statement of Heart Safe Motherhood at Penn Medicine, submitted by Mr. 

Burgess ................................................................................................................. 118 

Statement of various patient groups, submitted by Mr. Burgess ........................ 120 

Statement of Americans United for Life, submitted by Mr. Burgess .................. 123 

Statement of the Nurse-Family Partnership, submitted by Mr. Burgess ........... 126 

Statement of the Preeclampsia Foundation, submitted by Mr. Burgess ............ 127 

Statement of Timoria McQueen Saba, submitted by Mr. Burgess ...................... 132 

Statement of the American College of Surgeons, submitted by Mr. Burgess ..... 137 

Study entitled, ’’Reducing Infant Mortality in Indiana,’’ KSM Consulting, 

2014, submitted by Mr. Burgess 3

Statement of SAP America, submitted by Mr. Burgess ....................................... 139 

Study entitled, ‘‘Analytics Paves the Way for Better Government, Forbes 

Insights, 2014, submitted by Mr. Burgess ......................................................... 141 

Page

VI 

Statement of Johnson & Johnson Services, Inc., submitted by Mr. Burgess ..... 145 

1 The information can be found at: https://docs.house.gov/meetings/IF/IF14/ 

20180927/108724/HHRG-115-IF14-20180927-SD022.pdf. 2 The information can be found at: https://docs.house.gov/meetings/IF/IF14/ 

20180927/108724/HHRG-115-IF14-20180927-SD023.pdf. 3 The information can be found at: https://docs.house.gov/meetings/IF/IF14/ 

20180927/108724/HHRG-115-IF14-20180927-SD004.pdf. 

(1) 

BETTER DATA AND BETTER OUTCOMES: REDUCING MATERNAL MORTALITY IN THE 

U.S. 

THURSDAY, SEPTEMBER 27, 2018 

HOUSE OF REPRESENTATIVES, 

SUBCOMMITTEE ON HEALTH, 

COMMITTEE ON ENERGY AND COMMERCE, 

Washington, DC. 

The subcommittee met, pursuant to call, at 10:00 a.m., in room 

2123 Rayburn House Office Building, Hon. Michael Burgess (chairman of the subcommittee) presiding. 

Members present: Representatives Burgess, Guthrie, Barton, 

Shimkus, Latta, Lance, Griffith, Bilirakis, Long, Bucshon, Brooks, 

Mullin, Hudson, Carter, Walden(ex officio), Green, Engel, Schakowsky, Castor, Schrader, Kennedy, Ca ́ rdenas, DeGette, and Pallone (ex officio). 

Staff present: Mike Bloomquist, Staff Director; Samantha Bopp, 

Staff Assistant; Daniel Butler, Staff Assistant; Adam Fromm, Director of Outreach and Coalitions; Zach Hunter, Director of Communications; Ed Kim, Policy Coordinator, Health; Ryan Long, Deputy Staff Director; Drew McDowell, Executive Assistant; Brannon 

Rains, Staff Assistant; Austin Stonebraker, Press Assistant; Josh 

Trent, Deputy Chief Health Counsel, Health; Hamlin Wade, Special Advisor, External Affairs; Jacquelyn Bolen, Minority Professional Staff; Jeff Carroll, Minority Staff Director; Evan Gilbert, Minority Press Assistant; Waverly Gordon, Minority Health Counsel; 

Tiffany Guarascio, Minority Deputy Staff Director and Chief 

Health Advisor; Tim Robinson, Minority Chief Counsel; and 

Samantha Satchell, Minority Policy Analyst. 

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS 

Mr. BURGESS. And the Subcommittee on Health will now come 

to order. I recognize myself 5 minutes for purpose of an opening 

statement. And I want to thank everyone for joining us this morning to discuss a topic that is important to each and every one of 

us. This is a subject matter that has been brought to the forefront 

by members of this subcommittee, members of Congress generally, 

actions of state legislators, and the media. 

Having spent 3 decades myself practicing OB/GYN, I believe it 

should be a national goal to eliminate all preventable maternal 

mortality. Even a single maternal death is too many. All too often 

we have read about the stories of seemingly healthy pregnant 

2 

women who are thrilled to be having a child and then to everyone’s 

surprise suffers severe complications, death, or near death during 

a pregnancy, birth, or postpartum. The death of a new or expecting 

mother is a tragic event that devastates everyone involved, and if 

there are preventable scenarios we need to do what we can to stop 

that. 

The alarming trend in our country’s rate of maternal mortality 

first came to my attention in September 2016 reading a copy of the 

American College of Obstetricians and Gynecologists, The Green 

Journal. The original research found that the maternal mortality 

rate had increased in 48 states and Washington, D.C. from 2000 

to 2014, while the international trend was moving in the opposite 

direction. Since reading that article, I have spoken to providers, 

hospital administrators, state task forces, and public health experts. The more I looked into this troubling issue, the more I realized that we have got much more we need to understand. 

This subcommittee had an informational briefing last year on 

this topic to inform members and to start the road toward this 

hearing. This is an issue that we cannot solve without accurate 

data. There were efforts in our nation to address maternal and infant mortality in the first half of the 20th century and the data 

showed that these efforts were indeed successful. 

But according to the Centers for Disease Control and Prevention 

the United States’ maternal mortality rate, 7.2 deaths per 100,000 

in 1999 and increased to 18 deaths per 100,000 live births in 2014. 

The Centers for Disease Control began conducting national surveillance of pregnancy related deaths in 1986 due to a lack of data on 

causes of maternal death. 

In 2003, the Centers for Disease Control National Center for 

Health Statistics revised standards for certain death certificates 

and added a pregnancy checkbox. While this checkbox has led to 

increased data collection on maternal deaths, it does not provide 

enough insight as to why or how these deaths occurred. Representative Jaime Herrera Beutler joining us this morning, the discussion 

draft that she has put forward will address the complex issue of 

maternal mortality by enabling states to form maternal mortality 

review committees to evaluate, improve, and standardize their maternal death rate. 

This is a critical step in the right direction as physicians, public 

health officials, and Congress are unable to reach conclusions based 

upon current data as to what the causes for maternal mortality increases are. Once we establish what these are, there will be an opportunity to use the data to implement the best practices toward 

a solution. 

Texas is a good example of a state that has enacted legislation 

to create and sustain a Maternal Mortality and Morbidity Task 

Force. Texas has put time and effort in funding and to reviewing 

maternal deaths in order to find the trends in the increases and 

the causes of death. The Task Force’s September 2018 report, 

which I have here and later on we will ask unanimous consent to 

be made part of the record, stated that the leading causes of pregnancy-related death in 2012 included cardiovascular, obstetric hemorrhage, infection sepsis, and cardiomyopathy. 

3 

This report is just a snapshot of the national picture as causes 

do vary from state to state. Additionally, this May, various researchers involved in the review of Texas’ maternal deaths published a paper, again in The Green Journal, detailing that unintentional user error and other issues led to inaccurate reporting of maternal mortality. The researchers concluded that relying solely on 

obstetric codes for identifying maternal deaths appears to be insufficient and can lead to inaccurate ratios. 

The moral of this story is we must ensure accurate data to accurately pinpoint the clinical issues contributing to these tragic 

deaths. I would like to submit a statement for the record from Dr. 

Gary Hankins and, without objection, so ordered, the chairman of 

the Department of OB/GYN at the University of Texas Medical 

Branch in Galveston. 

[The information appears at the conclusion of the hearing.] 

Mr. BURGESS. And Dr. Hankins was one of those doctors who 

briefed us during the briefing last year. Dr. Hankins has subspecialty training in maternal fetal medicine and served as vice 

chair for the Texas Morbidity and Mortality Review Committee. 

At one time we were scheduled to be joined by Dr. Lisa Hollier, 

also of Texas, who is also part of that committee. I think we had 

to postpone last week because of a hurricane and she could not accommodate the reschedule. But Dr. Hollier has also been integral 

in working on this at the state level. 

So I certainly look forward to hearing from our panel of witnesses today as how we can address this vital and devastating 

issue. 

[The prepared statement of Mr. Burgess follows:] 

PREPARED STATEMENT OF HON. MICHAEL C. BURGESS

Good morning. Thank you to everyone for joining us this morning to discuss a 

topic that is important to each and every one of us, maternal mortality. This is a 

subject matter that has been brought to the forefront by Members of this Subcommittee, actions of State Legislatures, and the media. Having spent nearly three 

decades as an OB/GYN, I believe it should be a national goal to eliminate all preventable maternal mortality—even a single maternal death is too many. 

All too often do we read about stories of seemingly healthy pregnant women who 

are thrilled to be having a child, and to everyone’s surprise, suffers severe complications, or death during pregnancy, birth, or post-partum. The death of a new or expecting mother is a tragic event that devastates everyone involved, but in many 

cases these are preventable scenarios. 

The alarming trend in our country’s rate of maternal mortality first came to my 

attention in September 2016, when I was reading my copy of the Green Journal. 

The original research found that the maternal mortality rate increased in 48 states 

and Washington DC from 2000 to 2014, while the international trend was moving 

in the opposite direction. Since reading that article, I have spoken with providers, 

hospital administrators, state task forces, and public health experts. The more I 

dove into this troubling issue, the more I realized how little we understand. This 

Subcommittee held an informational briefing last year on this topic to inform members and pave the road to this hearing. 

This is an issue that we cannot solve without accurate data. There were great efforts in our nation to address maternal and infant mortality in the first half of the 

20th Century, and the data showed that those efforts were successful. Yet, according 

to the Centers for Disease Control and Prevention (CDC), the U.S. maternal mortality rate was 7.2 deaths per 100,000 live births in 1999, and increased to 18 

deaths per 100,000 live births in 2014. 

CDC began conducting national surveillance of pregnancy-related deaths in 1986 

due to a lack of data on causes of maternal death. In 2003, the CDC National Center for Health Statistics revised standards for certain death certificates, and added 

4 

a pregnancy checkbox. While this checkbox has led to increased data collection on 

maternal deaths, it does not provide enough insight into why or how these mothers 

are dying. 

Representative Jamie Herrera-Beutler’s discussion draft will address the complex 

issue of maternal mortality by enabling States to form maternal mortality review 

committees to evaluate, improve, and standardize their maternal death data. This 

is a critical step in the right direction, as physicians, public health officials, and 

Congress are unable to reach conclusions based upon current data as to what the 

causes for maternal mortality are. Once we establish what these are, there will be 

an opportunity to use the data to implement best practices. 

Texas is a great example of a state that has enacted legislation to create and sustain a maternal mortality and morbidity task force. Texas has put much time, effort, 

and funding into reviewing maternal deaths in order to find trends in the causes 

of death. The Task Force’s September 2018 report stated that leading causes of 

pregnancy-related death in 2012 included cardiovascular and coronary conditions, 

obstetric hemorrhage, infection/sepsis, and cardiomyopathy. This report is just a 

snapshot of the national picture, as causes vary from state to state. 

Additionally, this May, various researchers involved in the review of Texas maternal deaths published a paper in the Green Journal detailing that unintentional user 

error and other issues led to inaccurate reporting of maternal mortality. The researchers also concluded that ‘‘relying solely on obstetric codes for identifying maternal deaths appears to be insufficient and can lead to inaccurate maternal mortality 

ratios.’’ The moral of this story is that we must ensure accurate data to accurately 

pinpoint the clinical issues contributing to these tragic deaths. 

I would like to submit a statement for the record from Dr. Gary Hankins, Chairman of the Department of OB/GYN at The University of Texas Medical Branch. He 

has subspecialty training in Maternal Fetal Medicine and served as Vice Chair for 

the Texas Maternal Morbidity and Mortality Review Committee. 

I look forward to hearing from our expert panel of witnesses as to how we can 

address this vital yet devastating issue. 

Mr. BURGESS. The chair recognizes the ranking member of the 

subcommittee, Mr. Green, 5 minutes for your opening statement, 

please. 

OPENING STATEMENT OF HON. GENE GREEN, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS 

Mr. GREEN. Thank you, Mr. Chairman, for calling today’s hearing on maternal mortality in the United States, and I would also 

like to thank our colleague who is in our distinguished panelists for 

joining us this morning. 

I would like to take just a moment, Mr. Chairman. My deputy 

chief of staff, LD/LA, Sergio Espinosa, this will be his last committee hearing and he has been working with me on health care 

in our office for many years—8 years, it has been 8 or 9. This is 

his last hearing. And those of you who someday decide you are not 

going to run for reelection, you will know that you will be losing 

staff members in the last 2 or 3 months. But I just want to thank 

Sergio for his work in the office on many issues, but particularly 

in the last number of months on health care. 

So—and I will continue with my statement. 

[Applause.] 

Mr. GREEN. The Centers for Disease Control and Prevention reports that more than 700 women in the United States die each 

year due to complications related to pregnancy and childbirth, and 

more than 50,000 women experience a life-threatening complication. Maternal mortality in our country has more than doubled between 1987 and 2014, from 7.2 to 18 maternal deaths per 100,000 

live births. In comparison, a recent World Health Organization 

5 

study found that maternal mortality is on the decline in 157 of the 

183 countries. 

These numbers are troubling as we are because even more acute 

when you look at the existing racial, socioeconomic, and geographic 

disparities, for example, African American women are nearly three 

times as likely to die of complications relating to pregnancy and 

childbirth compared to white women. In America in the 21st century, no woman should ever die of complications related to pregnancy and childbirth. 

Congress has a duty to act and reverse this terrible trend. I 

would like to thank my colleagues both Congresswoman Diane 

DeGette and Congresswoman Jaime Herrera Beutler for offering 

their discussion draft, The Preventing Maternal Deaths Act that 

will help protect pregnant and postpartum mothers. This legislation will provide grants to states and tribes to help establish and 

support already existing maternal mortality review committees, 

MMRCs, to identify and review pregnancy-related and pregnancyassociated deaths. 

MMRCs which are currently operating in over 30 states have 

been helping strengthen public health surveillance by linking vital 

data to the multidisciplinary healthcare professionals practicing in 

women’s health. I support the bipartisan legislation and hope our 

committee will recommend it in consideration before the full House 

before the end of the year. 

My Preventing Maternal Deaths Act is an important first step. 

Our committee can and must do more to protect our nation’s mothers. Despite the gains made under the Affordable Care Act, nearly 

one in seven women of childbearing age remain uninsured. The biggest barrier to women of childbearing age receiving healthcare coverage is continuing refusal of 19 states, including my home State 

of Texas, to expand Medicaid. Continuing of a comprehensive 

health insurance is critical for expecting and postpartum mothers 

to receive the post and postnatal care they need for themselves and 

their babies. 

Medical research shows chronic conditions such as hypertension, 

diabetes, heart disease, and obesity which are becoming more common for expecting mothers can increase their risk for complications 

during pregnancy. Ensuring continuing of coverage preceding pregnancy will help women of childbearing age best manage these 

chronic conditions before they become a problem. 

Last year I introduced Incentivizing Medicaid Expansion Act, 

H.R. 2688, in order to incentivize states to provide critical Medicaid 

coverage for uninsured Americans and avoid the kinds of tragedy 

that has led to the rising rate of mortality in my home State. My 

legislation would guarantee that the Federal Government covers a 

hundred percent of expansion costs for the first 3 years for states 

that have not yet expanded, and no less than 90 percent afterwards. I ask the committee to give this legislation the serious consideration that it deserves and help reverse the public health crisis 

that maternal mortality and severe maternal morbidity have become too many for our communities and our country. 

And in my last 39 seconds, UTMB in Galveston has been the 

catchment for most of the births in East Texas and South Texas 

and for decades, and I appreciate that university and that medical 

6 

school for doing that for our families. In the Houston area we have 

a hospital district, but Medicaid would at least help get them reimbursed. But UTMB is the catchment for problem pregnancies in 

South Texas and East Texas. 

Thank you, Mr. Chairman. I yield back. 

Mr. BURGESS. The chair thanks the gentleman. The gentleman 

yields back. The chair recognizes the gentleman from Oregon, the 

chairman of the full committee, Mr. Walden, 5 minutes for your 

opening statement, please. 

OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF OREGON 

Mr. WALDEN. Well, thank you, Chairman Burgess. 

Doctor, we are glad that you are chairing this subcommittee and 

this subcommittee hearing especially given your many decades of 

real-world experiences in OB/GYN. So we are glad to have you at 

the helm for this hearing especially. It is a difficult topic and it is 

one that is close to many of us. 

Far too many mothers die because of complications during pregnancy, and the effects of such a tragedy on any family is impossible 

to fully understand. What is both surprising and devastating is 

that despite massive innovation and advances in health care and 

technology we have experienced recent reports that have indicated 

that the number of women dying due to pregnancy complications 

is actually increasing. It is actually going up. 

According to the Centers for Disease Control and Prevention, maternal mortality rates in America have more than doubled since 

1987, and I think we are all asking how can that be? Well, this is 

not a statistic any of us wants to hear. There are questions as to 

whether the increases due to data collection are broader questions 

about healthcare delivery. The bill before us today will help us answer these really important questions and hopefully ensure that 

expectant newborn mothers receive even better care. 

I want to thank Congresswoman Herrera Beutler, my neighbor 

to the north in Washington State, for bringing this issue to our attention. She has been a real leader on this effort for many, many 

months, if not years. And especially given what you have been 

through in your own situation, we are proud of you and of your 

children and so we are glad to have you before the committee. 

I also want to thank my colleague and friend from Colorado, 

Diana DeGette, for her partnership on the draft legislation that is 

before us today. She has been a real leader on 21st Century Cures 

and other public health issues that are so important. And I want 

to extend a sincere thank you to the members of our second panel. 

Mr. Johnson, it is good to see you again. We appreciate you coming 

back here. I am sorry for what you have been through, but I appreciate your willingness to come share with us. Your testimony 

makes a difference in public policy. 

The draft bill we are examining today is the Preventing Maternal 

Deaths Act of 2018. The bill would enhance our Federal efforts to 

support maternal mortality review committees in each of our 

states. And earlier this year, the Oregon legislature passed a bill 

to establish such a committee in my home State which brings a 

wide range of medical providers together with community organizaVerDate Nov 24 2008 13:47 Jun 17, 2019 Jkt 037690 PO 00000 Frm 00012 Fmt 6633 Sfmt 6633 U:\MY DOCS\HEARINGS 115\HEARINGS\115-169 CHRIS
7 

tions and with public health experts to study maternal mortality 

and figure out its underlying causes. That information and lessons 

learned will then be shared with law enforcement and healthcare 

providers across Oregon. Congress should support and it should 

build off of these efforts and others across the country so many of 

these deaths could be prevented if best practices for maternal 

health care were followed and more widely understood. 

So that is what this hearing is all about. We appreciate you 

being here and we look forward to the testimony from our other 

panelists and of course from our colleague. I will tell you in advance we actually have two subcommittees going on simultaneously, and as chairman of the overall committee I have to bounce 

back and forth between them. But thank you for being here and 

we look forward to moving forward to find solutions. 

And with that, Mr. Chairman, I yield back. 

Mr. BURGESS. The chair thanks the gentleman. The gentleman 

yields back. The chair recognizes the gentleman from New Jersey, 

Mr. Pallone, the ranking member of the full committee, 5 minutes 

for an opening statement, please. 

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW JERSEY 

Mr. PALLONE. Thank you, Mr. Chairman. Hundreds of women die 

each year from pregnancy-related or pregnancy-associated complications in the United States, and more than 60 percent of these 

deaths are preventable. Shamefully, the maternal mortality rate in 

the U.S. has increased while most of the rest of the developed 

world has actually fallen. And this is not just alarming, it is unconscionable. We have a responsibility to understand why this is happening and what we should be doing to combat this crisis. 

Mr. Green and I wrote a letter to Chairman Burgess and Chairman Walden on this issue in May and I am pleased we are finally 

holding a hearing today. Today we will discuss a draft of the Preventing Maternal Deaths Act, which mirrors a version that passed 

out of the Senate Health Committee. This is a good bill. It is critical that we have the necessary data to understand the underlying 

causes of maternal deaths and identify strategies that can help us 

combat it. 

This bill encourages states to implement maternal mortality review committees to study this data and make recommendations on 

ways to combat maternal death. Review committees that are diverse and interdisciplinary can identify trends, patterns, and disparities that contribute to preventable maternal deaths. And with 

this information, healthcare providers can monitor the effectiveness 

of their policy and practice changes. 

Now my home State of New Jersey was the second state in the 

nation to institute a maternal mortality review committee which 

has worked extensively to review New Jersey’s maternal death 

cases to better understand their root causes and prevent deaths in 

the future. However, New Jersey’s maternal mortality rate remains 

much too high and much more work still needs to be done. 

Extensive public reporting has vividly described the risks American woman face in childbirth and the postpartum period and has 

8 

also highlighted the vast disparities in outcome. While women of 

all backgrounds are at risk for pregnancy-related complications, it 

is critical we also examine why maternal death rates are disproportionately higher for women of color, low-income women, and women 

living in rural areas. And we must understand why, and work together to address these disparities. 

However, we must also consider other ways we can combat maternal mortality, including by expanding health insurance coverage 

and ensuring all women have access to the reproductive health 

services they need. Unfortunately, efforts by the Trump administration to sabotage the Affordable Care Act, curtail the Medicaid 

program, and limit family planning services have only served to 

harm women and their families. Reducing maternal deaths in the 

United States must be a public health priority. I look forward to 

working with my colleagues to advance this bill and to begin addressing this crisis in a meaningful way. 

And I would like to now yield 2 minutes to my colleague, the 

Democratic sponsor of H.R. 1318, Ms. DeGette. 

Ms. DEGETTE. Thank you very much for yielding. 

Mr. Chairman, thank you so much for having this hearing. And 

I know my co-sponsor, Congresswoman Herrera Beutler, and I very 

much hope that we can mark this bill up and pass it during the 

lame duck session. In my opinion, it has been far too delayed given 

what we are seeing in this country. 

Maternal mortality rose in the United States between 2000 and 

2014 by 26 percent. This is really shocking to people who I talk to 

about this because other developed nations in the world have 

slashed their maternal mortality rates in half. And here is what is 

even worse, maternal mortality disproportionately affects women of 

color. Pregnancy-related death is nearly four times higher among 

African American women. And there are multiple factors that contribute to these maternal mortality rates—the high incidence of 

preeclampsia, obstetric hemorrhaging, and mental health conditions. 

Now to combat this trend, 33 states have established maternal 

mortality review committees. These panels bring together local 

healthcare professionals who collectively review individual maternal deaths and then target individual policy solutions towards 

them. The panels have been very effective. In California, for example, which established one in 2006, they have reduced their maternal mortality by more than 55 percent. And that is why what this 

bill does is it provides federal support for state-based maternal 

mortality review committees including for states, critically, that 

have not yet established these panels. It also promotes efforts to 

standardize data collection practices for maternal mortality which 

will help public health experts, researchers, and policymakers develop evidence-based solutions to address this crisis. 

The bill has 171 co-sponsors and a number of organizations, 

some which are here in the audience today. The March of Dimes, 

the American College of Obstetrics and Gynecologists, and others 

all support it and so I really hope we can quickly advance the bill. 

I hope we can pass it by the end of the year and send it to the 

President’s desk. Thank you and I yield back. 

9 

Mr. BURGESS. The chair thanks the gentlelady. The gentlelady 

yields back and this concludes with member opening statements. 

The chair would remind all members that pursuant to committee 

rules, members’ opening statements will be made part of the 

record. 

We do want to thank our witness on the first panel for being 

here today and taking time to testify before the subcommittee. 

I do want, as a housekeeping note, after Representative Herrera 

Beutler testifies we will move immediately to the second panel. We 

will not break in between the panels of witnesses. And again as is 

the custom, when we have a Member at the witness table there 

will not be questions from the dais to the Member, so we will go 

right into the second panel after Representative Herrera Beutler 

testifies. 

So our first witness is Representative Herrera Beutler from the 

State of Washington who is principal author of this legislation. We 

appreciate you being here today and you are recognized 5 minutes 

for your opening statement, please. 

STATEMENT OF HON. JAIME HERRERA BEUTLER, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF WASHINGTON 

Ms. HERRERA BEUTLER. Thank you, Mr. Chairman, for having 

this hearing and for your work in this field. This isn’t an issue of 

the moment for you, but this is what you have dedicated your life 

to and we are very grateful. 

Thank you, Ranking Member Green, for your support of this critical issue, and members of the subcommittee today for participating in this effort to reduce maternal mortality in the United 

States and for giving me this opportunity to speak in strong support of this discussion draft of the Preventing Maternal Mortality 

Deaths Act that is before us. 

So you either are a mom or you have a mom, so this issue impacts you. The very title of this bill speaks to why I have introduced this bipartisan legislation with my co-sponsor Ms. DeGette 

from Colorado. We have to take vital steps towards moving this bill 

in Congress and I believe we are going to save lives and prevent 

more families from suffering the profound loss of a cherished family member. 

The testimonies today will shed light on a truly disturbing trend 

in our nation. More mothers die from pregnancy-related or pregnancy-associated deaths here in the U.S. than in any developed 

country in the world. Although the assumption is often that a nation with some of the most advanced obstetric and emergency care 

would also demonstrate low maternal mortality rates, tragically, an 

estimated 700–900 maternal deaths occur in the U.S. every year. 

And not only does the U.S. rank 47th for maternal mortality 

globally, we have actually seen an increase in maternal deaths in 

recent years. This makes us one of only eight nations in the world 

with rising maternal mortality rates. It is unacceptable. In fact, 

Iran has a better maternal mortality rate than we do here in the 

United States. 

In New Jersey where Mr. Pallone is from, and he knows this, if 

you are a woman of color, a black woman, out of 100,000 deaths, 

10 

79 are likely to pass away from a pregnancy-associated or pregnancy-related death. You are three or four times more likely as a 

woman of color to experience this tragedy in our country. It is unacceptable. For families, single fathers, grandparents, and children 

who have all lost a mother, perhaps the most heart-wrenching of 

all of this is that according to the CDC 60 percent of these maternal deaths could have been prevented. 

As a mother, as a citizen, and a lawmaker, I believe we can and 

we must do better. It is time for this to become a national priority, 

which is why I am proud to speak in support of the Preventing Maternal Deaths Act. This legislation would enable states to establish 

and strengthen maternal mortality review committees. MMRCs 

bring together local experts in maternal, infant, and public health 

to review each and every instance of a pregnancy-related or pregnancy-associated death. We are going to investigate every single 

one because these moms are worth it. This is going to give us the 

information to understand why it is happening and what we need 

to do to fix it. This is how we are going to save future mothers’ 

lives. 

As members of the committee are aware, we know many of the 

conditions that contribute to high maternal mortality rate such as 

preeclampsia, gestational diabetes, obstetric hemorrhage, as well as 

emerging challenges such as suicide and substance use disorder. 

However, the truth is that the available data is woefully inadequate, which greatly hinders our ability to understand why mothers are dying. The Preventing Maternal Deaths Act seeks to address this data deficiency by empowering states to participate in 

national information sharing through the CDC, allowing for increased collaboration and the development of best practices. 

Now before closing, I want to note that the legislation before us 

was crafted from key policy recommendations made by multiple organizations supporting this bill including the Association of Maternal & Child Health Programs, the American College of Obstetricians and Gynecologists, the March of Dimes, Preeclampsia Foundation, the Society for Maternal-Fetal Medicine—thank you to all 

of you tireless warriors in this fight. 

Finally, and most importantly, I would like to extend my deepest 

gratitude to the families, fathers—one of whom you are going to 

hear from today, sitting behind me. Charles Johnson is going to tell 

you the story of the preventable death of his hero and hopefully 

this will be a tribute to ending those tragedies. He wants no one 

else to go through what he has gone through. 

And to every advocate who has spoken out, shared their stories, 

and called for change, these courageous individuals are the champions of this movement and this bill. With wide bipartisan support 

and well over a 160 co-sponsors in the House, I remain committed 

to passing the Preventing Maternal Deaths Act into law and I look 

forward to working with this committee, you, Mr. Chairman, and 

my colleagues in Congress to accomplish this imperative goal. 

With that I thank you and I yield back. 

[The prepared statement of Ms. Herrera Beutler follows:] 

11 


36730.001

U.S. House of Representatives Energy and Commerce Committee 

Subcommittee on Health Hearing: 

"Better Data and Better Outcomes: Reducing Maternal Mortality in the U.S." 

Testimony of: Congresswoman Jaime Herrera Beutler 

September 27, 2018 

Thank you Chainnan Burgess, Ranking Member Green, and Members of the Subcommittee for holding 

this hearing on reducing maternal mortality in the United States and for this opportunity to speak in 

strong support of the discussion draft of the Preventing Maternal Deaths Act that is before us. 

The very title of this bill speaks to why I have introduced this bipartisan legislation and to why we are 

here today. We are here to take vital steps toward moving a bill in Congress that I believe will save lives 

and prevent more families from suffering the profound loss of a mother. 

The testimonies today will shed light on a truly disturbing trend in our nation- more mothers die from 

pregnancy-related or pregnancy-associated causes here in the U.S. than any other developed country in 

the world. 

Although the assumption is often that a nation with some of the most advanced obstetric and emergency 

care would also demonstrate low maternal mortality rates, tragically, an estimated 700 - 900 maternal 

deaths occur in the U.S. every year. Not only does the U.S. rank 47th for maternal mortality globally, we 

have actually seen an increase in maternal deaths in recent years. This makes us one of only eight 

nations in the world with rising maternal mortality rates. 

For the families, single fathers, grandparents, and children who have lost a mother, perhaps the most 

heart-wrenching of all is that the Centers for Disease Control and Prevention estimates that 60 percent of 

these maternal deaths could have been prevented. 
12 


36730.002

As a mother, a citizen, and a lawmaker, I believe that we can and must do better. It is time for this to 

become a national priority, which is why I am proud to speak in support of the Preventing Maternal 

Deaths Act. 

This legislation would enable states to establish or strengthen maternal mortality review committees. 

MMRCs bring together local experts in maternal, infant, and public health to review each and every 

instance of a pregnancy-related or pregnancy-associated death in order to understand what went wrong 

and how to save future mothers' lives. 

As Members of the Committee are aware, we know of many conditions that contribute to high maternal 

mortality rates, such as preeclampsia, gestational diabetes, obstetric hemorrhage, as well as emerging 

challenges such as suicide and substance use disorder. However, the truth is that the available data is 

woefully inadequate, which greatly hinders our ability to understand why mothers are dying. 

The Preventing Maternal Deaths Act seeks to address this data deficiency by empowering states to 

participate in national information sharing through the CDC, allowing for increased collaboration and 

the development of best practices. 

Before closing, I would like to note that the legislation before us was crafted from key policy 

recommendations made by multiple organizations that arc supporting this bill - including the 

Association of Maternal & Child Health Programs, the American College of Obstetricians and 

Gynecologists, March of Dimes, Preeclampsia Foundation, and the Society for Maternal-Fetal Medicine. 

Finally, and most importantly, I would like to extend my deepest gratitude to the families, fathers, and 

advocates who have spoken out, shared their stories, and called for change. These courageous 

individuals are the champions of this movement and this bill. 
13 


36730.003

With wide bipartisan support and over 160 cosponsors in the House, I remain committed to passing 

Preventing Maternal Deaths Act into law and I look forward to working with the Committee and my 

colleagues in Congress to accomplish this imperative goal. 

Thank you. 
14 

Mr. BURGESS. We thank you, Representative Herrera Beutler, 

for, number one, putting forward the discussion draft and working 

on it so hard over this past year in bringing all of the different people together that had to finally come together to get this hearing 

a reality today. And I know it took a lot of work on your part and 

we really appreciate your dedication. So thank for being with us 

this morning and we will move immediately to our second panel. 

And while the transition is occurring, I will just use this time to 

thank all of our witnesses for being here today and taking time to 

testify before the subcommittee. Each witness will be given the opportunity to deliver an opening statement followed by questions 

from members. 

Mr. GREEN. Mr. Chairman? 

Mr. BURGESS. For what purpose does the gentleman from Texas 

seek recognition? 

Mr. GREEN. I would like to submit the following letters, ask 

unanimous consent to submit the following letters for the record. 

From the Moms Rising, Alexis Joy Foundation, and the Society for 

Maternal Fetal Medicine into the record. 

Mr. BURGESS. Without objection, so ordered. 

[The information appears at the conclusion of the hearing. 

Mr. BURGESS. Do we have copies of those? 

Mr. GREEN. Yes. 

Mr. BURGESS. So today we are going to hear from Mr. Charles 

Johnson, founder of 4Kira4Moms; Ms. Stacey Stewart, president of 

the March of Dimes; Dr. Lynne Coslett-Charlton, Pennsylvania 

District Legislative Chair, The American College of Obstetricians 

and Gynecologists; and Dr. Joia Crear Perry, president of the National Birth Equity Collaborative. We appreciate each of you being 

here today. 

And Mr. Johnson, you are now recognized 5 minutes for an opening statement. Please turn your microphone on. Pull it close. This 

is the premier technology committee in the United States House of 

Representatives and we have fairly rudimentary amplification devices. 

So Mr. Johnson, you are recognized. 

STATEMENTS OF CHARLES S. JOHNSON, IV, FOUNDER, 

4KIRA4MOMS; STACEY D. STEWART, PRESIDENT, MARCH OF 

DIMES; LYNNE COSLETT-CHARLTON, M.D., PENNSYLVANIA 

DISTRICT LEGISLATIVE CHAIR, THE AMERICAN COLLEGE 

OF OBSTETRICIANS AND GYNECOLOGISTS; AND, JOIA 

CREAR PERRY, M.D., FOUNDER AND PRESIDENT, NATIONAL 

BIRTH EQUITY COLLABORATIVE 

STATEMENT OF CHARLES JOHNSON 

Mr. JOHNSON. I think I will manage. Thank you so much. So, 

first and foremost, to members of this committee, thank you. It is 

an honor to be here speaking on behalf of the tens of thousands of 

families that have been affected by this maternal mortality crisis 

and hundreds of thousands of women who have been affected by 

near misses. 

So let me just begin by telling you about the woman that absolutely changed my life. My wife, Kira Dixon Johnson, was the closVerDate Nov 24 2008 13:47 Jun 17, 2019 Jkt 037690 PO 00000 Frm 00020 Fmt 6633 Sfmt 6633 U:\MY DOCS\HEARINGS 115\HEARINGS\115-169 CHRIS
15 

est thing that I had ever met to a superhero. She made me far better than I ever thought I could be and she was far better than I 

ever deserved. We are talking about a woman that ran marathons; 

that raced cars; that spoke five languages fluently. 

So we were blessed to welcome our first son, Charles, on September 18th of 2014. We always wanted back-to-back boys, Chairman Burgess, and we were blessed to find out we were going to 

welcome our second son, Langston, in April of 2016. We walked 

into Cedars-Sinai Medical Center on April 12th of 2016 with a 

woman that just wasn’t in good health, she was in exceptional 

health. This picture that you see on the screen is literally taken 10 

days before Kira went in for the procedure. 

We went in for what was supposed to be a routine scheduled Csection on what was supposed to be the happiest day of our lives 

and we walked right into what was a nightmare. Shortly after the 

procedure took place around 2 o’clock, shortly afterwards we went 

back to recovery. As I am sitting there reflecting in all this glow 

and pride of being a new father for the second time, Kira is resting, 

my new baby is resting, and as I look at her bedside I begin to see 

the catheter begin to turn red with blood. 

I brought it to the attention of the staff, the nurses at CedarsSinai. They came in. They said we are going to do a couple of 

things. We are going to order a set of tests and we are going to 

order a CT scan to be performed stat. I was concerned, but I said 

you know what, my wife is healthy and we are at what is supposed 

to be one of the best hospitals in the world. I am concerned but we 

have got a plan, OK. 

Blood work comes back, it is showing that it is abnormal and she 

is hemorrhaging and they ordered a CT scan that was supposed to 

be performed stat. Keep in mind this is around 4 o’clock. 5 o’clock 

comes, no CT scan. Her blood level was continuing to drop. By this 

time she is beginning to shiver uncontrollably. 6 o’clock and no CT 

scan. She is beginning to become pale, she is in extreme pain. 7 

o’clock, 8 o’clock comes, no CT scan. I am begging, I am pleading 

the staff to do something. 

And around 9 o’clock as I continue to plea for my wife’s life, the 

staff at Cedars-Sinai Medical Center tells me, sir, your wife just 

isn’t a priority right now. 8 o’clock comes, 9 o’clock, 10 o’clock. They 

said, well, we need to do a blood transfusion. I am saying, well, 

where is the CT scan? It wasn’t until after midnight that they finally took my wife back to surgery, after I begged and pleaded for 

them to take action for more than 10 hours. When they took Kira 

back to surgery they opened her up and there were three and a 

half liters of blood in her abdomen and she coded immediately. 

Now I am here to tell you this. I am not here to tell you what 

I think. I am here to tell you what I know. There are people on 

this panel that are far more intelligent than I will ever be that are 

going to talk to you about the statistics and how horrifying they 

are. What I am here to tell you is this. That there is no statistic 

that can quantify what it is like to tell an 18-month-old that his 

mother is never coming home. There is no matrices that can quantify what it is like to explain to a son that will never know his 

mother just how amazing she was. 

16 

My wife deserved better. Women all over this country deserve 

better. I am so grateful to my shero, Congresswoman Jaime Herrera Beutler. Thank you so much, Congresswoman DeGette. And 

for those of you all who have supported this bill, I honest to goodness would love to come up there and just give you a big hug, but 

I have been explained that that is not protocol. 

And let me say this for those that choose to stand in opposition 

of this bill, you don’t owe me an explanation. You owe an explanation to my boys. You owe Tara Hansen’s son an explanation. You 

owe Mustafa Shabazz and his son an explanation. We have an opportunity to do something, here and now, to send a loud, definitive 

message to this country that women and babies matter. 

Lastly, Kira and I always talked about raising men that would 

change the world. It is time for us to stop telling our children that 

they can change the world and show them how it is done. Thank 

you for your time. 

[The prepared statement of Mr. Johnson follows:] 

17 


36730.004

September 24, 2018 

TESTIMONY 

OF 

CHARLES JOHNSON IV 

HUSBAND OF THE LATE KIRA JOHNSON 

FOUNDER OF 4KIRA4MOMS 

ADVOCATE FOR IMPROVED MATERNAL HEALTH POLICIES 

BEFORE THE 

SUBCOMMITTEE ON HEALTH 

COMMITTEE ON ENERGY AND COMMERCE 

U.S. HOUSE OF REPRESENTATIVES 

"BE_II_EJ~_I:>b TAJ\Nj) BETTER Ol!I~QMES.:_l~BDQC:ING MATERNALMQRTALITY IN 

TIJE :tLS." 

9:15a.m., THURSDAY, SEPTEMBER 27th, 2018 
18 


36730.005

Testimony of Charles Johnson IV, Founder of 4Kira4Moms 

in Support ofH.R. 1318: Preventing Maternal Mortality Act of2017 

"BETTER DATA AND BETTER OUTCOMES: REDUCING MATERNAL MORTALITY IN 

THE U.S." 

U.S. House Energy and Commerce Subcommittee on Health 

September 27th, 2018 

*** 

Good Morning Mr. Chairman, Ranking Member Green, members of the committee: my name 

is Charles Johnson the IV. I'd like to thank the committee for inviting me to testify today on 

H.R. 1318: Preventing Maternal Deaths Act of2017. I have envisioned the opportunity to 

speak before this committee for sometime now and could not be more grateful than to share my 

family's story with you today. 

I have just introduced myself to you in my opening statement as Charles Johnson the IV, 

however, these days I am known as "Charles and Langston's Dad." Following the esteemed 

title of Dad, is that of "Kira' s husband." 

I met Kira several times before we connected. Trying to catch Kira's attention was like trying 

to catch a butterfly. Kira was the most amazing person I have ever met. She spoke four 

different languages, lived in China and had run several companies. Her idea of a relaxing date 
19 


36730.006

was skydiving ... her idea of a romantic date was drag racing. I was smitten with her zest for 

life- her enthusiasm- I couldn't wait to see what was going to happen next. We got married in 

a surprise destination wedding, one which I took pains to make sure I made an impressive 

impact on my bride, like she made on me everyday. It was a dream come true: our wedding, 

our honeymoon, our new life as a married couple, the start of our new family. We had the rest 

our of lives in front of us! Nothing could stop us. 

On April12, 2016 my life partner, my best friend and amazing Mom, Kira lost her life after a 

routine sheduled c-section at Cedars Sinai delivering our 2nd son, Langston Johnson. Kira had 

delivered our first son, Charles V, via cesarean section, so we were both prepared for the 

process, procedure and recovery. 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 oftest were orderd. Along with aCT scan to be preformed 

"STAT". I understood "STAT" to mean the CT scan would be performed imediatley. Hours 

passed and Kira's symptoms escalated throughout the rest of the afternoon and into the 

evening. We were told by the medical staff at Cedars Sinai Kira was not a priority and we 

waited for her CT scan to be done ... we waited for the hospital to act so she could begin her 

recovery. Kira kept telling me, "Charles, I'm so cold; Charles, I don't feel right." She repeated 

these same words to me for several hours. After more than I 0 hours of waiting. After I 0 hours 

of watching my wifes condition detcroiotate. After 10 hours of watching Kira suffer in 

excrutiating pain needlesly. After 10 hours of begging and pleading them to help her. The 

medical staff at Cedars Sinai finaly 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 
20 


36730.007

said, "Baby, I'm scared." I told her, without doubt, everything was going to 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 horrible medical negligence that 

occurred during her routine C-section. She had approximately 3litters of blood in her 

abdomen. Kira died at 2:22a.m. Aprill7, 2016. Langston was 11 hours old. 

As someone who experienced first hand what it is 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. 

I vowed that I would take this tragedy and tum it into a mission fueled by the memory ofKira 

and the passion she brought to life every day. I have taken my grief and found peace by 

tirelessly working on maternal health and maternal outcomes. I am the founder of 

4Kira4Moms. 4Kira4Moms mission to advocate for improved maternal health policies and 

regulations, to educate the public about the impact of maternal mortality in communities, 

provide peer support to the victim's family, friends, and promote the idea that maternal 

mortality should be viewed, and discussed, as a human rights issue. My Kira lost her life, and I 

simply could not believe that her death, my family's experience, was not an anomaly. My 

situation and my family are not unique. The maternal mortality rate is rising in the United 

States. According to the Lancet, 26.7 women out of I 00,000 die directly as a direct result of 

maternal mortality. Maternal mortality figures have been rising exponentially in the United 

States over the past 2 decades .. In 1990, the US had 674 recorded maternal mortality deaths 
21 


36730.008

per lOOK; by 2015, the number had risen to 1063 women per lOOK. Women color, regardless 

of income or education, are dying at a rate of 3 to 4 times higher. My wife is now a 2017 

maternal mortality rate statistic. 

Each maternal death is equal to approximately 70 mothers experience a "near miss", meaning 

they almost die. Based on CDC figures, approximately 50K mothers almost died from 

childbirth as recent at 2014. This has to stop! 

I'm here today because the committee wanted to hear my story, Kira's story, Charles and 

Langston's story. The importance of passing H.R. 1318: Preventing Maternal Mortality Act of 

2017 is part of that story. This country deserves to know why our Mother's are dying. Women 

and families who want to bear children should know what leads to maternal mortality, and "near 

misses." I want to help everyone out there who wishes to someday become a parent, the most 

blessed gift in the world, and every provider who helps those amazing women bring life into the 

world, to understand what to look for; how to help, when to listen. 

Thank you for the opportunity to hear my testimony today. The time is now for political will to 

address a situation that chose me without any knowledge. HR 1318: Preventing Maternal 

Mortality Act of 2017 will assist states to give us the knowledge on why our country's Mothers 

are dying and how to help put an end to such tragedy. That knowledge may have saved Kira's 

life. 
22 


36730.009

1\DDENDUM: 

4Moms4Kira Campaign 

Too many mothers are dying after childbirth. A hospitaL)19_pes to save them. 

G_h<Jrles JohnsollJlhill:_es Kir!l~.~tQry at the hlilr.ch for Moms Washinton DC 

https://www .youtube.com/watch ?v=05uBCBfrY 4g 

Attached :copy of Johnson family complaint for damages. Oulining the timline of the events that 

lead to Kira Johnson's death. 

Attached: photos of Kira Dixon 
23 


36730.010

2 

3 

4 

5 

6 

Michael L. Oran, Esq. (SBN: 110970) 

LAW OFFICES OF MICHAEL L. ORAN 

801 South Grand Avenue 

11th Floor 

Los Angeles, California 90071 

TEL: (213) 624-1177 

FAX: (213) 624-1161 

EMAIL: miloran@mloeso.com 

Attorneys for Plaintiffs 

Ctll·-iH:::tllliicD 0Gr'Y 

ORIGIN/.[. FILED Superior Court of Cr.lltornla Co0t1ty of Ln•· Angeles 

MAR 2 2 2017 

7 

8 

9 

SUPERIOR COURT OF THE STATE OF CALIFORNIA 

FOR THE COUNTY OF LOS ANGELES 

10 

11 CHARLES JOHNSON, IV; CHARLES 

JOHNSON, V, a minor, by and 

12 through his Guardian ad Litem, 

CHARLES JOHNSON, IV; LANGSTON 

13 JOHNSON, a minor, by and 

through his Guardian ad Litem, 

14 CHARLES JOHNSON, IV, 

15 Plaintiffs, 

16 vs. 

17 CEDARS-SINAI MEDICAL CENTER, a 

business organization, form 

18 unknown; ARJANG NAIM, M.D.; 

KATHRYN SHARMA, M.D.; SARA 

19 CHURCHILL, M.D.; STUART MARTIN, 

M.D.; BENHAM KASHANCHI, M.D.; 

20 and DOES 1 to 100, Inclusive, 

21 Defendants. 

22 

CASE NO. BC655107 

COMPLAINT FOR DAMAGES: 

(1) Wrongful Death 

(2) Negligent Infliction of 

Emotional Distress 

23 Plaintiffs Charles Johnson, IV, Charles Johnson, V, a minor, 

24 by and through his Guardian ad Litem, Charles Johnson, IV, and 

25 Langston Johnson, a minor, by and through his Guardian ad Litem, 

26 Charles J·ohnson, IV, allege as follows: 

27 I I I 

28 I I I 

COMPLAINT FOR DAMAGES 
24 


36730.011

2 

3 

FIRST CAUSE OF ACTION FOR WRONGFUL DEATH BY 

PLAINTIFFS CHARLES JOHNSON, IV, CHARLES JOHNSON, V 

and LANGSTON JOHNSON AGAINST ALL DEFENDANTS 

4 1. Kyira Adele Dixon was born on June 26, 1976. Kyira was 

5 married to Charles Johnson, IV. Their first son, Charles 

6 Johnson, V, was born on September 18, 2014 by primary cesarean 

7 section delivery. Plaintiff Charles Johnson, IV had been present 

8 at the cesarean section delivery of his first son. Kyira Adele 

9 Dixon was a healthy, vibrant, fun, loving wife and mother. 

10 2. In 2015, Kyira became pregnant again. She, her husband 

11 and son relocated to Los Angeles to pursue business and other 

12 opportunities. Once here, her pre-natal care was transferred to 

13 Defendant Benham Kashanchi, M.D. Defendant Benham Kashanchi, 

14 M.D. followed her through her pre-natal care. However, before 

15 her planned elective cesarean section, her care was transferred 

16 to Defendant Arjang Nairn, M.D. Both Defendants Arjang Nairn, M.D. 

17 and Benham Kashanchi, M.D. were in the Defendant Cedars-Sinai 

18 Medical Center's operative suite at the time of the delivery 

19 described herein. 

20 3. The facts leading up to the death of Kyira Adele Dixon 

21 taken from the medical records, and with approximate times, 

22 include, but are not limited to, the following: 

23 (A) Kyira was 39 years-old; 

24 (B) Kyira, accompanied by her husband, Plaintiff Charles 

25 Johnson, IV, presented to Defendant Cedars-Sinai Hospital on 

26 April 12, 2016 at approximately 12:30 p.m. for a repeat elective 

27 cesarean delivery. The delivery was performed by Defendant 

28 Arjang Nairn, M.D. and assisted by Defendant Benham Kashanchi, 

2 

COMPLAINT FOR DAMAGES 
25 


36730.012

M.D. Plaintiff Charles Johnson, IV, was present in the operating 

2 room; 

3 (C) Kyira was taken to the operative suite at 2:00 p.m. A 

4 foley catheter was inserted at 2:15p.m. The delivery started at 

5 2:31 p.m. Langston Johnson was born at 2:33 p.m. The procedure 

6 was completed at or about 2:48p.m. At 3:00p.m., Kyira was out 

7 of the operating room and taken to the Post Anesthesia Care Unit 

8 (PACU). Plaintiff Charles Johnson, IV, continued to be present 

9 with his wife. At 3:04 p.m. Kyira was "skin to skin" bonding 

10 with their baby; 

11 (D) At 4:45 p.m., Kyira's fundus 1 had risen from +2 to +4 

12 ems above the umbilicus. This may be associated with failure of 

13 the uterus to contract after delivery, a condition called uterine 

14 atony. Atony can lead to or be a symptom of a potentially 

15 life-threatening condition known as postpartum hemorrhage; 

16 (E) Shortly before 5:00p.m., blood tinged urine was seen 

17 in Kyira's foley catheter; 

18 (F) By 5:24 p.m., Kyira's foley catheter was draining bright 

19 red blood. The records indicate that a resident physician was 

20 called by a nurse "to evaluate the rising fundus and concern for 

21 excessive bleeding."; 

22 (G) Shortly thereafter, the foley catheter was removed for 

23 "bloody urine." It was replaced at 5:30p.m. Defendant Dr. Nairn 

24 was made aware of his patient Kyira's situation; 

25 /// 

26 Ill 

27 

28 The fundus is the upper rounded extremity of the uterus 

above the openings of the uterine tubes. 

3 

COMPLAINT FOR DAMAGES 
26 


36730.013

(H) At 5:38p.m., Kyira's fundus continued to be at +4 and 

2 frank red blood was still present and seen in Kyira's foley 

3 catheter; 

4 (I) 7 minutes later Kyira's foley catheter was draining 

5 "complete red blood." A bedside ultrasound showed a 6 em (2.3 

6 inches) heterogenous fluid collection posterior to bladder/ 

7 anterior to uterus compressing the bladder suspicious for large 

8 hematoma'. Uterotonics, Pitocin and Cytotec, were ordered for 

9 apparent uterine atony; 

!0 (J) Defendant Dr. Nairn was again notified; 

11 (K) Kyira was given Dilaudid for pain. She was also given 

12 an intravenous fluid bolus of 500 ml.; 

13 (L) At 6:12p.m., labs were ordered. Kyira's results 

14 showed: 

15 • White Blood Count abnormal at 19.1 (normal 

16 range: 4-11 1000 UL); 

17 • Red Blood Count abnormal at 3.01 (normal 

18 range: 3.6-5.11); 

!9 • Hemoglobin abnormal at 9.2 (normal range 

20 12-16.0 G/dl); and 

21 • Hematocrit abnormal at 27% (normal range 36-47%). 

22 In addition, the records reflect that Dr. Kashanchi also 

23 ordered a separate hemoglobin and hematocrit blood test. The 

24 results showed: 

25 • Hemoglobin abnormal at 9.2; and 

26 • Hematocrit abnormal at 27%. 

27 

28 2 A hematoma is a mass or abnormal collection of clotted blood 

within the tissues. 
27 


36730.014

A fibrinogen' blood test at about the same time showed a result 

2 of 228 which is on the low end of normal (normal range is 200-400 

3 mg/dl); 

4 (M) At 6:44p.m., a "stat" CT of Kyira's abdomen and pelvis 

5 and CT urogram were ordered by Stuart Martin, M.D. The records 

6 indicate the "reason for stat/expedite: surgical emergency." The 

7 records also document that Kyira had "intractable" abdominal pain 

8 and frank blood per foley catheter. The order comments also 

9 state: "Please add imaging, i.e. CT abd/pelvis with IV contrast 

10 as needed to fully evaluate the patient's post op abdomen and 

11 pelvis; high concern for pelvic hematoma but uncertain regarding 

12 injury to bladder and ureters."; 

13 (N) Kyira's bleeding continued. At 7:13p.m., Dr. Sharma 

14 noted that Kyira had not had any urine output after 5:00 p.m. 

15 Dr. Sharma performed another ultrasound. It showed the hematoma 

16 had enlarged. Kyira and her husband were told that although the 

17 hematoma appeared "stable" there was concern regarding the "blood 

18 in foley with little to no urine output. Will obtain STAT 

19 imaging of pelvis and lower urinary tract to ensure 

20 integrity ... ". Dr. Nairn was made aware; 

21 (0) More fluids were provided via IV infusion. Labs 

22 reported between 7:35 and 8:01 showed: 

23 • White Blood Count abnormal at 21.5; 

24 • Red Blood Count abnormal at 2.58; 

25 Ill 

26 

27 

28 

3 Fibrinogen is a protein in the plasma that originates in the 

liver. It is converted to fibrin during the blood clotting process 

(coagulation). 
28 


36730.015

• Hemoglobin abnormal at 7.6; 

2 • Hematocrit abnormal at 23.7%; and 

3 • Fibrinogen abnormal at 186. 

4 (P) At 8:00 p.m., Kyira was seen by Dr. Churchill. She had 

5 still only produced little to no urine despite having been given 

6 fluids. There was still blood in her foley catheter. Kyira's 

7 hemoglobin and hematocrit were noted as continuing to drop and 

8 her heart rate was tachycardic. 4 The estimated blood loss was 

9 about 1500 cc's. "This suggests symptomatic acute blood loss 

10 anemia and decision made to proceed with 2 units of PRBC" [packed 

11 red blood cells]. "Proceeding also with CT urogram to evaluate 

12 kidneys/ureters/bladder given frank blood in foley"; Kyira's 

13 situation was discussed with Dr. Nairn and Dr. Sharma; 

14 (Q) Although packed red blood cells were started at 8:41 

15 p.m., plasma, which provides blood clotting proteins including 

16 fibrinogen, was not ordered until 11:21 p.m.; 

17 R) At 8:47 p.m. the records document that Dr. Nairn was at 

18 the bedside examining Kyira in the PACU. Dr. Nairn knew at that 

19 time that Kyira continued with "bloody urine," had an abnormal 

20 hemoglobin of 7, that her heart rate was consistent with 

21 tachycardia and that she had a "possible hematoma."; 

22 (S) At just about 9:00p.m., Kyira was holding her baby in 

23 the PACU where she had remained and still had not been 

24 transferred to post partum; 

25 II I 

26 Ill 

27 

28 'Tachycardia is a resting heart rate of at least 100 beats per 

minute. 

6 

COMPLAINT FOR DAMAGES 
29 


36730.016

(T) At 10:44 p.m., that the CT scans that had been ordered 

2 "stat" 4 hours earlier still had not been done. In fact the 

3 records do not reflect these scans were ever performed; 

4 (U) At 10:55 pm the nurse notified the doctors that Kyira's 

5 blood pressures were in the 70's/50's. Dr. Churchill and another 

6 doctor were at the bedside to assess Kyira. Even after changing 

7 the blood pressure cuff, Kyira's blood pressure was 82/53; 

8 (V) At approximately 11:25 p.m., Dr. Nairn was notified with 

9 a concern "for active internal bleeding." Despite blood in the 

10 foley, no urine output, abnormal labs, symptoms suggesting acute 

11 blood loss, enlarging hematoma, it was not until approximately 

12 11:30 p.m. and thereafter that a surgical discussion was held and 

13 consent provided for surgery; 

14 (W) At 11:42 p.m., Dr. Churchill and Dr. Sharma were at the 

15 bedside. Kyira felt "a little more groggy then before", her heart 

16 rate was 120 at rest and her blood pressure was 90/70. Dr. Sharma 

17 performed a repeat ultrasound. The ultrasound "found expanding 

18 hematoma and now free fluid." Dr. Sharma and Dr. Churchill 

19 recommended taking Kyira to surgery to identify the source of the 

20 bleeding. Yet Dr. Nairn, who was also at the bedside at this 

21 time, and in the face of these abnormql findings as previously 

22 set forth, wished "to continue expectant management at this 

23 time."; 

24 (X) Shortly thereafter, the massive transfusion protocol was 

25 initiated on Kyira. Massive Transfusion Protocol means packed 

26 red blood cells, platelets and plasma given in "massive• 

27 quantities to support circulation and coagulation during massive 

28 hemorrhage; 

FOR DAMAGES 
30 


36730.017

(Y) Kyira was taken to surgery around 12:30 a.m. on April 

2 13, 2016. During surgery Kyira was found to have 3 liters of 

3 blood in her abdomen; 

4 (Z) Kyira did not survive the ongoing massive blood loss. 

5 Kyira was pronounced dead at 2:22 a.m. on April 13, 2016; and 

6 (AA) The autopsy stated that the cause of "death was due to 

7 hemorrh~gic shock, due to acute hemoperitoneum," status post 

8 cesarean section. 

9 4. The surviving heirs of Kyira Adele Dixon, deceased 

10 (hereinafter referred to as "decedent") are Charles Johnson, IV 

II (husband), Charles Johnson, V (son) and Langston Johnson (son). 

12 There are no other heirs that Plaintiffs are aware of. 

13 5. Defendants DOES 1 through 10, inclusive, are potential 

14 heirs of decedent and entitled to bring this action pursuant to 

15 C.C.P. Section 377.60, and they are named as Defendants in this 

16 action as their true names and capacities as potential heirs are 

17 presently unknown to Plaintiffs herein. 

18 6. The true names, identities or capacities, whether 

19 individual, associate, corporate or otherwise of Defendants DOES 

20 11 through 100, inclusive, are unknown to plaintiffs who 

21 therefore sue said defendants by such fictitious names. When the 

22 true names, identities, or capacities of such fictitiously 

23 designated defendants are ascertained, Plaintiffs will ask leave 

24 of court to amend this Complaint to insert the true names, 

25 identities and capacities together with the charging allegations. 

26 7. At all times herein mentioned, Defendants and each of 

27 them, were the agents, servants, employees and joint venturers of 

28 each other and of their said codefendants, and were acting within 
31 


36730.018

the purpose and scope of their employment, agency or joint 

2 venture. 

3 8. Plaintiffs are informed and believe and thereon allege 

4 that each of the Defendants sued herein as a DOE (except DOES 1 

5 through 10, inclusive) is responsible in some manner for the 

6 events or happenings herein referred to, thereby proximately 

7 causing the injuries and damages to their decedent Kyira as 

8 herein alleged. 

9 9. That all of the facts, acts, events and circumstances 

10 herein mentioned and described occurred in the County of Los 

11 Angeles, State of California. 

12 10. That at all times herein mentioned, Defendants Arjang 

13 Nairn, M.D., Kathryn Sharma, M.D., Sara Churchill, M:D., Stuart 

14 Martin, M.D., Benham Kashanchi, M.D. and DOES 11 through 30, 

15 inclusive, were and now are physicians and surgeons, holding 

16 themselves out as duly licensed to practice their professions 

17 under and by virtue of the laws of the State of California, and 

18 were and now are engaged in the practice of their professions in 

19 the State of California. 

20 11. At all times mentioned herein, Defendants Arjang Nairn, 

21 M.D., Kathryn Sharma, M.D., Sara Churchill, M.D., Stuart Martin, 

22 M.D., Benham Kashanchi, M.D. and DOES 11 through 30, inclusive, 

23 held themselves out to the public at large and to Plaintiffs 

24 herein as qualified physicians and surgeons duly licensed to 

25 practice their professions by virtue and under the laws of the 

26 State of California, with expertise, specialized knowledge, 

27 training, education, learning skill, techniques and expertise in 

28 certain specialities of medicine. 

9 

COMPLAINT FOR DAMAGES 
32 


36730.019

12. That holding themselves out as experts and specialists 

2 in specialized fields of surgery and medicine, possessing skills, 

3 learning and experience in said specialties, Defendants herein, 

4 at all times mentioned herein, represented to Plaintiffs that 

5 they would, at all times, exercise and use skill, prudence, 

6 learning and experience in said specialties. Defendants herein, 

7 at all times mentioned herein, represented to Plaintiffs that 

8 they would at all times exercise and use the skill, prudence, 

9 learning, knowledge and expertise in the care and treatment of 

10 decedent in accordance with the standard of practice among 

11 competent, reputable and prudent physicians practicing their 

12 specialties in the State of California. 

13 13. At all times herein mentioned, Defendants Arjang Nairn, 

14 M.D., Kathryn Sharma, M.D., Sara Churchill, M.D., Stuart Martin, 

15 M.D., Benham Kashanchi, M.D. and DOES 11 through 30, inclusive, 

16 held themselves out to the public at large and to Plaintiffs as 

17 duly qualified physicians and surgeons, duly licensed to practice 

18 their profession by virtue of and under the laws of the State of 

19 California, and exercising prudence, reasonable judgment and care 

20 in the selection, employment and control of qualified, trained, 

21 experienced nurses, nursing personnel, assistants, aides and 

22 employees, performing services and caring for patients, 

23 including, but limited to decedent, under their supervision, 

24 control, direction, responsibility and authority. 

25 14. At all times herein mentioned, Defendants Cedars-Sinai 

26 Medical Center and DOES 31 through 50, inclusive, were business 

27 organizations, form unknown, organized and existing under the 

28 laws of the State of California. 

10 

COMPLAINT FOR DAMAGES 
33 


36730.020

15. At all times herein mentioned, Defendants Cedars-Sinai 

2 Medical Center and DOES 31 through 50, inclusive, were and at all 

3 times herein mentioned are, a partnership. Defendants DOES 11 

4 through 20, inclusive, are, and at all times herein mentioned 

5 were, members of the foregoing named partnership and are sued 

6 herein individually and by said common name pursuant to the 

7 provisions C.C.P. Section 369.5. 

8 16. At all times herein mentioned, Defendants DOES 51 

9 through 60, inclusive, were and are registered nurses, nurse 

10 practitioners, licensed vocational nurses, practical nurses, 

11 registered technicians and other paramedical personnel, holding 

12 themselves out as duly licensed to practice their profession 

13 under and by virtue of the law of the State of California, and 

14 were and now are engaged in the practice of their profession 

15 under and by virtue of the laws of the State of California. 

16 17. At all times herein mentioned, Defendants DOES 61 

17 through 70, inclusive, were aides, attendants, technicians, 

18 nursing or medical students, acting as agents, employees or 

19 servants of some or all of the other defendants, within the 

20 course and scope of said agency or employment. 

21 18. Defendants Cedars-Sinai Medical Center and DOES 71 

22 through 80, inclusive, were at all times herein mentioned, duly 

23 organized California corporations and partnerships existing under 

24 and by virtue of the laws of the State of California. Said 

25 defendants, and each of them, owned, operated, managed, 

26 controlled and administered a general medical facility, hospital 

27 or 24-hour care facility within said County, State of California, 

28 and held themselves out to the public at large and to Plaintiffs 

11 

COMPLAINT FOR DAMAGES 
34 


36730.021

herein as properly equipped, fully accredited, competently 

2 staffed by qualified and prudent personnel and operating in 

3 compliance with the standard of care maintained in other properly 

4 equipped and efficiently operated and administered accredited 

5 general medical facilities, hospitals and outpatient clinics in 

6 said co~munity, offering full, competent and efficient hospital, 

7 emergency, clinical, medical, surgical, laboratory, x-ray, 

8 anesthesia, paramedical services and outpatient clinics to the 

9 general public and to decedent herein. Plaintiffs are informed 

10 and believe and thereon allege that said defendants, and each of 

II them, administered, governed, controlled, managed and directed 

12 all the necessary functions, activities and operations of said 

13 general medical facility, hospital or 24-hour care facility, 

14 including its nursing care, intern, resident and house staff, 

15 physicians and surgeons, medical staff, x-ray, intensive care, 

16 recovery room and emergency room departments and clinics, 

17 including but not limited to personnel, staff and supplies of 

18 said facilities and clinics. 

19 19. Plaintiffs are informed and believe and upon such 

20 information and belief allege that at all times herein mentioned, 

21 Defendants, and each of them, were the agents, servants, 

22 employees and copartners of their said codefendants, and as such, 

23 were acting within the course and scope of such agency, 

24 partnership, and employment at all times herein mentioned; that 

25 each and every defendant, as aforesaid, when acting as a 

26 principal, was negligent in the selecting, hiring and maintaining 

27 of each and every other defendant, as its agents, servants, 

28 partners and employees. 

12 

COMPLAINT FOR DAMAGES 
35 


36730.022

20. At all times herein mentioned, Plaintiffs' decedent 

2 Kyira was in the exclusive custody and control of Defendants, and 

3 each of them. 

4 21. Prior to April 13, 2016, decedent Kyira, who was 

5 pregnant, consulted defendants, and each of them, for the purpose 

6 of obtaining her medical care and treatment and employed 

7 defendants to care and do all things necessary in caring for her. 

8 Said Defendants undertook the employment and understood and 

9 agreed to diagnose, care and treat decedent and do all things 

10 necessary and proper in connection therewith, and said 

11 defendants, and each of them, thereafter entered into such 

12 employment, individually, and by and through their employees, 

13 employers and agents. 

14 22. At all times herein mentioned, and prior and subsequent 

15 thereto Defendants Cedars-Sinai Medical Center and DOES 71 

16 through 80, inclusive, and each of them, so negligently and 

17 carelessly failed to properly ensure the character, quality, 

18 ability and competence of individuals treating patients in said 

19 centers, hospitals and clinics, that Plaintiffs were caused to 

20 suffer and did suffer, the injuries and damages hereinafter 

21 alleged. 

22 23. Plaintiffs name the defendants herein, and each of 

23 them, because plaintiffs are in doubt and do not know from which 

24 of said defendants plaintiffs are entitled to redress and whether 

25 the injuries and damages to the plaintiffs herein alleged were 

26 caused by the combined negligence of all of the defendants, or 

27 one or more of them. For that reason, Plaintiffs name all of 

28 said defendants and ask that the Court determine liability of 
36 


36730.023

each and all of the said defendants in this action as to what 

2 extent and what responsibility falls upon each of said defendants 

3 either jointly or severally as may be found liable. 

4 24. From and after said times, defendants, and each of 

5 them, so negligently examined decedent Kyira and diagnosed and 

6 failed to diagnose her condition and so negligently treated and 

7 cared for decedent while she was in the exclusive control of said 

8 defendants, and so negligently operated, managed, maintained, 

9 selected, designed, controlled and conducted their services, 

!0 activities and equipment in connection with the care and 

ll treatment of decedent such that as a proximate result thereof, 

12 decedent Kyira died on April 13, 2016. The negligence of the 

13 Defendants, and each of them, includes, but is not limited to: 

14 • Failing to appreciate and properly manage Kyira's postIS partum hemorrhage in a timely manner; 

16 • Failing to return Kyira to surgery in a timely manner; 

!7 • Among other acts and omissions. 

18 25. Plaintiff Charles Johnson, IV is the husband of 

19 decedent Kyira and Plaintiffs Charles Johnson, V and Langston 

20 Johnson, are the sons of decedent Kyira. 

21 26. At or about the time of the filing of this complaint, 

22 Charles Johnson, IV, the father of Plaintiffs Charles Johnson, V, 

23 a minor (DOB: 09/18/2014) and Langston Johnson, a minor (DOB: 

24 04/12/2016), was appointed to serve as the Guardian Ad Litem for 

25 both Charles Johnson, V and Langston Johnson. 

26 27. As a direct and proximate result of said negligence of 

27 the defendants and the death of decedent, Plaintiffs have been 

28 and will continue to be deprived of the love, companionship, 

COMPLAINT 
37 


36730.024

comfort, affection, society, solace, moral support, care, 

2 counsel, physical assistance, services, financial support and 

3 protection of decedent Kyira, and have thereby sustained 

4 pecuniary loss in a sum according to proof in the jurisdiction of 

5 this Court. 

6 28. As a further, proximate result of the negligence of 

7 Defendants, and each of them, and the death of decedent, 

8 plaintiffs have incurred expenses for the funeral, cremation 

9 and/or burial of decedent Kyira, in a sum to be proven at the 

10 time of trial. 

11 29. That prior to the filing of this action, three years 

12 had not elapsed from the date of the death, and a period of less 

13 than one calendar year had elapsed after Plaintiffs first 

14 learned, or had a reasonable opportunity to learn, of the fact 

15 that the injuries and death suffered and complained of herein 

16 were a proximate result of the negligent acts or omissions to act 

17 on the part of the Defendants. 

18 SECOND CAUSE OF ACTION BY PLAINTIFF CHARLES JOHNSON, IV 

19 FOR NEGLIGENT INFLICTION OF EMOTIONAL DISTRESS 

20 30. Plaintiff repeats and realleges paragraphs 1, 2, 3, 6, 

21 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 20, 21, 23, 24 and 

22 29 of the allegations contained in the first cause of action as 

23 though each were set forth and incorporated herein in full. 

24 31. At all times herein mentioned, Plaintiff Charles 

25 Johnson, IV was the lawfully wedded husband of decedent Kyira 

26 Adele Dixon. 

27 Ill 

28 /// 

15 

COMPLAINT FOR DAMAGES 
38 


36730.025

32. Plaintiff Charles Johnson, IV was present and with his 

2 wife Kyira from the time she was admitted to give birth to their 

3 son until Kyira was taken to surgery on April 13, 2016. 

4 33. Plaintiff Charles Johnson, IV was seated on the side of 

5 his wife where the bag collecting her urine was located. 

6 Plaintiff Charles Johnson, IV saw Kyira's foley catheter bag 

7 tinged with blood, saw the bag begin to turn red, called the red 

8 colored foley catheter bag to the attention of Kyira's nurses, 

9 saw the foley catheter bag get redder and redder with blood, saw 

10 the heightened activity of the health care staff as they became 

II aware of the bright red blood in Kyira's foley catheter bag, saw 

I2 the foley changed, and then again saw bright red blood fill 

13 Kyira's foley catheter bag, saw the health care staff perform an 

I4 ultrasound on Kyira and state that there appeared to be a 

15 hematoma in her pelvis/abdomen, understood that a hematoma was a 

16 collection of blood, saw the health care providers perform 

17 another ultrasound and was advised that it still showed hematoma 

I8 or blood clot, discussed with Kyira and her health care providers 

19 that the bright red blood in Kyira's foley catheter bag was 

20 "concerning" and due to Kyira actively bleeding, advised by the 

21 health care providers that a "stat" CT scans had been ordered and 

22 understood it was needed and necessary to identify the source of 

23 Kyira's bleeding, was advised by Kyira's health care providers 

24 that further confirmation of the fact that Kyira was continuing 

25 to actively bleed were her blood count values which were 

26 continuing to decline, asked why the "stat" CT scans ordered for 

27 Kyira and necessary to identify the source of her bleeding had 

28 not been performed, observed Kyira continue to get pale and 
39 


36730.026

understood that Kyira's pallor was due to the continuing loss of 

2 blood, observed the health care providers provide Kyira with 

3 fluids and blood and understood that such fluids and blood was 

4 due to the Kyira's continuing loss of blood, repeatedly asked 

5 again why the ftstatn CT scans ordered for Kyira and necessary to 

6 identify the source of her active bleeding, understood that 

7 despite the passage of hours since the bright red blood he 

8 observed in Kyira's foley catheter bag the health care providers 

9 had still not done anything to identify the source of the active 

10 bleeding and had not done anything to stop the active bleeding 

11 which he knew was continuing and causing Kyira's condition to 

12 continue to deteriorate, continued to express concern progressing 

13 to demanding information why his wife was continuing to 

14 deteriorate without any intervention improving her condition and 

15 continued to ask and then demand why the ftstatn CT scans ordered 

16 for Kyira had not been done. The events described in this 

17 paragraph took place over approximately seven (7) hours. 

18 34. Because of what he observed, what he heard and what he 

19 was told by the health care providers, Plaintiff Charles Johnson, 

20 IV, knew that Kyira's continued active bleeding caused a serious 

21 risk of harm to her. Because of what he observed, what he heard 

22 and what he knew, Plaintiff Charles Johnson, IV, was 

23 contemporaneously aware and understood that the inadequate 

24 actions of the health care providers over a period of 

25 approximately seven (7) hours were causing harm to Kyira because 

26 the source of her active bleeding had not been identified, the 

27 bleeding had not stopped, Kyira's condition was deteriorating to 

28 the point where she was experiencing pain, Kyira was pale and 

7 

COMPLAINT FOR DAMAGES 
40 


36730.027

groggy, and Kyira had and was continuing to lose blood which the 

2 health care providers were unable to sufficiently replace with 

3 fluids and blood products. 

4 35. As a direct and proximate result of the failure of the 

5 Defendants to properly and timely respond to his wife's symptoms 

6 and the inadequate treatment provided to her by defendants, and 

7 each of them, Plaintiff Charles Johnson, IV did suffer serious 

8 and severe emotional disturbance, distress and shock and injury 

9 to his nervous system, all of which has caused, and continues to 

10 cause, and will cause in the future, serious mental and emotional 

11 suffering, in an amount in excess of the minimum jurisdiction of 

12 this court. 

13 WHEREFORE, Plaintiffs pray for judgment against the 

14 Defendants, and each of them, as follows: 

15 FOR THE FIRST AND SECOND CAUSES OF ACTION: 

16 

17 

18 

19 

20 

21 

1. 

2. 

3. 

4. 

5. 

6. 

General damages according to proof; 

Special damages according to proof; 

Funeral and burial expenses according to proof; 

Prejudgment interest; 

For all costs of suit herein incurred; and 

For such other and further relief as the Court may deem 

22 just and proper. 

23 DATED: March 24), 2017 

24 

25 

26 

27 

28 

LAW OFFICES OF MICHAEL L. ORAN 

ey, ~ ewJi?u__ "tCHAELt:. ORAN, ESQ. 

18 

Attorneys for Plaintiffs 

CHARLES JOHNSON, IV, 

CHARLES JOHNSON, V and 

LANGSTON JOHNSON 

COMPLAINT FOR DAMAGES 
41 


36730.028
42 

Mr. BURGESS. Mr. Johnson, we do sincerely appreciate your testimony and as a committee I will say we are terribly sorry for your 

loss, but grateful for your courage to be here today and present 

your testimony to us. Thank you, Mr. Johnson. 

Ms. Stewart, you are recognized for 5 minutes. 

STATEMENT OF STACEY STEWART 

Ms. STEWART. Thank you, Mr. Chairman. 

Mr. BURGESS. I know, he is tough to follow. 

Ms. STEWART. Very hard to follow that so—and I am known by 

my family to be one of the biggest crybabies, but it is for good reason. 

So thank you for inviting me to testify at this very important 

hearing today. I am Stacey Stewart. I am President of the March 

of Dimes. March of Dimes is leading the fight for the health of all 

moms and babies. And I would like everyone in this room to take 

a look at this blanket. Just about everyone that has had a child 

will never forget the very moment when a doctor placed a precious 

baby boy or baby girl into our arms wrapped into one of these blankets. 

More than 700 times a year, beautiful babies are wrapped into 

these blankets, in one just like this one, but unfortunately there is 

no mother to hold a child that is wrapped in that blanket. So that 

is not just a statistic. There are 700 mothers that die every single 

year and almost and over 50,000 who experience dangerous complications that could have killed them, making the U.S. the most 

dangerous place in the developed world to give birth. 

And we think and we know that you agree that this situation is 

completely unacceptable. Our nation is in the midst of a crisis of 

maternal and child health. Across this nation, virtually every 

measure of the health of pregnant women, new mothers, and infants is going in the wrong direction. The number of babies born 

premature is rising in this country. In many communities, infant 

mortality, rates of infant mortality exceed those in developing nations. Nations such as Slovenia and French Polynesia have better 

infant mortality rates than here in the United States. 

Women are tragically dying, women like Kira, from pregnancyrelated causes and are suffering from severe health consequences 

like infertility. While other countries have reduced their infant 

mortality rates, the number of women who die from pregnancy-related causes in the U.S. has doubled in the last 25 years. And as 

we have heard this morning already, black women are three to four 

times more likely to die from pregnancy-related causes than white 

women, which is a truly shocking and appalling disparity. 

Maternal mortality is also significantly higher in rural areas 

where obstetrical providers may not be available and delivery in 

rural hospitals is associated with higher rates of postpartum hemorrhage. March of Dimes will release a report in the coming weeks 

that will show that maternity care deserts exist in this country and 

in these deserts pregnant women face serious challenges in receiving appropriate care. 

The state of maternal health in the United States is dire, but 

there are things we can do and we must do. Many factors are contributing to the maternal health crisis in this nation and our work 

43 

to address it is important and it must be equally multifaceted. The 

bill before the subcommittee today is a critical step towards preventing death or serious health outcomes for pregnant women and 

new mothers. 

The discussion draft of H.R. 1318, the Preventing Maternal 

Deaths Act, would provide grants to states and tribes to help establish or improve maternal mortality review committees or MMRCs. 

MMRCs are interdisciplinary groups of local experts that come together in maternal, infant, and public health to investigate the 

cases of maternal death, identify those systemwide factors that contributed to these deaths, and then develop recommendations that 

would help prevent future cases. 

MMRCs are unique in that they identify solutions. Not just collect the data, but then identify solutions that are targeted to the 

needs of pregnant women and mothers in specific states, cities, and 

communities. The discussion draft of H.R. 1318 would also establish a demonstration project to determine how best to address disparities in maternal health outcomes. 

Mr. Chairman and members of the subcommittee, while this bill 

is extremely important, maternal mortality is not a single problem 

with a single solution. The causes of maternal mortality and severe 

maternal morbidity are diverse. They include physical health, mental health, social determinants, and much more. They can be traced 

back to the issues in our healthcare system including the quality 

of care as we just heard so passionately from Charles, systems 

problems, and of course the issue of implicit bias that exist in our 

healthcare system. They stem from factors in our homes, our workplaces, and our communities. 

Mr. Chairman and members of the subcommittee, thank you for 

recognizing the urgency and the magnitude of this public health 

crisis. Our nation’s mothers and babies cannot wait any longer. We 

must act now to save the lives and the health of pregnant women, 

new mothers, and their babies. Thank you. 

[The prepared statement of Ms. Stewart follows:] 

44 


36730.029

TESTIMONY OF STACEY D. STEWART 

PRESIDENT, MARCH OF DIMES 

BEFORE THE ENERGY AND COMMERCE SUBCOMMITIEE ON HEALTH 

HEARING 

"BETIER DATA AND BETIER OUTCOMES: REDUCING MATERNAL 

MORTALITY IN THE U.S." 

SEPTEMBER 27,2018 

MARCH OF DIMES 
45 


36730.030

Thank you, Mr. Chairman, for this opportunity to testify today before the Energy and Commerce 

Subcommittee on Health at this hearing, "Better Data and Better Outcomes: Reducing Maternal 

Mortality in the U.S." I am Stacey D. Stewart, President of March of Dimes, and I would like to commend 

you for holding this important hearing. March of Dimes is leading the fight for the health of all moms 

and babies. 

Imagine, if you would, a classic hospital receiving blanket. It's made of soft white flannel, with a pastel 

blue and pink stripes on each end. Any of us with children will never forget that first moment when the 

doctor placed our precious baby boy or girl in our arms, wrapped warmly in one of these blankets. More 

than 700 times a year, a beautiful baby is wrapped up in a blanket just like this one -- but there is no 

mother to hold that child. That is not just a statistic; 700 mothers die every year, and over 50,000 others 

experience dangerous complications that could have killed them - making the U.S. the most dangerous 

place in the developed world to give birth. This situation is completely unacceptable. 

Our nation is in the midst of a crisis in maternal and child health. Across our nation, virtually every 

measure of the health of pregnant women, new mothers, and infants is going in the wrong direction. 

Preterm birth rates are rising. In many communities, infant mortality rates exceed those in developing 

nations. Nations like Slovenia and French Polynesia have a better infant mortality rate than the U.S. 

Striking disparities exist among the health of mothers and babies of different racial and ethnic 

backgrounds. Black children face the highest child mortality rate among racial/ethnic groups- more 

than 2 times higher than the rate for Asian children and 1.5 times higher than the rate for white 

children.' There are dramatic variations in key measures like well-visits for women and infants among 

different racial and ethnic groups as well as geographic areas. 

MARCH OF DIMES 
46 


36730.031

Maternal Mortality and Severe Maternal Morbidity Are a Public Health Crisis 

Across the United States, women are tragically dying or suffering serious consequences from pregnancyrelated causes. Despite the fact that many countries around the world have successfully reduced their 

maternal mortality rates since the 1990s, the U.S. rate is still higher than most other high-income 

countries,;, and the U.S. maternal mortality rate has doubled in the past 25 years.m A significant racial and 

ethnic disparity in maternal mortality exists in the U.S., with black women being three to four times more 

likely to die from pregnancy-related causes compared to white women.;v,v 

Maternal mortality is also significantly higher in rural areas, where obstetrical providers may not be 

available,'; and delivery in rural hospitals is associated with higher rates of postpartum hemorrhage!;; 

March of Dimes will release a report in the coming weeks that will show these "maternity care deserts," 

where pregnant women face serious challenges in receiving appropriate care. 

Approximately 700 women die each year in the U.S. as a result of pregnancy or pregnancy-related 

complications.';;; The Centers for Disease Control and Prevention {CDC) estimates that up to 60% of 

these deaths are preventable.;'·' For every maternal death, there are about 100 episodes of severe 

maternal morbidity (SMM) affecting more than 50,000 women in the United States every year." 

According to the CDC, pregnancy-related deaths are those that occur during pregnancy or within the 

following year due to pregnancy complications, because of a chain of events initiated by pregnancy, or 

because of an unrelated condition that was aggravated by pregnancy.';; Severe maternal morbidity 

includes unexpected outcomes of labor and delivery that result in significant short or longer term 

consequences to a woman's health.';;; 

MARCH OF DIMES 
47 


36730.032

Causes of maternal deaths include cardiovascular conditions, hypertensive disorders of pregnancy 

(preeclampsia/eclampsia), infection, hemorrhage, suicide and drug overdose. Identifying and treating 

medical conditions before, during and after pregnancy are essential to preventing maternal morbidity 

and maternal mortality, as part of the continuum of care for all women of childbearing age. This requires 

a commitment to high-quality clinical care and enhanced maternal quality improvement and safety 

initiatives in hospitals, particularly those that address disparities, structural barriers to care, differential 

care experienced by women of color, and provider implicit racial bias.''v 

March of Dimes supports efforts to eliminate preventable maternal mortality and SMM and the 

unacceptably large disparities in rates experienced by black women. To achieve this, March of Dimes: 

Encourages every state to have a maternal mortality review committee that investigates each 

death of a pregnant woman or new mother to understand causes and recommend interventions 

for the future. 

• Supports efforts to improve ways to collect data on maternal mortality and SMM, research into 

their causes and prevention, and promotion of proven ways to keep all mothers healthy. 

• Supports ensuring access to inpatient obstetrical facilities and qualified obstetrical providers in 

rural settings. 

• Supports state perinatal quality collaboratives working with hospitals to identify and review 

cases of SMM and implement hospital based quality improvement initiatives to improve care 

and promote patient safety. 

• Supports efforts to ensure that all women have quality, affordable health insurance and health 

care to include but not limited to postpartum depression screening, mental health treatment, 

M\ 

MARCH OF DIMES 
48 


36730.033

substance use treatment, affordable contraception, including long-acting reversible 

contraception (LARC), and access to health care providers who understand and meet their 

health needs before, during and after pregnancy. 

• Supports improving the social and economic conditions and quality of health care at all stages of 

a woman's life. 

Encourages acceleration of policies and programs shown to provide preventive and supportive 

care for women during pregnancy, including group prenatal care. 

The Preventing Maternal Deaths Act is a Critical Step Forward 

The state of maternal health in the U.S. is dire, but there are things we can and must do. Many factors 

are contributing to the maternal health crisis in our nation, and our work to address it must be equally 

multi-faceted. The bill before the subcommittee today represents a critical step toward preventing 

death or serious health outcomes for pregnant women and new mothers. 

The discussion draft of H.R. 1318, the Preventing Maternal Deaths Act, sponsored by Representatives 

Jaime Herrera Beutler (R-WA), Diana DeGette (D-CO) and Ryan Costello (R-PA) mirrors S. 1112, the 

Maternal Health Accountability Act, as recently passed by the Senate Committee on Health, Education, 

Labor and Pensions. would provide grants to states and tribes to help establish maternal mortality 

review committees (MMRCs)- interdisciplinary groups of local experts in maternal, infant and 

public health- to investigate cases of maternal death, identify system-wide factors that contributed 

to the deaths, and develop recommendations to prevent future cases. MMRCs are unique in that 

they identify solutions targeted to the needs of pregnant women and mothers in specific states, 

cities and communities. The discussion draft of H.R. 1318 would also establish a demonstration 

MARCH OF DIMES 
49 


36730.034

project to help ascertain how best to address disparities in maternal health outcomes. Together, 

these provisions will help us obtain the information and recommendations we need to prevent 

women from dying or experiencing serious health consequences of pregnancy. Congress should 

pass this important legislation as quickly as possible. 

Our nation cannot prevent maternal mortality if we lack data about where and why it takes place. 

This legislation will fill significant gaps in our current knowledge by ensuring we have nationwide 

data on maternal mortality rates as well as information about causes. It will provide states and 

tribes with new resources to gather information and ensure their maternal mortality review 

committees operate according to best practices. Finally, it will protect the privacy of women and 

their families by ensuring strong confidentiality processes are in place to prevent the unauthorized 

release of information. 

Mr. Chairman and members of the subcommittee, while this bill is extremely important, maternal 

mortality is not a single problem with a single solution. The causes of maternal mortality and severe 

maternal morbidity are diverse; they include physical health, mental health, social determinants, 

and much more. They can be traced back to issues in our health care system, including quality of 

care, systems problems, and implicit bias. They stem from factors in our homes, our workplaces, 

and our communities. The effort to save women's lives can't just end with one hearing and one bill. 

I urge Congress to launch a series of hearings into the root causes of maternal mortality and to pass 

additional measures to improve maternal and child health, because every mom and baby deserve a 

healthy start. 

M\ 

MARCH OF DIMES 
50 


36730.035

In conclusion, I would like to thank you, Mr. Chairman and members of the subcommittee, for 

recognizing the urgency and magnitude of this public health crisis, Our nation's mothers and babies 

cannot wait any longer. We must act now to save the lives and health of pregnant women, new 

mothers and their infants. Piecemeal efforts are not enough; moms and babies are dying. We need 

blanket change. March of Dimes stands ready to assist you in working to protect and improve the 

health of all women and babies, 

'America's Health Rankings Health of Women and Children Report. March 2018. United Health Foundation. 

Available at https://assets.americashealthrankings.orglappluploads/ahr hwc 2018 report summary 022818a.pdf 11 WHO. Trends in Maternal Mortality 1990-2015. Available at: 

http:llwww.who.intireproductivehealth/publicationslmonitoringlmaternal-mortalitv-2015/enl 

'"CDC. Pregnancy Mortality Surveillance System. Available at: 

https://www.cdc.gov/reproductivehealthlmaternalinfanthealth/pmss.html 

'' Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Pregnancy-related mortality in the United 

States, 2006-2010. Obstet Gynecol2015;125(1):5-12. 

'Callaghan WM. Overview of maternal mortality in the United States. Semin Perinatol2012;36(1):2-6. 

''Faron, Dina. Maternal Health Care is disappearing in rural America. Scientific American, February 15, 2017. 

'" Kozhimannil KB, Thao V, Hung P, Tilden E, Caughey AB, Snowden JM. Association between hospital birth volume 

and maternal morbidity among low-risk pregnancies in rural, urban, and teaching hospitals in the United States. Am 

J Perinatal 2016 May;33(6):590-9. 

'"' MMRIA. Report from Nine Maternal Mortality Review Committees. February 2018. Available at: 

https://www.cdcfoundation.org/buildinq-us-capacity-review-and-prevent-maternal-deaths 

"Berg CJ, Harper MA, Atkinson SM, et al. Preventability of pregnancy-related deaths: results of a state-wide review. 

Obstet Gynecol 2005;106(6):1228-1234. 

'MMRIA. Report from Nine Maternal Mortality Review Committees. February 2018. Available at: 

https:i/www.cdcfoundation.org/buildinq-us-capacitv-review-and-prevent-maternal-deaths 

" CDC. Severe Maternal Morbidity in the United States. Available at: 

https://www.cdc.gov/reproductivehealthlmaternalinfanthealth/severematernalmorbidity.html 

"' CDC. Pregnancy Mortality Surveillance System. Available at: 

https:/lwww.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html 

""CDC. Severe Maternal Morbidity in the United States. Available at: 

https://www.cdc.gov/reproductivehealth/maternalinfanthealthlseverematernalmorbidity.html 

'''Jain JA, Temming LA, D'Aiton ME, et al. SMFM Special Report: Putting the "M" back in MFM: Reducing racial and 

ethnic disparities in maternal morbidity and mortality: A call to action. Am J Obstet Gynecoi2018;218(2):B9-B17. 

MARCH OF DIMES 
51 

Mr. BURGESS. Thank you, Ms. Stewart. 

Dr. Coslett-Charlton, you are now recognized for 5 minutes, 

please. 

STATEMENT OF LYNNE COSLETT-CHARLTON 

Dr. COSLETT-CHARLTON. Chairman Burgess, Ranking Member 

Green, Chairman Walden, Ranking Member Pallone, and distinguished members of the Energy and Commerce Subcommittee on 

Health, thank you for inviting me to speak with you today on behalf of the American College of Obstetricians and Gynecologists at 

this hearing entitled, Better Data and Better Outcomes: Reducing 

Maternal Mortality in the U.S. 

ACOG, with a membership of more than 58,000, is the leading 

physician organization dedicated to advancing women’s health. Today’s hearing will focus on a discussion draft of H.R. 1318, the Preventing Maternal Deaths Act, sponsored by Representatives Jaime 

Herrera Beutler, Diana DeGette, and Ryan Costello. I want to extend a special thank you to the bill sponsors for working so diligently on this bipartisan legislation, a critical first step in improving maternal health outcomes for women in this country. 

A special thanks also to you, Dr. Burgess, my colleague OB/GYN, 

for your leadership highlighting this critically important issue and 

making maternal mortality a top priority. 

As many of you know, the United States has a maternal mortality crisis. Too many women die each year in the United States 

from pregnancy-related and pregnancy-associated complications. 

We have higher maternal mortality rates than any other developed 

country. At a time when 157 of 183 countries in the world report 

decreases in maternal mortality, ours is rising. Black women are 

disproportionately affected and are three to four times more likely 

to lose their lives than white women. And for every maternal death 

in the United States there are a hundred women who experience 

severe maternal morbidity or near misses. 

This is all unacceptable and the time for action is now. We know 

that over 60 percent of maternal deaths are preventable. Common 

causes include hemorrhage, cardiovascular and coronary conditions, 

cardiomyopathy, or infection. Overdose and suicide, driven primarily by the opioid epidemic, are also emerging as the leading 

causes of maternal mortality in a growing number of states including my own. If we have a clear understanding of why these deaths 

are occurring and what we can do to prevent them in the future, 

we can save women’s lives. 

The Preventing Maternal Death Act assists states in creating or 

expanding maternal mortality review committees through the Center of Disease Control and Prevention. MMRCs are multidisciplinary groups of local experts in maternal and public health as 

well as patient and community advocates that closely examine maternal death cases and identify locally relevant ways to prevent future deaths. While traditional public health surveillance using vital 

statistics can tell us about trends and disparities, MMRCs are the 

vehicle best positioned to comprehensively assess maternal deaths 

and identify, most importantly, opportunities for prevention. 

As ACOG’s Pennsylvania Section Chair and incoming District III 

Legislative Chair and a practicing physician for over 20 years, adVerDate Nov 24 2008 13:47 Jun 17, 2019 Jkt 037690 PO 00000 Frm 00057 Fmt 6633 Sfmt 6633 U:\MY DOCS\HEARINGS 115\HEARINGS\115-169 CHRIS
52 

dressing maternal mortality is of critical importance to me. As an 

OB/GYN, seeing a woman die while pregnant or after delivering a 

baby is something that sticks with you for life and has stuck with 

me throughout my career. Preventing that kind of tragedy and ensuring the health and safety of the women we care for is central 

to our mission. 

When I took over as ACOG’s Pennsylvania Section Chair, Pennsylvania did not have MMRC, though the city of Philadelphia did. 

And over the past 2 1⁄2 years I have worked diligently to organize 

the campaign with other OB/GYNs and other advocates in my state 

and the Department of Health to urge the state legislators to pass 

legislation to form our first statewide MMRC. Finally, on May 9th, 

Governor Wolf signed the Maternal Mortality Review Act. Our first 

meeting is next week. Enthusiasm like this for MMRCs is growing 

all over the country. Today, approximately 33 states have MMRC 

and as many of those 33, including Pennsylvania, are brand new 

this year. 

But states like ours need help. The CDC plays a vital role in assisting these states to ensure their MMRCs are robust, multidisciplinary, and using standardized reporting, which is why it is important to have this federal legislation as mechanisms. The Building U.S. Capacity to Prevent Maternal Deaths Initiative, a partnership between the CDC’s National Center for Chronic Disease Prevention and Health Promotion, the CDC Foundation, the Association for Maternal & Child Health Programs, and Merck for Mothers has made tremendous progress giving technical assistance to 

states to help them establish MMRCs or ensure established 

MMRCs are operating with evidence-based practices. 

In Pennsylvania we need to ensure that this type of technical assistance is amplified so that we can get our MMRC off the ground 

and working correctly. Once MMRCs are up and running they lead 

to opportunities for quality improvement. For example, to participate in the Alliance for Innovation on Maternal Health, or AIM, a 

state must first have an MMRC. AIM convened under ACOG’s 

leadership is a national alliance of clinicians, hospital administration, patient safety organizations, and patient advocates that work 

to reduce maternal mortality and severe morbidity by creating condition-specific bundles which are evidence-based toolkits to improve 

maternal outcomes. Some of these bundles include severe hypertension, maternal mental health, obstetric care for women with 

opioid use disorder, obstetric hemorrhage, and racial disparities in 

maternity care. To participate in AIM, a state must first have 

MMRC. The data recommendations from MMRCs instruct states 

where they need to invest to address specific conditions that affect 

women in their community and ensure proper appropriate targeting of limited resources. 

For us to clearly understand why women are dying from preventable maternal complications across the country and make lasting 

improvements, every state must have a robust MMRC. The Preventing Maternal Death Act will help us reach that goal and ultimately improve maternal health across this country. Thank you 

very much for the opportunity to speak to you about this pressing 

issue and in support of this very important legislation. 

[The prepared statement of Dr. Coslett-Charlton follows:] 

53 


36730.036

Written Testimony 

Of 

The American College of Obstetricians and Gynecologists 

Submitted by: 

lynne Coslett-Charlton, MD, FACOG 

Before the 

House Energy and Commerce Subcommittee on Health 

Regarding the Subcommittee Hearing 

Better Data and Better Outcomes: Reducing Maternal Mortality in the U.S. 

September 27, 2018 
54 


36730.037

Chairman Burgess, Ranking Member Green, Chairman Walden, Ranking Member Pallone, and 

distinguished Members of the Energy & Commerce Subcommittee on Health, thank you for inviting me 

to speak with you today on behalf of the American College of Obstetricians and Gynecologists (ACOG) at 

this hearing entitled, "Better Data and Better Outcomes: Reducing Maternal Mortality in the U.S." 

ACOG, with a membership of more than 58,000, is the leading physician organization dedicated to 

advancing women's health. Today's hearing will focus on a discussion draft of H.R. 1318, the Preventing 

Maternal Deaths Act, sponsored by Representatives Jaime Herrera Beutler, Diana DeGette, and Ryan 

Costello. I want to extend a special thank you to the bill sponsors for working so diligently on this 

bipartisan legislation- a critical first step in improving maternal health outcomes for women in this 

country. Special thanks also to you, Dr. Burgess, a colleague ob-gyn, for your leadership highlighting this 

critically important issue and making maternal mortality a top priority. 

As many of you may know, the United States has a maternal mortality crisis. Too many women die each 

year in the United States from pregnancy-related or pregnancy-associated complications.' We have a 

higher maternal mortality rate than in any other developed country. At a time when 157 of 183 

countries in the world report decreases in maternal mortality, ours is rising.;; Black women are 

disproportionately affected and are three to four times more likely to lose their lives than white 

women.;;' For every maternal death in the United States, there are 100 women who experience severe 

maternal morbidity, or a "near miss". This is all unacceptable, and the time for action is now. 

We know that over 60 percent of maternal deaths are preventable.'' Common causes include 

hemorrhage, cardiovascular and coronary conditions, cardiomyopathy, or infection. Overdose and 

suicide, driven primarily by the opioid epidemic, are also emerging as the leading causes of maternal 
55 


36730.038

mortality in a growing number of states.' If we have a clear understanding of why these deaths are 

occurring, and what we can do to prevent them in the future, we can save women's lives. 

The Preventing Maternal Deaths Act assists states in creating or expanding maternal mortality review 

committees (MMRCs) through the Centers for Disease Control and Prevention (CDC). MMRCs are 

multidisciplinary groups of local experts in maternal and public health, as well as patient and community 

advocates, that closely examine maternal death cases and identify locally-relevant ways to prevent 

future deaths. While traditional public health surveillance using vital statistics can tell us about trends 

and disparities, MMRCs are best positioned to comprehensively assess maternal deaths and identify 

opportunities for prevention. 

As ACOG's Pennsylvania Section Chair, incoming ACOG District Ill legislative Chair, and practicing 

physician for over 20 years, addressing maternal mortality is of critical importance to me. As an ob-gyn, 

seeing a woman die while pregnant or after delivering a baby is something that sticks with you for life. 

Preventing that kind of tragedy and ensuring the health and safety of the women we care for is central 

to our mission. When I took over as ACOG Pennsylvania Section Chair, Pennsylvania didn't have a 

maternal mortality review committee, though the city of Philadelphia did. Over the past two years, I 

have worked diligently to organize a campaign with other ob-gyns and advocates to urge the state 

legislature to pass legislation to form a statewide MMRC. Finally, on May 9, 2018, the governor signed 

the Maternal Mortality Review Act. 

Enthusiasm like this for MMRCs is growing all over the country. Today, approximately 33 states have an 

MMRC- and many of those 33, including Pennsylvania, are brand new this year.'' But states like ours 

need help. CDC plays a vital role in assisting these states to ensure their MMRCs are robust, 
56 


36730.039

multidisciplinary, and using standardized reporting mechanisms. The Building U.S. Capacity to Prevent 

Maternal Deaths initiative- a partnership between the CDC's National Center for Chronic Disease 

Prevention and Health Promotion, the CDC Foundation, the Association for Maternal & Child Health 

Programs, and Merck for Mothers- has made tremendous progress giving technical assistance to states 

to help them establish MMRCs or ensure established MMRCs are operating with evidence-based 

practices. In Pennsylvania, we need to ensure that this type of technical assistance is amplified, so we 

can get our MMRC off the ground and working correctly. 

Once MMRCs are up and running, they lead to opportunities for quality improvement. For example, to 

participate in the Alliance for Innovation on Maternal Health, or AIM, a state must have an MMRC. 

AIM, convened under ACOG's leadership, is a national alliance of clinicians, hospital administrators, 

patient safety organizations, and patient advocates that work to reduce maternal mortality and severe 

maternal morbidity by creating condition-specific "bundles"- evidence-based toolkits to improve 

maternal outcomes. Some of these bundles include: severe hypertension, maternal mental health, 

obstetric care for women with opioid use disorder, obstetric hemorrhage, and racial disparities in 

maternity care. 

To participate in AIM, states must have an MMRC. The data and recommendations from MMRCs instruct 

states where they need to invest to address specific conditions that affect women in their community 

and ensure appropriate targeting of limited resources. 

For us to clearly understand why women are dying from preventable maternal complications across the 

country and make lasting improvements, every state must have a robust MMRC. The Preventing 
57 


36730.040

Maternal Deaths Act will help us reach that goal, and ultimately improve maternal health across this 

country. 

Thank you for the opportunity to speak to you about this pressing issue and in support of this important 

legislation. I'm happy to answer any questions. 

'Building U.S. Capacity to Review and Prevent Maternal Deaths. (2018). Report from nine maternal mortality review 

committees. Retrieved from http:/ /reviewtoaction.org/Report_from_Ni ne_MMRCs 

"Lu MC. Reducing Maternal Mortality in the United States. JAMA. Published online September 10, 2018. 

doi:l0.1001/jama.2018.11652 

iii Pregnancy Mortality Surve!!lance System. Centers for Disease Control and Prevention. Available at: 

https:/ /www.cdc.gov I reproductivehealth/materna linfanthealth/pmss.html 

111 Building US Capacity to Review and Prevent Maternal Deaths. (2018). Report from nine maternal mortality review 

committees. Retrieved from http://reviewtoaction.org/Report_from_Nine_MMRCs 

'Ibid. 

111 Ibid. 
58 

Mr. BURGESS. Thank you, Dr. Charlton. 

Dr. Crear Perry, you are recognized for 5 minutes, please. 

STATEMENT OF JOIA CREAR PERRY 

Dr. PERRY. So, thank you fellow ACOG member, Dr. Burgess. 

Mr. BURGESS. And if you will suspend for a moment, in the interest of full disclosure I am a dues-paying member of the American 

College of Obstetricians and Gynecologists. 

Dr. PERRY. Here we go. 

Mr. BURGESS. And I am current on that. And I don’t do the emeritus stuff, I pay the full freight. You may proceed. 

Dr. PERRY. And Ranking Member Green, thank you as well, and 

to my fellow colleagues on the panel. I really feel like going last 

is always a great way to go because you can hear what the gap 

might be in explaining this. 

I get to work with the 33 states who are doing the MMRCs. As 

an organization we provide technical assistance. We also get to 

work in places like Philadelphia. We have been doing it for awhile. 

So a concrete example would be in Philadelphia they had a lot of 

women who were dying from cardiomyopathy, which sounds really 

medical, right, because your heart fails, it won’t pump as well. 

When they actually reviewed the deaths, many of the women had 

heroin addiction, right, so it was something you could prevent if 

you actually put in mental healthcare services for addiction. So it 

is important for us to have a broader view. 

Someone brought up California, which is really important. So 

California has decreased their deaths, but they still have a racial 

disparity. Still, in California despite having these great outcomes, 

they have had increased deaths for black women. So what they are 

doing now is really going back to look at implicit bias that was 

mentioned, making sure that their providers are culturally cognizant and having really some rules around what does it mean if 

you don’t value a woman and she is not seen for several hours, how 

does that system respond to that and what can we do differently 

to ensure that people are seen in an appropriate amount of time. 

So just wanted to give some teeth to how important this is and 

how having the ability to actually look at the deaths individually 

and to talk to family members and to have mental health there 

really can help us to get to some answers. 

So now I want to tell you a little bit of my own story, because 

every woman’s story needs to be heard and this is what the MMRC 

allows you to do. So when I was a third-year medical student in 

my home of Louisiana after attending Princeton for undergrad, my 

then-husband and I were expecting our planned second child. At 

about 5 1⁄2 months pregnant, my water broke. My mother, who is 

here and a pharmacist, still recounts how panic-stricken she was 

when she was counseled by my physician about the risk of infection 

to my son and I that included death. 

I had access to excellent health care for him provided by my 

health insurance coverage, but the stress of racism was my only 

risk factor for the premature birth of my son. The hospital where 

I was training was named Confederate Memorial just 20 years 

prior to this. Luckily, my 22-year-old son and I survived, but the 

sad reality is that my 25-year-old daughter has a higher risk of 

59 

dying in childbirth than I did when I had her. The same is true 

for all of us who have daughters in the United States. We are failing our daughters, especially our black daughters who are dying at 

three to four times the rate of their white counterparts. 

So, ultimately, what we are asking for this bill, when you think 

about what Charles said and what all of us have said, is we can 

no longer delay acting. This bill has been reiterated many times in 

Congress and I am excited to hear that maybe we can have it done 

by the end of this year, because it is important for us to say that 

we as a country—I got to testify at the U.N. about this very issue— 

the world is watching us. The world sees us. I get flown to Geneva 

to talk about how important it is for the United States to actually 

value women and to pay for and look at why women are dying, so 

this is an opportunity for us to say yes, we do value women and 

yes, we do want to see what is actually happening to them. 

So ultimately what women, especially black women, in the 

United States need is accountability. We need to know that our 

lives are valued. We need to know that this accountability might 

be difficult, it might be complicated, but government still has an 

obligation to act. Accountability is a value that all Americans can 

agree upon, yet racism, classism, and gender oppression are killing 

all of us from rural to urban America. This is not about intentions. 

Lack of action is unintentionally killing us. It is a human rights 

imperative. We just ensure that prevention efforts and resources 

are being directed towards the areas of greatest need and be willing to name the problem directly. 

Much can be accomplished through improving monitoring and 

data collection. 

Me and my big writing because my eyes are getting bad, I am 

getting old. 

H.R. 1318 is a tremendous step forward in showing that we do 

recognize, yes, black mamas matter. That is it. 

[The prepared statement of Dr. Perry follows:] 

60 


36730.041

September 25, 2018 

TESTIMONY 

OF 

JOIA CREAR- PERRY, MD 

FOUNDER and PRESIDENT 

NATIONAL BIRTH EQUITY COLLABORATIVE 

ADVISORY BOARD MEMBER 

BLACK MAMAS MATTER ALLIANCE 

BEFORE THE 

SUBCOMMITTEE ON HEALTH 

COMMITTEE ON ENERGY AND COMMERCE 

U.S. HOUSE OF REPRESENTATIVES 

"BETTER DATA AND BETTER OUTCOMES: REDUCING 

MATERNAL MORTALITY 

THE U.S." 10:00 a.m., FRIDAY, SEPTEMBER 27, 2018 
61 


36730.042

Testimony of Dr. Joia Crear-Perry 

Founder National Birth Equity Collaborative 

In Support of H.R. 1318: Preventing Maternal Mortality Act of 

2017 "BETTER DATA AND BETTER OUTCOMES: 

REDUCING MATERNAL MORTALITY IN THE U.S." U.S. 

House Energy and Commerce Subcommittee on Health September 

27,2018 

Good Morning Mr. Chairman, Ranking Member Green, members 

of the House Committee on Energy and Commerce Health 

Subcommittee for allowing me, Dr. Joia Crear- Perry, to testify at 

this Better Data and Better Outcomes: Reducing Maternal 

Mortality in the US hearing representing the National Birth Equity 

Collaborative and the Black Mamas Matter Alliance. 

H.R.1318 will support states in their work to save and sustain the 

health of mothers during pregnancy, childbirth, and in the 

postpartum period. Of vital importance to my reproductive justice 

peers and I, it will work to eliminate disparities across maternal 

health outcomes for pregnancy-related and pregnancy-associated 

deaths. H.R. 1318, working with groups such as ours, will also 

identify solutions to improve health care quality and health 

outcomes for mothers. 

As you may be aware, the United States is the only developed 

country in the world where maternal mortality is on the rise. 

Further, Black women in the U.S. die at 3 to 4 times the rate of 

their white counterparts. Despite clear evidence of this inequity, 

policymakers, and as a consequence, government had not, until 

now, addressed this urgent public health and human rights issue. 

The Centers for Disease Control defines Pregnancy Related death 
62 


36730.043

as the death of a woman while pregnant or within one year of the 

end of a pregnancy - regardless of outcome, duration or site of the 

pregnancy - from any cause related to or aggravated by pregnancy 

or its management. Based on that definition, the CDC found in 

their surveillance, 2, 726 women died in the United States between 

2011 and 2014 and of those 1,010 or 38% were Black. As a Black 

woman from the Deep South, who is an obstetrician and a mother, 

my strong desire to end this inequity is amplified every time I look 

into the faces of my daughter and patients. 

As a Black mother, I cannot buy or educate my way out of dying at 

3 to 4 times the rate of a white mother in the United States. The 

inequity in maternal mortality rates persists regardless of our 

income or education status. A White woman with less than a high 

school education has a better chance to live in childbirth than a 

Black woman with a college degree. The legacy of a hierarchy of 

human value based on the color of our skin continues to cause 

differences in health outcomes, including maternal mortality. 

Racism is the risk factor - not Black skin. There is no "Black" 

gene. 

Maternal mortality extends beyond the period of pregnancy or 

birth. Nine months of prenatal care cannot counter underlying 

social determinants of health inequities in housing, political 

participation, transportation, education, food, environmental 

conditions, and economic security; all of which have racism as 

their root cause. We have data that shows that a Black woman who 

initiates prenatal care in the first trimester has a worse outcome in 

birth than a white woman with late or no prenatal care. 

Good maternal health outcomes depend upon implementation of all 

sexual and reproductive rights, from comprehensive sexual 

education to access to all forms of birth control. We know that 

Medicaid Expansion is critical to ensuring that Maternal Mortality 

rates improve across our great nation. We have data that shows that 

this investment in states, such as my own great state of Louisiana, 
63 


36730.044

saves money and lives. Even if women are insured, coverage of 

sexual and reproductive health services is too often not 

comprehensive. Receiving the full range of reproductive options 

ensures safe healthy births for morns and babies. Reproductive life 

planning in schools, health facilities, community organizations and 

homes, reinforces the tools our future generations need to make 

healthy choices about when, how and if, they want to have children 

to optimize their physical, emotional and fiscal health in order to 

build a stronger, more secure nation. 

Closures of hospitals and maternity units create barriers to services 

and information. This lack of a safety net for poor and rural 

Americans produces gaps in access along the reproductive life 

span. This includes closures of rural hospitals from Texas, 

Kentucky, Michigan, Illinois, Tennessee, Ohio, Washington, New 

Jersey, Virginia, Florida, Missouri, Indiana, Oklahoma, North 

Carolina, Georgia, Oregon, New York, California, Maryland, New 

Mexico, Massachusetts, and Colorado. All of us are impacted 

when we make choices to defund Critical Access facilities and 

disinvest in communities that we deem not economically viable. 

As someone who grew up in rural America, I watched my best 

friend have her baby in the car on the way to the hospital that was 

an hour away. That child has severe cerebral palsy. What is the 

value of these often forgotten communities and families? What are 

we saying about how we value them in our policy and funding 

priorities? 

I am the founder of the National Birth Equity Collaborative and on 

the Advisory Committee for the Black Mamas Matter Alliance. 

The National Birth Equity Collaborative envisions a world where 

every Black baby lives to their first birthday with their family. The 

Black Mamas Matter Alliance serves as a national voice and 

coordinating entity for stakeholders advancing maternal health, 

rights, and justice, and intentionally centers Black women's 

leadership. BMMA has a network of organizations with the reach, 
64 


36730.045

relationships and capacity to support an intergenerational 

movement. BMMA organizes around four core strategies which 

aim to 1) advance policy that addresses black maternal health 

inequity 2) cultivate innovative research methods, 3) enhance 

holistic and comprehensive approaches to the care of black mamas, 

and 4) shift culture of the narratives of black motherhood by 

amplifying black women's voices. 

The Maternal Mortality Review is a process by which a 

multidisciplinary committee at the state or local jurisdiction level 

identifies and reviews cases of maternal death within one year of 

pregnancy. Review Committees often include representatives from 

the areas of public health, obstetrics and gynecology, maternalfetal medicine, nursing, midwifery, forensic pathology, mental 

health and behavioral health. Review Committees have access to 

multiple sources of information that provide a deeper 

understanding of the circumstances surrounding the death and 

develop action recommendations to prevent future deaths. 

According to the CDC, currently at least 36 states and 3 Cities 

have or are forming a Maternal Mortality Review Committee. Very 

few are fully functioning due to lack of fiscal support. 

Data availability and transparency is important. While making the 

reports available to the Centers for Disease Control ensures data 

quality and that we are able to look at national trends in maternal 

mortality and morbidity, state and local level entities and advocacy 

organizations also need access to data and reports to inform 

maternal health programs and services. Additionally, timely 

availability of reports equips these advocates with critical 

information to influence policy decisions that are impacting their 

communities directly. 

I applaud the expanded focus of the bill to include severe maternal 

morbidity. While maternal mortality in the U.S. is on the rise, data 

reflects that severe maternal morbidity is 100 times more 
65 


36730.046

common, impacting even more women and families. To 

acknowledge women experiencing a severe maternal morbidity is 

to recognize that there are women suffering, at times, life-long 

consequences and medical complications as a result of pregnancy 

and childbirth. 

I also applaud the bill's recognition of the value of community 

engagement and inclusion in the maternal mortality review 

process. Mandating that by a state's participation in the program, 

the maternal mortality review committee shall include "individuals 

and organizations that represent the populations ... most affected 

by pregnancy-related deaths or pregnancy-associated deaths and 

lack of access to maternal health care services" is critical. We must 

hold states accountable to this mandate. The individuals and 

communities impacted by this issue must have a seat at the table 

when discussing programs and policies that directly impact their 

health and access to health care services. 

Ultimately, what Black women in the U.S. need is accountability. 

We need to know that our lives are valued. This accountability 

may be complicated, but government still has an obligation to act. 

Racism, classism and gender oppression are killing all of us, from 

rural to urban America. This is not about intentions. Lack of action 

is "unintentionally" killing us. It is a human rights imperative. 

Throughout the bill, there is no mention of race, racism, or racial 

disparities. The inability to name this as a key focus to reduce 

RACIAL disparities in maternal mortality and morbidity will 

continue to exacerbate the problem. We must ensure that 

prevention efforts and resources are being directed toward the 

areas of greatest need and be willing to name the problem directly. 

Much can be accomplished through improved monitoring and data 

collection. H.R.1318 is a tremendous step forward in showing that 

we do recognize ... Yes, Black Mamas Matter. 
66 

Mr. BURGESS. Thank you, Dr. Perry, Dr. Crear Perry. I appreciate your testimony and appreciate all of our witnesses for being 

here. 

I will move to the question part of the hearing and I will recognize myself 5 minutes for questions. And Dr. Coslett-Charlton, let 

me ask you as a—we have heard the stories and yes, the review 

committees are important, legislation is important. But honestly, 

doctor to doctor, it is decisions that are made at the bedside and 

I honestly don’t know how you legislate correct decisions to be 

made at the bedside. 

So as part of this effort and as a fellow member in the American 

College of OB/GYN, it is really incumbent upon our professional societies, medical societies, our specialty society. This is where the 

rubber meets the road. We have to be—I don’t know how I can legislate something that stops what Mr. Johnson went through. I just 

don’t know how I can do that. Here was a situation where all the 

signs and symptoms pointed to exsanguination and he describes 

unfortunately in very painful detail what the natural consequence 

of exsanguination is, and I don’t know how I write legislation to 

stop that from happening. That is on us as a profession, right? 

Dr. COSLETT-CHARLTON. I totally agree. And I think that is why 

we are here and that is why we are sitting beside Mr. Johnson because those stories, I think, affect. And I know, Dr. Burgess, because you practiced for so long, I look at my intern year, I was on 

my internal medicine critical care rotation, probably the second 

month of rotation and I was called for a code for one who had a 

very rare condition called an amniotic fluid embolism, which I don’t 

know if you have seen one in your career, but I was like what could 

this be—one in 300,000—and she died in front of me. 

I was an intern observing, I wasn’t actively participating in the 

care at that time, but I seriously questioned whether or not I wanted to go into this field at that time because—and I am so glad I 

did, because the joy of being an OB/GYN far outweighs the unfortunate things that happen to patients sometimes. But I think seeing 

that, if we can prevent one death, if we can educate our members, 

and really the best way to do that is to understand where the problems lie. 

And the AIM programs are a great success story and if we are 

able to roll them out across the country and really see where we 

can use best practices to prevent things from happening that 

couldn’t otherwise, and really obstetric hemorrhage is a perfect example where having the beauty of the AIM program is that it is, 

really, readiness first, so the four Rs, readiness and then recognize 

that there is a problem. So the readiness includes things like having suture available, having medication available on the labor floor 

so that you are not calling a pharmacist to come, I need this medicine now not an hour from now while you approve it. 

So being ready, being able to recognize that there is a problem 

and educating staff members. Not just physicians, but also people 

that are on the front lines caring for the patients first. And also 

the response and having protocols for response that are appropriate, having blood products readily available for women when 

they are in transfusion protocols we have shown to be effective. 

67 

And, finally, reporting, because when we talk about maternal 

mortality and we talk about the deaths that is very important, but 

also the near misses are equally devastating and equally important 

that we know how to identify them. And not only, we are seeing 

the iceberg, if we can really get to the crux of that where we are 

truly going to improve the way we care for women in this country 

and I am positive we are going to see fewer maternal deaths. 

Mr. BURGESS. Well, and that is what is critical about this. Maternal mortality review committees, I think that is an excellent idea. 

I am all in favor of that. I will just say in the 1970s at Parkland 

Hospital it was called grand rounds. And you didn’t ever want to 

present at grand rounds. That probably meant your patient hadn’t 

done well, but what it really meant was you weren’t going to do 

well for the next couple of hours. And Dr. Jack Pritchard was the 

head of the department back then. He was pretty critical and had 

a way of asking those insightful questions that exposed any perhaps weakness in your clinical judgment or your thought process 

as you worked through a complicated issue. 

Let me just ask you, have we gotten away as a profession from 

that type of introspection that you probably were exposed to in 

residency? I know I was. 

Dr. COSLETT-CHARLTON. No, I think if you speak to any residents 

those processes still happen, but they happen mainly in academic 

centers. And really a part of this problem is that we have to better 

reach the communities. I practice in a small community hospital 

right now and it is very different. I think and educating practitioners in the community hospitals we know is equally as important, and access to care obviously as we have spoken to is equally 

important. 

So I think being able to collect the data, being able to see where 

the deficiencies and having a mechanism and a vehicle and support 

nationally down to the state levels and the tentacles that can get 

the boots on the ground to make sure that none of these things 

happen anywhere in the United States is critical. 

Mr. BURGESS. Well, Mr. Green gets extremely critical of me if I 

run over, so I will yield back my time and recognize the gentleman 

from Texas for 5 minutes for questions. 

Mr. GREEN. I just ask equal time, Mr. Chair. I want to thank all 

our witnesses. And, Mr. Johnson, being a father of two children 

and now a grandfather, I just, and as the chair said, I don’t think 

there is anything we can do. Of course there is no shortage. We 

have a lot of doctors in Congress but we also have a lot of lawyers. 

And so people say well, you can go to the tort system, and but that 

is not going to bring back your wife or your second baby. And it 

just, how do you do that? But we understand, those of us who have 

children and I know physicians particularly. 

So I want to thank all of our witnesses today being here and discussing the U.S.’s maternal mortality rate, which I would be remiss 

if I didn’t acknowledge my home state’s maternal mortality crisis 

as well. As widely reported in 2016, published in Obstetrics & Gynecology found the Texas maternal rate was doubled between 2010 

and 2012. The study’s authors acknowledge these statistics were 

unexplainably high. 

68 

In the wake of this report, Texas’ Maternal Mortality and Morbidity Task Force underwent review of all pregnancy-related deaths 

in Texas to determine the accuracy of these findings. What the task 

force found was that data collection errors and lack of standardization in reporting has resulted in varying statistics. If we can’t depend on the research, that is a problem. 

Dr. Coslett-Charlton, can you explain why the standardization of 

data collection is so critical when discussing maternal death rates? 

Dr. COSLETT-CHARLTON. That is a very important question, Representative Green. And I think the crux of the issue is that the vehicles of looking at vital statistic records we are able in the pregnancy checkboxes, if someone pregnant within a year or 42 days in 

Texas of delivery that those measures certainly can identify and 

are inherent to error. 

But the important thing and why we are here today is to make 

sure that all of those deaths are reviewed so that we can have accurate data. And that is why these maternal mortality review committees are essential, because not only are they going to review the 

deaths but they are going to be able to determine if they could have 

been preventable deaths and that is where the impact truly could 

be made. 

Mr. GREEN. What can we learn from this study in Texas, and tell 

me Texas is not the only state that has that kind of statistics that 

you can’t depend on. Is it other states, in Pennsylvania, or other 

states in the country? 

Dr. COSLETT-CHARLTON. Well, in Pennsylvania we have had the 

checkbox for the past 5 years and I think that in Philadelphia 

there has been a small community that they have been able to 

focus on that data. But I think like I was saying, the essential part 

of this is that having accurate data is really, really, truly important 

and the Texas studies truly exemplify that how important these 

MMRCs are. 

The Texas committee at that time was not as sophisticated as it 

is now and their means of collecting aren’t as sophisticated, so I 

think that going forward it is a perfect example of why this is essential. 

Mr. GREEN. The Texas Maternal Mortality and Morbidity Task 

Force put out a series of recommendations on ways to improve maternal health and prevent pregnancy-related complications. Just 

this last month, the task force released its joint biannual report for 

our Department of State Health Services. Their first recommendation is we increase access to healthcare services to improve the 

health of women, facilitate continuity of care, and enable an effective care transitions and promote safe birth spacing. 

Dr. Crear Perry, would you agree with the recommendation to 

improve maternal health we must improve the access to care? 

Dr. PERRY. Sure. And I want to also piggyback on the last question a little bit about the data because it is important that we— 

it is a common phenomenon across the country, so it is not just 

Texas and it is not just Pennsylvania. A lot of states need this 

money to help with collect more accurate data, it would be really 

helpful. 

And as far as access it is a big barrier. We see that places where 

closing rural hospitals in Texas, in Georgia, that when women have 

69 

to travel an hour to have a baby they are more likely to hemorrhage. They are more likely to have a heart attack. They are more 

likely to have these medical conditions. So if you don’t have a systemic review you can’t look at the match between where your access is being denied and where women are also dying in the same 

place. So having a more robust review of the deaths will allow you 

to look at that. 

Mr. GREEN. From my perspective coming from Texas, one way to 

improve access to care is expanding access to Medicaid and ensuring low-income individuals have the care that they need. And do 

you agree with that? 

Dr. PERRY. Sure. I am from the great State of Louisiana and so 

we have seen actual data since Louisiana expanded Medicaid. We 

are one of the few deep southern states that expanded Medicaid 

where we have had improved outcomes. Our governor, really it was 

important for him to ensure that we had access to Medicaid expansion. Women are getting preventive services so you know that you 

have diabetes before you become pregnant and you don’t show up 

at the hospital pregnant with uncontrolled blood sugars. So it is 

important that we have expanded Medicaid. 

Mr. GREEN. And in my last 9 seconds, there is no replacement 

for prenatal care and having a mother who has a relationship with 

their doctor and that is why we need to have that access no matter 

who pays for it—Medicare, private sector or whatever. 

So, Mr. Chairman, thank you for your time. 

Mr. BURGESS. The chair thanks the gentleman. The gentleman 

yields back. The chair recognizes the gentleman from Kentucky, 

Mr. Guthrie, the vice chair of the committee, 5 minutes for questions. 

Mr. GUTHRIE. Thank you, Mr. Chairman, and I appreciate everybody being here. 

Mr. Johnson, I appreciate you coming here and being willing to 

share your story. I know that a lot of times we have policy developed and things develop because people went through tragic things 

and they are willing to bring that to our attention and share. And 

I know it is difficult to do, but it is one way that they live on and 

it is a way that it actually changes what is going on in the country, 

so we appreciate that. 

And this is something that has been on the mind of the committee, I know the chairman, I know from his background, but also 

I remember being in a meeting earlier and we were trying to just 

get down to the policy that needs to happen. And your story, I remember one of the roundtables that the chairman has talking 

about the—it is not just access to care. It sounds like your wife was 

in a fantastic hospital situation and everything and it seems C-sections were something that could be common. 

And we are the most, it is not that people aren’t getting care. A 

lot of people are getting C-sections. And my wife has had—I have 

three children, we have had three, so it really made me cringe 

when I heard that in your story, because it seems the second or 

third or whatever, C-sections seem to be something that is something we need to address in moving forward and that gets to just 

finding the right data. 

70 

And Dr. Coslett-Charlton—Charlton or Charlton? Charlton. I 

know you are with ACOG and in this bill today we are looking at 

data and how to move data. I know ACOG has endorsed—a number of medical societies and ACOG has endorsed this bill and it is 

my hope that we can get sound data to see exactly the actions that 

we need to take. So can you speak to ACOG’s perspective on the 

role of data in your efforts to reduce maternal mortality? 

Dr. COSLETT-CHARLTON. So I think to some degree when you are 

speaking about specific situations like C-section rates and talking 

about, you know, once a woman has a first C-section, second C-section, third C-section, we know each time that a woman has a Csection risk can increase with subsequent pregnancies. And those 

are important reasons why, number one, we need access to good 

care. 

But also, the part of the AIM bundles where we talk about preparedness or readiness is that when we know a woman has a third 

C-section, knowing that you could—if she has the ability to have 

important prenatal care to recognize the potential complications 

and be ready for those complications, that is critical and essential. 

And the last thing, if we talk about the AIM bundles, one of the 

bundles is looking at how to improve primary Caesarean section 

rates so that is something that is good data that is coming out of 

California that we hope can translate, sharing data across state 

lines. Women are women in Pennsylvania the same as in Arizona. 

So, it really isn’t rocket science. We should be able to share data 

and establish best practices and the way to do that is to have the 

vehicle or the mechanism to accurately be able to identify and look 

through that data. 

Mr. GUTHRIE. It just seems standard—not being a physician at 

all, I am a manufacturing person—but it just seems to be standard 

now that if somebody is having their second or third C-section that 

the symptoms your wife showed seems to be clear from what you 

said that maybe there should be a team waiting to see if something 

happens and being ready for any type of those. I would love if you 

wanted to comment. 

Mr. JOHNSON. Absolutely. I think that the astronomical C-section 

rates are something that needs to be examined. When we talk 

about Kira’s case, there was a C-section, indeed, but it wasn’t the 

C-section that led to her ultimate passing. And I will share this 

with the committee and I didn’t share—what I had shared earlier 

was a very condensed version of what was happening to Kira. 

But what we found subsequently when we go back and look at 

the medical records, which I shared as part of my record, is that 

in Kira’s case she was exceptionally healthy, she went in for a routine scheduled C-section. And from what I understand, and Dr. 

Burgess and some of the medical people here, is what I understand 

is that for a woman who is having a Caesarean section, the cut 

timing and the time that they make the incision until the time that 

the baby is born, for a healthy woman and the baby is not under 

stress should be between 12 and 15 minutes. Is that fair, Dr. Burgess? OK. And in a situation where a woman has had a previous 

Caesarean you should add another 3 to 5 minutes so that you can 

cut around the scar tissue. 

71 

Mr. GUTHRIE. The problems with scar tissue in the second or 

third, Dr. Burgess explained that to me. 

Mr. JOHNSON. Yes. So this is the point I would like to make is, 

so we are talking about between 15 to 20 minutes, ballpark, for a 

woman that is healthy, second Caesarean section, the baby is not 

in distress. When we received the medical records from CedarsSinai Hospital, the cut time on the delivery for my second son, 

Langston, was less than 2 minutes. Less than 2 minutes. And in 

the process of him rushing he lacerated her bladder. 

But once again, and so the way that has been described is that 

this was not a medical tragedy, this was a medical catastrophe 

meaning that everything that could have gone wrong did go wrong. 

So let’s talk a minute about AIM which is a phenomenal program. And I want to salute ACOG for the work that they are doing 

in conjunction with AIM and being rolled out in various states. 

California, where we were where my son was delivered, is one of 

the trademark states for AIM and what they have done to reduce 

the maternal mortality rate with their hemorrhage bundle. But as 

long as we have these tools that are a suggestion and they are not 

a protocol, women are going to continue to pass away. 

So the AIM bundle was available in Kira’s case. It is one of the— 

it is ground zero for the wonderful work they have done reducing 

the maternal mortality rate in California, but they just chose to ignore it and I continued to beg and plead while her condition deteriorated. 

So Caesareans are a challenge, but in Kira’s—— 

Mr. GUTHRIE. Different. 

Mr. JOHNSON. She was extremely healthy and they just let her 

continue to deteriorate. So we have got to have a fundamental 

standard of care that is not just a suggestion as AIM, as it is in 

the situation with AIM—and it is phenomenal—but if we can make 

a fundamental standard of care across the board that will make a 

big difference. 

Mr. GUTHRIE. Thank you. Thank you for sharing and my time 

has expired. I yield back. 

Mr. BURGESS. Thank you, Mr. Guthrie. 

Mr. Ca ́ rdenas, you are recognized for 5 minutes, please, for questions. 

Mr. CA ́ RDENAS. Thank you very much. And to Mr. Johnson, it is 

just amazing and incredible that you are doing what you are doing 

and thank you so much. You are saving lives and I appreciate that 

very much and so does everybody in this country and the world 

who will benefit from hopefully good decisions that we make, all of 

your efforts. 

First, I would like to ask some questions if the doctors would— 

I recently read about a program in California that has been very 

successful since both the March of Dimes and the College of Obstetricians and Gynecologists are part of the California Maternal 

Quality Care Collaborative. I am hoping that both Dr. CoslettCharlton and Ms. Stewart can tell us more about this program. 

But in California’s private-public partnership it was stressed 

that it was because of the views from a diverse panel of experts 

that they could avoid missing important details on women’s deaths. 

And one of the things that I think it is important for us to underVerDate Nov 24 2008 13:47 Jun 17, 2019 Jkt 037690 PO 00000 Frm 00077 Fmt 6633 Sfmt 6633 U:\MY DOCS\HEARINGS 115\HEARINGS\115-169 CHRIS
72 

stand is—I have been given a chart about the red line shows the 

mortality rate across the country while the highlighted yellow line 

actually shows California’s. And we see a dramatic drop since 2007 

when California has implemented the process of teaching each 

other, learning from each other, sharing data. And you are looking 

at California that has a mortality rate of 7.3 per 100,000 and 

across the country it is still up at 22. 

So what I would like to see happen is we as Congress and those 

of us who are involved, or those of you who are involved on the 

day-to-day process that we can come together and create a national 

best practices, and I hope that that is the outcome not only at this 

hearing but of this Congress. 

Dr. Coslett-Charlton and Ms. Stewart, if you can, can you talk 

a bit about how the diversity of these panels has changed and improved the maternal outcomes? 

Ms. STEWART. Well, let me just start with a couple of points, 

which is I think that it is notable that California has had so much 

success, obviously, and I think the idea of the committee that has 

been formed, the way they have come together to look at data, to 

design interventions, identify where the problems are within the 

state and really design interventions that have made a meaningful 

difference has been important. And that is important to say at a 

high level, but again when it comes down to each individual person 

who still may be affected by the gaps in the system like Charles 

and like his wife Kira, then we still have a problem. 

I want to say one thing about diversity in general and the importance of how this issue shows up and the disparate outcomes that 

many women of color experience as a result of the gaps in the system. And I agree with the chairman we can’t legislate morality, but 

what we can do is ensure that we are tracking the performance of 

the system, we are tracking those women that are impacted disproportionately by the system, and that we are intentional in designing interventions that will make a difference. 

The gaps in the system don’t just start though when women 

show up in the hospital. They start well before then. We know that 

for example to make sure that we have healthier babies it doesn’t 

just happen in the 9 months of pregnancy. And I am not a physician. I am not an OB/GYN, but I think I have known that in my 

own experience having had two babies and leading the March of 

Dimes, which is the leading organization in the fight for the health 

of moms and babies. 

The same is true for healthier mothers. We have got to make 

sure that women have access to health care before they are pregnant especially if they have chronic diseases, chronic health challenges that might risk their health or the health of their baby. We 

have got to make sure they have access to good affordable care during pregnancy and what we know now is that it is important that 

women have access to excellent care after. 

And it is especially important and we have had research and 

studies to show that women of color also feel less trust and less 

well-served by the system. They feel less listened to and respected 

in terms of their symptoms when they articulate those symptoms. 

And these are women that are not only low-income women of color, 

these are women that are affluent women of color, women that are 

73 

highly educated who simply have reported—and again studies 

show this—that their needs are not being met at the same level at 

the same rate as white women and other women. 

So I just want to say that I think this issue of diversity is really 

important not just in the panels but across the board in listening 

to the issues of disparate outcomes that we see across all communities. 

Mr. CA ́ RDENAS. So best practices are something that we can improve and hopefully will become more prolific so we can have the 

outcomes that you just described. My time is limited, but hopefully 

during the testimony some of you can talk about the toolkits and 

how these toolkits are free. 

But a quick, quick question to Mr. Johnson is since you have lost 

Kira, it has been 2 years, how has this affected you and your family, if you could describe that for us, so we can understand the true 

responsibility that we have and we can make sure that this happens less and less and less. Thank you. 

Mr. JOHNSON. Well, this has been the most challenging experience that I could ever—even more challenging than anything that 

I could ever comprehend. That being said, the true blessing in all 

of this is the two tremendous gifts that Kira left us and that is my 

son Charles and my son Langston. They really, truly are what 

keeps myself, my mother who is seated behind me, all of us going. 

And, it is difficult as they mature and as they are, now 2 and 

just turned 4 years old, their ability to process and understand the 

absence of their mother evolves. And like I said, when you talk to 

a 2 year old he wants to know why his mommy is not coming 

home. And you explain to him, well, your mother is in heaven and 

she is doing important work with God. And he tells you, well, I 

want to go to heaven too. 

And so there is nothing that I can prepare for, there is nothing 

that I can do to fix that and I hope that over time that—the heart 

is saying to just be completely honest with you is I am proud to 

be here representing these families, but at the end of the day I am 

just a father that whose heart aches for his sons and a husband 

that misses his wife desperately. And so while there is every day 

I search for answers and how to support these amazing gifts, what 

I am clear about is that what I have to do is, although there is 

nothing I can do to bring Kira back I have to do everything that 

I can whenever I can to make sure that I send other mothers home 

with their babies. 

And that if I can prevent another father from going through this, 

if I can prevent another child from having to understand why his 

mother isn’t showing up at school—and I will share this with the 

committee. This is something that I have never even shared with 

my family, is when a 3-year-old asks you, Daddy, is Mommy mad 

at me? I want Mommy to come home. Why won’t she come home? 

And I have never shared that with anybody because it is just too 

painful for me to articulate. 

But I am clear that the work that we are doing here is going to 

prevent this to continue to happen to other women and it is going 

to make sure that other women get to go home with their babies. 

Mr. CA ́ RDENAS. Mr. Chairman, if you will allow me a few seconds 

to thank Mr. Johnson, my time has expired. Thank you so much. 

74 

Thank you for your courage, your strength, and your commitment 

to community and to others and God bless you and your family. 

And know that your wife is doing good work in heaven, but you are 

doing tremendous work on earth. Thank you. I yield back. 

Mr. BURGESS. The chair thanks the gentleman. The gentleman 

from California referenced the California Toolkit to Transform Maternity Care. I did print off a copy of that and at the conclusion 

of the hearing I will ask unanimous consent to make that as part 

of the record. 

The chair now recognizes the gentleman from Ohio, Mr. Latta, 

5 minutes for your questions, please. 

Mr. LATTA. Thank you very much, Mr. Chairman. And thanks so 

much for our panel of witnesses and for being with us today because it is so important for the work that you are doing in getting 

this message out. 

Ms. Stewart, if I could start my questioning, I am also concerned 

for soon-to-be mothers and new moms that live in our rural areas 

of our country. The national data indicates that more than half of 

all rural U.S. counties are without hospital obstetric services. With 

an increase of women dying due to pregnancy-related complications, how does access to care and hospital services affect pregnancies and postpartum recovery and is this issue exacerbated for 

women in our rural communities? 

Ms. STEWART. Thank you very much. It is a very serious issue 

and thank you for the question. And as I mentioned in my statement earlier, the March of Dimes is working currently on a report 

that would really show this issue of maternity care deserts. The 

issue of the closing of community hospitals in rural areas has been 

well documented. 

One of the things that we are missing is that it is not just the 

closing of hospitals. It is the closing of hospitals compounded by the 

lack of obstetrical services and OB/GYNs, the lack of midwives and 

doulas in areas, the distance that women often have to travel just 

to receive care, and it is particularly acute not just—in rural areas 

there is a major challenge, but one of the things we are looking at 

is even where in urban areas there can be maternity care deserts 

as well. 

I will give you a good example of this. Here in the District of Columbia there is no hospital that provides obstetrical services east 

of the river in Wards 7 and 8. So east of the Anacostia River, tens 

of thousands of women who live there who have no hospital to go 

to, who then have to travel. If they have no transportation they 

have to go on the Metro often an hour or more to even go to a prenatal visit. If you are a high-risk pregnancy or you have a highrisk pregnancy, the complications that are then exacerbated or the 

complications that can result because of that distance, because that 

lack of access is increased significantly. 

So one of the things that we really need to talk about in the system is the fact that even in the District of Columbia, for example, 

where there may be the number of beds may be sufficient for the 

number of women, that doesn’t mean that those beds or that care 

is available to all the women that need it when they need it, and 

that is a very significant problem. 

75 

So I think one of the things that we are doing in the March of 

Dimes is to try to work with our friends in health care, our partners—ACOG has been a longtime partner of ours—working with 

hospitals and others to make sure that services are available. 

The last thing I will just mention is that because all these issues 

that we are talking about today really just disproportionately again 

impact women of color. Women of color, African American women, 

are three to four times more likely to die as a result of childbirth. 

We also need to look at other ways in which services can be provided. We know that African American women, for example, are far 

more likely to want to receive services and care from a doula working within the formal healthcare system. And we have got to make 

sure that those services are also available so that women have 

places they can go they can trust. They know they go to places that 

will listen to them and that will respond to their needs and that 

will deal with their situation if they have high-risk needs as well. 

And what we are seeing today is that there are significant gaps in 

rural areas as well as in urban areas too. 

Mr. LATTA. Dr. Coslett-Charlton, our country is facing an opioid 

epidemic and especially in the State of Ohio we are, unfortunately, 

about the third worst in the country. And while Congress and especially this committee has done a lot of work and we have passed 

a lot of bills trying to reverse this devastation, I can’t help but 

think of the pregnant women and the new mothers who struggle 

with addiction. 

And how prevalent is opioid abuse in maternal deaths? 

Dr. COSLETT-CHARLTON. Well, I would comment that it is very 

significant and that is why it is so important that these maternal 

mortality review committees include diverse members including 

mental health professionals, substance abuse professionals and I 

know when we established our panel in Pennsylvania it was imperative that we had representatives from communities where—because that is a very significant issue and I know Philadelphia has 

seen a large increase. That they have done a good job of looking 

at their data, almost a doubling of maternal deaths over a short 

period of time related directly to the opioid abuse process. 

And ACOG really appreciates all of the work that government is 

doing to make sure that—pregnant women are a special population 

that sometimes have different needs, so the pregnant addicted 

mother, number one, it is a great population to invest in because 

women that are pregnant that have opioid use disorders are often 

motivated to get better. You have a reason to get better. Not that 

everybody doesn’t, but a pregnant woman is a special population. 

And the other thing that we have seen is that doing, not only 

paying attention to different prescribing needs as we are limiting 

prescriptions, I see in my state things like that to make the special 

considerations for pregnant women that may have difficulties with 

access and need and to make sure that they continue on treatment 

during pregnancy and postpartum. 

The last thing is that there are special pilot projects that are 

coming out of these committees looking at the special population of 

pregnant women, and like soft landing centers where we are not 

separating moms and babies, and, very importantly, not making 

punitive decisions based on maternal care and that because we 

76 

know that women, the fear of losing their child or going into a system are not going to seek prenatal care and how imperative that 

is for the health of the woman and the child that she is carrying. 

So those are all things that ACOG is working very passionately on 

to try to improve the health care of women related to opioid use 

disorder. 

Mr. LATTA. Well, thank you very much. And, Mr. Chairman, my 

time has expired and I yield back. 

Mr. BURGESS. The chair thanks the gentleman. The gentleman 

yields back. The chair recognizes the gentlelady from Colorado, Ms. 

DeGette, 5 minutes for questions, please. 

Ms. DEGETTE. Thank you so much, Mr. Chairman, and I want 

to thank all of our witnesses, but especially you, Mr. Johnson. I 

just can’t even imagine what it must be like raising those two boys 

and I am glad your mom is here to help you. But, I want to come 

over and help myself, but I am not sure what I—and I think probably most of us feel that way if there is anything we can do. 

I think the first thing we can do is pass this bill. And I have 

been working with my co-sponsor, Representative Herrera Beutler, 

to try to get this bill passed by the end of the year and I think your 

testimony is what will bring us over the line. So if people wonder, 

does it make a difference that answer would be yes, so thank you. 

I want to ask you—am I pronouncing it correctly, Crear Perry? 

Crear Perry, OK. I want to ask you, Doctor, according to the CDC, 

the Nation’s maternal mortality rate rose by 26 percent between 

2000 and 2014; is that correct? 

Dr. PERRY. Yes. 

Ms. DEGETTE. One of the most striking aspects that I have been 

researching of this uptake is that African American women are 

nearly four times as likely to experience a pregnancy-related death 

than other women; is that right? 

Dr. PERRY. It is. In some places it is higher. 

Ms. DEGETTE. It is higher in some places? 

Dr. PERRY. Yes. In New York City it was 12 to 1. 

Ms. DEGETTE. Wow. And can you explain to me why this is? But 

it goes across—— 

Dr. PERRY. It does. 

Ms. DEGETTE [continuing]. Socioeconomic lines, which is stunning. Can you explain a little bit about that for me? 

Dr. PERRY. Well, and I think, for me, Charles’ story really reflects this idea, right. 

Ms. DEGETTE. Yes. 

Dr. PERRY. Like in general in the United States we have not 

really grasped the idea that women, when they are pregnant, are 

special populations and it is important that we value them. So to 

have someone in the hospital for a long time without evaluating 

them, it means there is a fundamental lack of valuing them as a 

person and wanting to come and check on them. And saying she 

is not a priority right now and what we don’t do when we just look 

individually at the doctor, it wasn’t just the doctor. So a lawsuit, 

when you have an entire system and a structure—— 

Ms. DEGETTE. Just the whole hospital. 

Dr. PERRY. And it is the whole structure. So how do we get to 

a space where black women and women in general, right? Because 

77 

the reason that the gap is high in New York and not in Texas is 

because white women in Texas are dying. So it is not so much that 

black women are doing so great in Texas, so in general across this 

country. 

Ms. DEGETTE. There is just fewer of them. 

Dr. PERRY. Right, exactly. So across this country we don’t value 

women. We don’t have paid leave. We have to go back to work really quick, but we don’t have child care so all those things impact our 

ability to have a healthy pregnancy. So how we then get into the 

hospital and need to rush out or if someone is doing something 

quickly, it makes it more difficult for us to live. So that happens 

really acutely for women of color and so you see that impact of implicit bias. 

So what you can legislate is rules around training on implicit 

bias. What you can legislate is accountability for the entire system 

to look at every death and make sure that all the structures that 

they need to have in place are put there so there is not just one 

individual nurse or doctor but it is the entire structure. 

Ms. DEGETTE. Yes, yes. 

And Ms. Stewart, many nations have actually been able to cut 

the rate of maternal mortality in half. I talked about that in my 

opening statement. I wonder if you can give us some ways that 

they have been able to do that, that we can model our own behavior on in the U.S. 

Ms. STEWART. Well, in many of those countries, Congresswoman, 

all of the outcomes relative to moms and babies are far better than 

they are here in the U.S. So one of the things about what is going 

on here in the United States is we are focusing on maternal mortality today as we should and maternal morbidity as we should. 

But if you look at all the outcomes around moms and babies, 

whether it is around premature birth, infant mortality, our outcomes are far worse than many other, most other developed countries in the world. 

Ms. DEGETTE. And many underdeveloped countries too. 

Ms. STEWART. And some in many underdeveloped, emerging 

countries. I mentioned in my opening statement our maternal mortality rates are worse than even countries like Slovenia and—— 

Ms. DEGETTE. So what are some of the things these countries 

have done? 

Ms. STEWART. So I think it starts at the highest level of a policy 

environment and an environment that respects and cares for and 

prioritizes women and women’s health and women and babies. So 

when you look at certain countries, Scandinavian countries for example, there are a range of policies that are far more supportive 

of women having a healthier lifestyle before being pregnant, having 

healthier pregnancies, and then having the kind of support even 

after pregnancy to make sure that they recover from their pregnancies well, that they feel supported, that they don’t feel overwhelmed. 

And we know the issues of stress in this country. Chronic stress, 

for example, can have a devastating impact on the health of women 

and the health of moms that impact not only them but their babies 

as well. So I think it starts with making sure that women have the 

healthcare coverage that they need, have access to the care we 

78 

need. We have talked about that. Half of the pregnancies in this 

country are covered by Medicaid. We need to make sure that all 

women have the kind of coverage they need. We need to make sure 

there are services in their communities that are accessible as we 

mentioned earlier around the deserts that exist. 

And then I think we need to make sure that postpartum, Medicaid doesn’t stop within 60 days of delivering the baby. That it extends so that moms have the kind of care and health care and support that they need even as they recover from their pregnancies. 

Ms. DEGETTE. Thank you. Thank you so much. I yield back, Mr. 

Chairman. Thanks to all of you. 

Mr. BURGESS. The chair thanks the gentlelady. The chair recognizes the gentleman from Virginia, Mr. Griffith, 5 minutes for your 

questions, please. 

Mr. GRIFFITH. Thank you very much, Mr. Chairman, and I thank 

our panelists for being here. 

Mr. Johnson, I am just so sorry. Nobody should have to go 

through that. And of course I am sitting there while you are testifying thinking about my wife, her C-section with my first son. So 

I am very, very sorry. And as Ms. DeGette said, if there is anything 

that we can do I am sure we would try including passing this bill. 

So here is a question for you all. I like the bill, and I like the 

bill because it will have us looking at it from a national perspective. If we just do it on a state perspective it may not work. Because I represent the corner of Virginia that is outside Appalachia 

and the Allegheny Highlands and so, I border four states. 

The Bristol Herald-Courier did a series of articles last year on 

neonatal abstinence syndrome because we have a high number at 

the hospital in Tennessee, but those are my constituents even 

though they are going to a hospital in Tennessee. I believe that 

hospital serves at least three states. And so if you are looking at 

it from a state perspective, Virginia is going to look a whole lot better on substance abuse and other things than Ohio. But if you compare Ohio just with my section of the state, we are probably in 

pretty good similarity. We are in sync along with West Virginia because we have similar problems and similar backgrounds. And I 

have got to have some of the deserts on your map because I have 

an area that two of my counties have lost their hospitals. 

And so, I want to see this data from a regional perspective not 

just a state perspective because my part of Virginia is not like Arlington or even Virginia Beach or Richmond. It is completely different and if you are just looking at it from a state perspective you 

get a skewed picture from my region. So I like the bill. 

So then the questions become, do we overload the bill, and you 

don’t want to do that. Sometimes you can put too much on it. Do 

we overload it by trying to include prenatal and neonatal care into 

the study? If we don’t and if Ms. Beutler is in agreement, I would 

say expand it. If it is going to overload it and we might not get it 

passed by the end of the year, let’s get this one passed and do 

something else. 

But how, Ms. Stewart, how do we fix it? I am a big advocate of 

telemedicine. Obviously can’t deliver the baby by telemedicine, but 

maybe some prenatal or pre-birth care, some neonatal care could 

be done that way. What do you think of that? 

79 

Ms. STEWART. Yes. Actually, we think the prospects of telemedicine especially for prenatal care can be very exciting and very productive. There have been several studies to show that women in 

rural areas, in urban areas, low-income women are very comfortable actually receiving care. And we also know that in the 

postpartum, we have some programs going on right now in the 

postpartum stages where uploading data, checking, taking blood 

pressure at home, uploading that data has actually reduced maternal deaths significantly in places like Philadelphia and can do the 

same in rural areas. 

So we think the aspect of telemedicine in this space can be extremely helpful to overcome some of the gaps and barriers that we 

have. I will say that we, for sure, believe very strongly that this 

area and the period of time postpartum is the most critical period 

for this bill and for these issues that we are talking about. So 

whatever we can do to make sure that women have the care they 

need during that period. 

We are measuring maternal deaths up to a year, so we need to 

make sure that women have the support they need after the baby. 

We are rightfully so, and we still need to focus prenatal, but what 

we are talking about now is the care postpartum that is now so 

critical and is contributing to so many of these deaths. So thank 

you for raising these issues. 

Mr. GRIFFITH. Thank you all for being here. I think as technology 

moves forward we may have different answers, but I do think we 

have to embrace everything we can for those areas that are underserved or have deserts as you call it. And I appreciate you all being 

here. Thank you all so much for what you do and I yield back. 

Mr. BURGESS. The chair thanks the gentleman. The gentleman 

yields back. The chair recognizes the gentlelady from Florida, Ms. 

Castor, 5 minutes for questions, please. 

Ms. CASTOR. Well, thank you, Mr. Chairman, for holding this 

very important hearing on maternal mortality. And I really want 

to thank my colleague, Diana DeGette, and Congresswoman Herrera Beutler, for their work on the Preventing Maternal Deaths 

Act. And thank you to all of the witnesses who, you all have all 

devoted your careers to this, and Mr. Johnson, I take your story to 

heart especially. 

This is a long overdue hearing and I do hope that this is just a 

start on an important focus on policy regarding maternal health because I don’t believe that most people in the United States of 

America today understand that we are not doing so well. That 

women in the United States are more likely to die from childbirth 

or pregnancy-related causes than women in other parts of the developed world. That is not acceptable and the racial disparities are 

particularly disturbing. In Florida, we have our Pregnancy-Associated Mortality Review committee. In Tampa we are home to at the 

University of South Florida, the Lawton and Rhea Chiles Center 

for Healthy Mothers and Babies, and I have some wonderful experts there who help me. They have shared with me the latest 

Florida pregnancy-related mortality rates. 

Since 1999, Florida’s pregnancy-related mortality rate has been 

flat with no significant trend. How can that be that since 1999 

things have not gotten better? I just, I think that is outrageous. 

80 

The committee found that hemorrhage-related deaths are the leading cause of pregnancy-related deaths in Florida by far. And of 

course we know that more than half of these deaths are preventable. Florida’s most recent review committee has the statistics for 

2016. They have identified 157 pregnancy-associated deaths, 21 

died during the postpartum period. That has been the focus of 

many of your remarks. 

Dr. Coslett-Charlton, I understand in May that ACOG released 

a number of recommendations on ways to optimize postpartum care 

for mothers including that new moms should have contact with 

their OB/GYN or other obstetric care provider within 3 weeks 

postpartum in a comprehensive, postpartum visit no later than 12 

weeks after birth. Why is focusing on that fourth trimester or 

postpartum period important for the health of new moms and what 

are the barriers? We talked a little bit about it, but let’s go into 

greater detail. What are the barriers that you and your colleagues 

see to prioritizing the fourth trimester? Transportation, child 

care—give us a little update on that. 

Dr. COSLETT-CHARLTON. So that is a wonderful question and that 

is one of the exciting things that ACOG has developed, like you 

said, over the past several months is reevaluating the fourth trimester or postpartum care. And we know that when we look at preventable deaths that about half of those preventable deaths occur 

within that year within delivery. 

So it is really important that we continue to engage patients on 

the importance of postpartum care and also reduce those barriers 

that you are discussing. Number one being access, number two 

being, in Pennsylvania I am fortunate to practice in a state that 

I did residency and medical school and practice in Pennsylvania, 

and in Pennsylvania when you are pregnant you are covered. And 

I cannot imagine a woman not being covered during pregnancy. 

But that coverage for Medicaid patients ends at 6 weeks 

postpartum and we know that things can happen afterwards. 

And it isn’t just the issues with—I have had plenty of women 

have preeclampsia or hypertensive disorders that need very close 

follow up. I have seen women seize 6 weeks after delivery in the 

emergency room related to preeclampsia. So those identification of 

patients that are at risk, number one. Number two, having important communications in a manner such as telemedicine within the 

first several weeks after delivery and especially in high-risk patients is critical. 

And also, we talk a lot about postpartum depression and mental 

health disorders and how important it is that we screen women 

adequately and continue screening and keeping them within that 

period and also educating patients of the importance of the 

postpartum period. And we think that that might come during the 

prenatal period and that we need to do work to emphasize the importance of postpartum to women when they are having their babies because, I am a mother of four children. 

I am embarrassed to say it. I don’t know if I went back for a 

postpartum visit. I know I am an obstetrician and I know that, are 

privy to knowing the signs, but I was caring for children and having important maternal and parental leave, it is very important 

having the transportation. So there are so many policy things that 

81 

are exciting and that, going forward hopefully we can look to all 

of you to make those favorable changes a reality. 

Ms. CASTOR. Yes. One of the major gaps I see in my state and 

other states, Florida is in the minority of states that did not expand Medicaid. And I worry about the continuity of care for young 

families, for young women especially if they are not taking care of 

themselves early on and then they reach a gap after they have 

their baby. Has Medicaid been expanded long enough for there to 

be any studies on the differences on maternal mortality in states 

that have expanded Medicaid and states that have not, do you all 

know? 

Dr. PERRY. I know for health in general, but not specifically maternal mortality and that is why this bill will be really helpful for 

us to be able to drill down on more details on maternal mortality. 

Ms. CASTOR. Thank you very much and I yield back. 

Mr. GRIFFITH [presiding]. The gentlelady yields back. The gentleman from Missouri, Mr. Long, is recognized for 5 minutes. 

Mr. LONG. Thank you, Mr. Chairman. And I have heard a lot of 

testimony over my years on the committee here and, Mr. Johnson, 

I don’t know that I have ever heard any more heartfelt or any more 

important testimony that what we heard from you here today. So 

thank you for being here and I know it is hard to do, and but hopefully your voice will add a voice and will garner more attention to 

this, so thank you for being here. 

A quick question for you, your first son, was that—I understand 

that was a C-section also? 

Mr. JOHNSON. Yes, sir. That was a C-section. 

Mr. LONG. Was that a planned C-section like the next one or an 

emergency? 

Mr. JOHNSON. No, that was not. So that was an emergency Csection so we went in for, we didn’t expect it and so that was part 

of the reason that the C-section was recommended during the delivery of Langston, our second son. 

Mr. LONG. OK, OK. Because I am curious, but yes, I am a little 

familiar with the emergency part of that situation, so yes. 

Ms. Stewart, I just want to thank you for what you do at March 

of Dimes and the big event you hold every year here in Washington, D.C. The cook-off I call it. What is the official name of it? 

Ms. STEWART. It is called a Gourmet Gala. 

Mr. LONG. That is what I was going to say if you hadn’t interrupted me. 

Ms. STEWART. It is a lot of good food there. 

Mr. LONG. Gourmet Gala. 

Ms. STEWART. Gourmet Gala. 

Mr. LONG. It is a dandy and it raises a lot of money every year 

for March of Dimes and I appreciate that. 

Ms. STEWART. Absolutely. And we appreciate all of your support 

for that. Thank you. 

Mr. LONG. Right. Dr. Coslett-Charlton, as you note, only 33 

states have a maternal mortality review committee, many of which 

are newly created. Could you talk about the important role the 

Centers for Disease Control and Prevention is giving technical assistance to states to either help them establish MMRCs or ensure 

that they are operating effectively and getting appropriate data? 

82 

Dr. COSLETT-CHARLTON. I would be happy to speak of that. As 

the state that has a very newly formed committee, I mentioned earlier that our MMRC is meeting for the first time at the end of October and I am very excited to see the outcomes of our getting together and being able to collect this data effectively. The CDC 

Foundation has actually reached out to us and has been integral 

in not only determining the makeup of the committee and working 

well with our Department of Health and members of the committee, but also ensuring again standardization and by knowing 

best practices from other states. So having that cooperation is essential. 

The other thing is that through the CDC there are data collecting tools, the MMRIA, collecting tools which will standardize 

the reporting part of the MMRCs so that we would be able, if the 

reports are looking different from every state it is a difficult task 

to try to come to a consensus. So we keep talking about the importance of making sure we keep standardization and the support 

through the CDC with the MMRIA application is an excellent example of that. 

Mr. LONG. OK. In your testimony you discuss Pennsylvania’s efforts to establish MMRC this year. What has been your experience 

so far in getting it up and running? 

Dr. COSLETT-CHARLTON. Well, fortunately we have an extremely 

supportive Department of Health for this issue and some of it has 

been similar to our efforts here is recognizing that there is a problem. And some of the national attention to the problem has really 

given some interest to members that have been very interested in 

participating in this bill. 

Our bill was supported unanimously—House, Senate, and by the 

Governor’s Office. So this was an easy ask at this time, but it really, it was more momentum initiative and a lot of the reports coming out that this truly is a problem that, you know, opened the eyes 

of many and we realized that we need to tackle this. And it is not 

a hard thing to tackle if you do it the right way and there are best 

practices already established. 

Mr. LONG. And getting data on why pregnancy-related deaths are 

happening is essential of course, but what can we do to improve 

outcomes once we receive that data and can you talk about the role 

MMRCs have once that data is collected? 

Dr. COSLETT-CHARLTON. So some of collecting the data is important so that we can use it to see where it needs not only nationally 

but also in communities. And we talk about these perinatal 

collaboratives that the CDC and the national effort to collect data 

will be the mothership and hopefully we will be able to send out 

the tentacles to go out in the communities and find where there is 

deficiencies and where there is disparities and do better to be able 

to connect patients and meet those needs and to hopefully a realization where access really is an issue. 

Maternity care is difficult to deliver and, we talk even about 

Philadelphia that has closed half of its maternity hospitals in the 

past decade. The only hospitals that are delivering right now are 

university institutions because a lot of hospitals find the reimbursement not adequate for the care and liability exposure and a 

multitude of things which is not for the conversation here. 

83 

But it is really important that we are able to identify where 

these deserts are—I think that is wonderful—in care and be able 

to improve upon that. 

Mr. LONG. OK, thank you. And once again thank you all very 

much for being here. I appreciate your time in taking time out of 

your day and week to come up here and testify. And, Mr. Chairman, I yield back. 

Mr. BURGESS. The gentleman yields back. The chair thanks the 

gentleman. The chair recognizes the gentlelady from Illinois, Ms. 

Schakowsky, 5 minutes for questions, please. 

Ms. SCHAKOWSKY. Thank you. I want to join my colleagues who 

have thanked you so much for this, all of you. I want to thank you, 

Mr. Johnson, for turning this tragedy into something positive. It 

took a lot of courage and probably a lot of time away from being 

a dad. And so I just want to express my appreciation to all of you 

and just mention that in particular. 

I think that the WHO and the CDC reports, et cetera, were really a wake-up call for people. I have been aware of communities 

near me, in Milwaukee for example, where we have seen this rise 

in maternal mortality, infant mortality as well, and it has really 

been unacceptable that we in a country, the richest country in the 

world, would see these kinds of results. It is really, it is absolutely 

shameful. 

So I wanted to—and I think there are a lot of ways that we are 

failing mothers and children, especially African American women 

who are three to four times more likely to die from childbirth. We 

just simply have to do better. But I am concerned about the new 

proposals, the Trump Public Charge Rule that puts maternal and 

infant health in grave danger. By targeting legal taxpaying immigrants in this country, this rule seeks to discourage immigrants 

from using the government services that pay for—that are paid for 

with their tax dollars—Medicaid, CHIP, SNAP, WIC, and the 

Earned Income Tax Credit, just to name a few. 

So let me ask Dr. Coslett-Charlton and Dr. Crear Perry, women 

who qualify for Medicaid that would cover pregnancy care and 

labor and delivery may face the impossible choice of jeopardizing 

their legal immigration status in this country or go without needed 

care. And let me just add that right now in my very diverse district, we are finding that people who qualify are not signing up for 

benefits, right now, because they are so fearful. So if women are 

forced to go without needed prenatal care, what could that mean 

to her health and risk of maternal mortality? 

Dr. PERRY. So it is an opportunity for us to use the same empathy we have when we talked earlier about with the opioid addiction 

moment we are having where we don’t want to criminalize moms 

who are addicted to opioids so we ensure that they have access to 

health care. If we criminalize women for using SNAP or Medicaid, 

we are also harming their ability to have a healthy pregnancy. 

So we should be able to use that same feeling of empathy for all 

mothers that everyone who is in the United States deserves to have 

a healthy pregnancy and a healthy baby and so how do we make 

sure that they don’t miss their prenatal care? For example, in Louisiana we didn’t for a long time cover immigrant mothers and after 

Katrina it was a big push of new immigrants. 

84 

Ms. SCHAKOWSKY. This is even legal. 

Dr. PERRY. Yes. And so we had to add that to the bill when we 

got more citizens coming because it was important for us to ensure 

that the babies had access and the babies had care. We saw an uptick in baby—— 

Ms. SCHAKOWSKY. But this would prohibit even citizen children 

of those parents from getting the benefits. 

Dr. PERRY. Right. So we have to think about what are value is, 

right, so if we don’t value citizen children, what do we value? If we 

don’t think it is important for them to have treatment from a physician then what are we asking for as a country. So it is just we 

have to think about our own values as a country. 

Ms. SCHAKOWSKY. I agree. 

Yes, Doctor. 

Dr. COSLETT-CHARLTON. And I would just like to add, ACOG 

strongly opposes any efforts to provide any barriers to any kind of 

care for pregnant women and postpartum and prenatal, and this 

rule obviously would do such. So and as a practitioner too, the 

woman is going to deliver the baby no matter what, so she is going 

to deliver. No matter what she is going to deliver. And, it is common sense that she needs prenatal care or, for fear of having rising 

morbidities and mortalities related to this. 

Ms. SCHAKOWSKY. Yes, go ahead. 

Ms. STEWART. I was going to say, Congresswoman, we have made 

a strong statement against that Public Charge Rule as well. 

Ms. SCHAKOWSKY. Thank you. And I yield back. Thank you so 

much, all of you. 

Mr. BURGESS. The chair thanks the gentlelady. The gentlelady 

yields back. The chair recognizes the gentleman from Florida, Mr. 

Bilirakis, 5 minutes for your questions, please. 

Mr. BILIRAKIS. Thank you, Mr. Chairman. I appreciate it. Thanks 

for holding this very important hearing. 

Ms. Stewart, as a parent I remember the birth of my children 

was such a joyful event. The idea that rates of maternal mortality 

are on the rise is horrifying as far as I am concerned. In our state 

it is on the rise. I read that women are dying from hemorrhage 

complications in the State of Florida. How does the Preventing Maternal Deaths Act help reverse the trend of women who are losing 

their lives to these typical medical complications? 

Ms. STEWART. Well, I will defer to my medical colleagues to describe the issues around hemorrhage and how it is contributing, 

but I will say that what this bill is designed to do is to establish 

across the country maternal mortality review committees that are 

designed to collect data on every maternal death and to make sure 

that every state understands the underlying causes of death for 

each woman that dies as a result of childbirth. 

But even beyond that what it is designed to do is to not just collect the data but to help states and to help the participants and 

the healthcare system design interventions that can actually eliminate deaths in the future. And that is one of the things that is really important about this bill is not only collecting the data, but then 

designing interventions. 

And of course if we collect data consistently across the country 

and if the sharing of interventions can also be shared we can cerVerDate Nov 24 2008 13:47 Jun 17, 2019 Jkt 037690 PO 00000 Frm 00090 Fmt 6633 Sfmt 6633 U:\MY DOCS\HEARINGS 115\HEARINGS\115-169 CHRIS
85 

tainly accelerate our ability to reduce and even eliminate maternal 

deaths. I will give you a couple of examples of how collecting data 

in MMRCs has been really helpful. 

In Colorado, for example, data was collected and what was found 

is that women that experienced maternal death had also been experiencing suicide and depression and they were, in Colorado, able 

to find and identify where there were gaps in mental health services and actually close those gaps and give more mental healthcare 

services to women where they needed it. 

In Ohio, they actually did something, which I think is really important, which is do additional training for hospital staff beyond 

just the doctors themselves, hospital staff where they went through 

simulations of training in obstetrical emergency situations so that 

they could actually be more responsive in the event of an emergency situation. 

So MMRCs are not only about collecting the data, but actually 

putting into action the things that can actually eliminate maternal 

deaths. And that is why this bill is so important and that is why 

a national bill and a national effort is also so important, so the 

data can be consistent, can be collected, we can see the data, we 

can actually track the interventions more successfully. 

Mr. BILIRAKIS. Thank you very much for that answer. 

Dr. Coslett-Charlton, according to the Centers for Disease Control and Prevention, it lists indicators. Severe maternal morbidity 

has steadily been increasing in the years. What are the key drivers 

of this increase and how can it be addressed? 

Dr. COSLETT-CHARLTON. Well, some things are recognizing and 

be able to maintain proper prenatal care and care of women 

throughout their reproductive years and identifying comorbidities 

such as, we talk about obesity and smoking cessation and where 

we see a rise in comorbidities with heart disease. So having active 

interventions before a pregnancy we find is critical to having a 

healthy labor and delivery for all women. 

Mr. BILIRAKIS. So you feel that they are increasing. In this day 

and age with all the technology we have or is it just that we are 

getting more data on this or there definitely are increases in maternal deaths? 

Dr. COSLETT-CHARLTON. Well, so far that is part of the purpose 

of this review is so that we were talking earlier about the accuracy 

of the data. So some speculation has been made that perhaps because for the past 5 years we were actually recording on death certificates whether or not a woman was pregnant when she died, or 

within a year after delivery whether or not that has caused a rise 

in the actual numbers that we are seeing. But when comparing to 

other countries that have had similar checkboxes on their certificates where they have seen a stabilization or a decrease, we have 

actually seen an increase. 

So these committees are really imperative to really, exactly what 

you are saying, really know and be able to assess and accurately 

determine if those disease entities as well as maternal death if 

there is a change and make sure that we have accurate data so 

that we can successfully portray appropriate interventions. 

Mr. BILIRAKIS. Yes, exactly. So, whether it is increasing or what 

have you, we have to focus on the issue. There is no question. 

86 

And, Dr. Johnson, you have my sympathies. I was in the VA 

Committee so I didn’t get a chance to hear your testimony, but I 

know how difficult it must be for you. 

Let’s see, Dr. Crear Perry, please, our maternal mortality data 

has been described again as limited, unreliable, and even embarrassing by top researchers. Do you agree with these characterizations? And I know, let’s expand upon this. Are there concerns with 

the research community regarding the integrity of the data being 

collected in states? What are those concerns and how might they 

be addressed federally? 

Dr. PERRY. That is me. That is OK. Hi. 

Mr. BILIRAKIS. Oh, you are over here. I am sorry. 

Dr. PERRY. And so it is important, Dave Goodman and the folks 

at CDC are doing a great job of doing the data. They have been 

doing it for a very long time. They have dedicated their life to it. 

And they have looked at if the increase is due to error in data 

versus if it is an increase, that is true, and all the studies so far 

have come back saying no, there is an increase and it is from the 

data. 

And so the robustness with which the CDC is working on to look 

at this issue is something that we should all value. And if they are 

part of this bill, they are not here testifying, but CDC is really integral to getting this work done and it is important that we understand that they are—that yes, there have been researchers that 

have given us pushback around the data over the years, but we 

have gotten better and better and this is just another way to get 

even more clear about how women are dying, because beginning at 

a granular level and look at the hospital level what is happening. 

So yes, there have been a lot of articles about the data, but we 

truly know through the CDC that the rates are increasing and that 

we can do something together to do it better with this bill. 

Mr. BILIRAKIS. Very good. Thank you and I yield back, Mr. 

Chairman. 

Mr. BURGESS. The chair thanks the gentleman and the gentleman yields back. 

The chair would just make the observation that I believe it was 

Dr. Callaghan from the CDC who came and spoke at one of our 

roundtables about a year ago. And you are correct. They are very 

thorough and they have been at this for a long time. They have a 

lot of good insights. 

The chair recognizes the gentleman from Massachusetts, Mr. 

Kennedy, 5 minutes for your questions, please. 

Mr. KENNEDY. Thank you, Mr. Chairman. I want to also thank 

you for your obviously lifelong and personal dedication to this issue 

given your profession before coming to Congress and still the work 

that you do. I want to also thank Representative Herrera Beutler 

who was here earlier and obviously our distinguished panel for 

joining us. 

Mr. Johnson, excuse me. I will apologize. I have been in and out. 

Your words are extremely powerful, sir. Kira sounds like quite a 

woman. I have two kids under 3. I was in a delivery room about 

9 months ago. Thoughts are with you and your family, sir. 

In 2018, the United States of America has the highest rate of 

maternal deaths in the developed world. Every single year we 

87 

mourn roughly 700 mothers who are lost to complications during 

their pregnancy, and at least 350 of those deaths are preventable. 

Most alarmingly, profound racial disparities exist in these statistics. Black women today are three to four times more likely to die 

of pregnancy or delivery complications than white women. 

Before we try to explain that away on socioeconomic terms, just 

access to care, access to education, and higher income, we have to 

be clear that even when you control for those factors a wealthy 

black woman with an advanced degree is still more likely to die or 

to have a baby die than a poor white woman without a high school 

diploma. In the United States, a black woman is 22 percent more 

likely to die from heart disease than a white woman, 71 percent 

more likely to die from cervical cancer. Those are haunting statistics, but they still pale in comparison to the one we discussed here 

today, for black women are 243 percent more likely to die from 

pregnancy or childbirth-related causes: 243 percent. So we can’t 

have a discussion about how to address a larger crisis in maternal 

mortality without having a discussion about how to confront the 

pervasive, systemic inequities that are buried deep within our system of health care in America. 

And the last point I have to make is this, that there are, as we 

speak, 20 Republican Attorneys General that are attempting to repeal the Affordable Care Act in our court system after most of my 

Republican colleagues have voted to do the very same thing more 

times than I can count. So let’s remember 9.5 million. That is the 

number of previously uninsured women that gained healthcare coverage including maternity care which is an essential health benefit 

under the Affordable Care Act. Coverage for women of color grew 

at more than twice the rate of women overall in 2013 to 2015. So 

to have a conversation about maternal mortality at a time when 

my Republican colleagues are using every tool in the book to roll 

back access to guaranteed maternal care and maternal coverage is 

a bit much. 

And with that I want to direct my questions to Dr. Crear Perry 

and by the work that you have done, Doctor, in discussing how we 

need to move away from seeing race as a risk factor in maternal 

health and call the real risk factor what it is: racism. So can you 

extrapolate that a bit for the committee and, specifically, what do 

you believe to be the leading cause of those racial disparities I 

mentioned in maternal mortality rates? 

Dr. PERRY. So we have done quite a bit of focus groups and work 

in hospitals around how patients feel disrespected and not heard 

and not listened to and not valued. And, a great example of that 

is Serena Williams, right. She gives an amazing story around how 

she had symptoms. She knew who she was. She is a very wealthy 

and healthy person as well and she still was not heard or valued. 

So what we miss in this country is really being honest about 

when you don’t see someone as being fully equal to you, you are 

less likely to think about their care in a very serious manner. You 

are less likely to address their issues in a serious manner, and you 

are less likely to spend the time that they need ensuring that they 

are healthy. 

And so what we have to be able to do is have some truth around 

that conversation first and not act as if that is not a true—— 

88 

Mr. KENNEDY. And so is there data that you would point to on 

this or is this something that is a bit bigger than fits into an Excel 

spreadsheet and a pie chart and how—— 

Dr. PERRY. This is going to be both a policy fix and a cultural 

shift, right. Like we have had policy shifts. We have had the civil 

rights movement, we have a lot of things of policy we can have, but 

as long as the culture still believes that black people are less valuable or inferior, and women, we are going to keep having the same 

conversations over and over and over again. So we have to have 

both a policy conversation and a culture shift. 

Mr. KENNEDY. Anybody else want to comment on that? Mr. Johnson? 

Mr. JOHNSON. So just talking about this from a personal experience and having an African American, extremely vibrant woman 

who was not in good health but in exceptional health at one of the 

top hospitals in the world, and to be quite honest with you, when 

this first happened and I was asked a question, do you think that 

this would have been different if your—do you think this is because 

your wife was black, or do you think the outcome would have been 

different if your wife was Caucasian, I was in so much pain I 

couldn’t process that and the thought that the color of my wife’s 

skin contributed to her death? 

But what I am clear about is that she was not seen or valued 

as human. She wasn’t. And the people who were responsible for her 

care that I trusted with her care failed to look at her in the same 

way that they would their daughter or their sister or their mother. 

And the reality of the situation is I am asked the question and people sometimes, and, the more I have spent with wonderful groups 

like Black Mamas Matter and the more I look at the data, people— 

and I am very clear about this issue of implicit bias and the contributing factors or racism. And people say you are making it a racial issue. I didn’t make it a racial issue, the statistics did. 

So what we have got to do is figure out how these women are 

valued and looked at as human, because what I said at night, 

thinking about my wife and I have to think about that question 

about would she be here today if she was Caucasian? Let me be 

clear that this is an epidemic that affects all families from all backgrounds and all walks of life, and unfortunately I know that personally because I have talked to these families and I have become 

very close to some of these fathers and some of these families and 

they are from all walks of life. 

But we cannot address this issue without head-on facing the way 

that it is disproportionately and horrifyingly affecting African 

American mothers. 

Mr. KENNEDY. Thank you, sir. 

Chairman, thank you for the extra time. Thank you all for being 

here. 

Mr. BURGESS. The chair thanks the gentleman. The gentleman 

yields back. The chair recognizes the gentleman from Georgia, Mr. 

Carter, 5 minutes for your questions, please. 

Mr. CARTER. Thank you very much, Mr. Chairman, and thank all 

of you for being here. And, Mr. Johnson, thank you for your efforts 

and your work on this especially, and I echo the comments of all 

of my colleagues here today. We appreciate your courage. 

89 

Mr. Chairman, I believe this hearing was set for another time 

and I requested and I am sure others did that it be delayed so that 

we could have it. It is important to me and I am sorry if it disrupted any of you all or inconvenienced you. 

But I am from the State of Georgia. In 2010, there was an Amnesty International report that flagged Georgia as being the number one state in maternal mortality. And that is why I expressed 

to the chairman, Mr. Chairman, I want to be at this hearing because this is real to me. In fact, when I served in the Georgia State 

Legislature and we passed Senate Bill 273 that created the MMRC 

and put it into the Georgia Department of Public Health. 

And I wanted to ask you, Dr. Perry, because when we created 

that, you know, we followed the guidelines and we did what we 

were supposed to do. But I believe that your group was involved 

in a study, When the State Fails: Maternal Mortality and Racial 

Disparity in Georgia; so you are familiar with that? 

Dr. PERRY. Yes, sir. 

Mr. CARTER. I know you are. And I had the chance to look at it 

and study it and one of the things that it pointed out was the racial 

disparity in Georgia was the fact that even though the four categories—access to and quality of care, insurance access and pricing 

funding, and accountability around data analysis and use, even 

though we had those in there we are still failing on those, particularly access. 

And my question is, what can we do? Tell me what I can take 

back to my state because this is important to me. I served in legislature. I was in Health and Human Services, vice chair of that 

committee, and I helped with this legislation. If, and the point has 

been made by my colleagues today, what can we do legislatively, 

but what can I do? What can I take back to the State of Georgia? 

Dr. PERRY. Thank you so much. And I do work with Dr. Lindsay 

and the folks at Grady around the Georgia work and they are specifically trying to look at their mental healthcare service structure. 

So supporting mental healthcare services in Georgia is important. 

Supporting Medicaid expansion in Georgia is important. Supporting rural hospital closures in Georgia is in support and like 

supporting support systems that include midwives and doulas in 

Georgia is important. 

All the social structures that we see, all the states where we 

allow for us to disinvest in women honestly have poor outcomes. 

Even though you can look and do the study and see, we are working on things inside of hospitals because you have some great doctors in Georgia. You have some phenomenal people and some 

nurses and midwives. But until we build a structure that holds the 

entire state together, right, like from rural Georgia from—then we 

are not going to be able to see an improvement and we are being 

separated around ideals that don’t allow us to come together. And 

it is important that we know we value all the moms in Georgia, 

rural moms, urban, they all need access to insurance. 

Mr. CARTER. Well, thank you for mentioning that because as you 

well know, knowing the state we have a disparity between rural 

and urban. 

Dr. PERRY. Exactly. 

90 

Mr. CARTER. I mean to say Georgia is Atlanta and everywhere 

else. So it really is. 

Dr. PERRY. Exactly. 

Mr. CARTER. Well, another part of that study that I was very interested in, because I am a big advocate of this, is the proposition 

that the state could develop ways to help religious organizations in 

leadership engage and advocate for quality health education and 

services. 

And I am really big with wanting to include the religious community. And can you give me examples of how we can do that or examples of how that has worked before? 

Dr. PERRY. Including, because if you think about mental health 

it is a great example, right, so a lot of religious organizations have 

access to therapy, access to group places where women can come 

to make sure they have grievance counseling. 

So there has been a lot of work that religious organizations are 

there to be a safety net and a support for women. They can’t replace medical care, but they can serve as a safety net. They can 

provide transportation. They can help with child care. Like all 

these other things that we are looking for that a community provides, because we know that women who have access to a community and to each other, the connectedness, have better outcomes. 

So how do we create connectedness and community across this 

country and across Georgia. 

Mr. CARTER. Right. And one last question and this could go to 

just about any of you. But the thing that I am wondering here is 

I know we are accumulating the data and we are, and I believe you 

said earlier the data is going to CDC. Are they crunching the 

science of it? Can we tie anything into this genetically, regionally? 

Ms. STEWART. I will try and then others. CDC has had a surveillance system in place for a number of decades and thankfully we 

are able to collect a lot of data mainly coming from death certificates. And just recently now, death certificates now include whether or not a woman was pregnant within the last year, and so that 

information has been helpful. 

But what we don’t get from all of that—and by the way that voluntary system, CDC asks states around the country to voluntarily 

submit the data. There are epidemiologists that then review the 

data and we learn as much as we can from death certificates. But 

what we don’t understand is that a death certificate does not necessarily tell the full story of how a woman may have died and what 

were the underlying causes and what were the potential interventions that could have been in place to prevent that. 

And that is what this is about is taking the data we collect, improving it, improving the collection, making it consistent, having 

committees that then can design interventions and having them 

well-funded so that they can actually see meaningful improvement 

over time. So that is the difference. 

Mr. CARTER. Good. Again, thank all of you. And, Mr. Johnson, 

thank you and God bless you. 

Mr. JOHNSON. And I would just like to say that I am actually a 

native of Georgia and currently—— 

Mr. CARTER. Did this happen in Georgia? 

91 

Mr. JOHNSON. It actually happened in California but I am a native of Georgia. 

Mr. CARTER. OK. 

Mr. JOHNSON. Kira grew up in Decatur, Georgia and I grew up 

in East Point and we are back living in Georgia. 

Mr. CARTER. Right. 

Mr. JOHNSON. So we look forward to working together with 

you—— 

Mr. CARTER. Absolutely. 

Mr. JOHNSON [continuing]. To see how we can help out too. 

Mr. CARTER. Can I ask you, was your wife originally from Georgia? 

Mr. JOHNSON. Absolutely. Decatur, Georgia. Born and raised. 

Mr. CARTER. OK, see this is the point I am getting at here. We 

are the Cardiac Belt. Has anybody looked at any of this to kind of 

try to tie this into it? 

Ms. STEWART. There is a lot of work being done on what is going 

on that is that are sort of the underlying causes to why so many 

women of color especially are dying, and there are a bunch of 

issues. I will mention one of them. By the way I am from Atlanta 

too. Don’t hold that against me. 

Mr. CARTER. I see a pattern here. 

Ms. STEWART. We have known each other a long time. 

Look, there is a very important study and we could go through 

a laundry list of things, but there is a very important study that 

has really helped all of us understand what are some of the underlying causes to why we see so many disparities among African 

American women in particular. 

A study that was done by a researcher who is now at the University of Michigan but she started this study in New Jersey, I believe, where she started to look at this as your weathering. The fact 

that African American women’s health tends to, and African American women tend to have more challenges the older they get, challenges in pregnancy, challenges in childbirth, challenges maybe 

post childbirth may be due to this issue of weathering, which is 

that the impact of chronic stress that may be coming from racism 

and discrimination over a long period of time. 

This issue of weathering which tends to deteriorate one’s health 

may be a big contributor why we see so many disparities. The fact 

that women are getting, are older as they are getting pregnant and 

the fact that if black women are older having babies and they are 

experiencing this impact from this weathering effect that that 

could explain in part why we are seeing so many outcomes. 

Having said that, we still need to address the fact that we don’t 

specifically have to accept that that is the case, we can actually do 

something about it. We can actually address those issues. We can 

actually deal with the underlying stress that exists. We can actually deal with the systems that may be creating the stress in the 

first place, and we can make sure that we understand when interventions are really effective across all communities. 

Mr. CARTER. Thank you, Mr. Chairman. I yield back. 

Mr. BURGESS. As the gentleman’s time has expired, the chair recognizes the long-suffering Mr. Engel from New York, 5 minutes for 

your questions, please. 

92 

Mr. ENGEL. Thank you, Mr. Chairman. I appreciate those words, 

thank you. 

Thank you, Mr. Chairman, for holding today’s hearing. Just in 

listening, it is just shocking that right here in the United States 

women are dying from preventable pregnancy-related complications. That alone is shocking, but that women are more likely to 

die from those complications here than in other parts of the developed world, that is shocking. And the fact that this risk is three 

to four times higher for black women than white women, that is 

shocking. 

So it is a tragedy and it is an emergency, and thank you, Mr. 

Johnson, for sharing your story with us. 

I want to thank my colleagues, Congresswoman Herrera Beutler 

and Congresswoman DeGette, for introducing the Preventing Maternal Death Act legislation which I am a proud co-sponsor of. And 

I hope that after today our committee can move forward on solutions to this problem that we really need to move more quickly. It 

is long past time we acted to reverse this horrible trend once and 

for all. 

So let me ask this question. I have long supported investments 

in family planning and reproductive health and I am particularly 

interested in the impact that such investments can have on maternal mortality. As the ranking member of a House Foreign Affairs 

Committee, I have seen that impact on a global scale. In fiscal year 

2016 alone, U.S. investments in family planning worldwide provided contraceptive services and supplies to 27 million women and 

couples, which in turn helped to prevent 11,000 maternal deaths. 

So let me ask Drs. Crear Perry and Coslett-Charlton, would you 

each explain why meeting unmet need for contraception helps to 

prevent maternal deaths? 

Dr. PERRY. So there has been some data that shows that the 

safety and security you get from having access to family planning 

and not having to worry about if you are going to get pregnant 

again because you are not planning to be pregnant at that moment 

really decreases your stress and your weathering and ensures that 

you have a healthier pregnancy. 

We know that we have looked at the states that have more supportive policies around family planning also have better infant 

mortality rates and better maternal mortality rates. So it is not a 

coincidence that when you invest in family planning and when you 

invest in infrastructure for moms and babies, you actually create 

a safety net where people can live longer and be healthier. So it 

is important that these policies that are created in this House improve the ability for moms and babies to live. 

Dr. COSLETT-CHARLTON. And I would certainly echo that response. But also it has been shown that women that are able to 

plan their pregnancies by spacing intervals between pregnancies 

and having access to adequate contraception that it improves the 

safety. There is very clear data to show that it improves outcomes 

in pregnancy and delivery also. 

Mr. ENGEL. So thank you. But along those lines, let me ask you 

if either of one of you would explain why women in the United 

States specifically have unmet need for contraception. By that I 

mean they want to use modern contraception but are not currently. 

93 

Dr. PERRY. Well, it is a state and local issue, usually, around access to family planning and reproduction and because when we 

allow that to be made state-based wide people’s personal, you get 

gaps in what states pay for, things like sex education, what states 

allow for, things like having birth control inside of high schools. 

Once again I will say for my great State of Louisiana, we struggle with getting sex education in the schools. We struggle with getting access to family planning for the people who actually need it 

very desperately. So I think in an attempt to make for a safe environment for our state sometimes we mislabel what safety looks 

like. Safety looks like having access to choice when it comes to your 

reproduction. And when you have that access to choice and information, you can have a safer pregnancy and a safer outcome. 

Mr. ENGEL. Well, thank you. Obviously there is a lot more work 

to do on this front. Let me mention this. A December report from 

the Guttmacher Institute estimated that globally, ‘‘fully meeting 

the unmet need for modern contraception would result in an estimated 76,000 fewer maternal deaths each year.’’ That is 76,000. 

So I want to ask either one of you doctors to please, if you agree 

is it fair to say that improving access to contraception for American 

women could help address the rates of maternal death in the 

United States? 

Dr. PERRY. Yes. 

Dr. COSLETT-CHARLTON. Yes. 

Mr. ENGEL. That is a loaded question, but I wanted to put it out 

on the record. I want to also take this opportunity to briefly talk 

about legislation. I have introduced with Congressman Stivers, the 

Quality Care for Moms and Babies Act. The legislation would bring 

together diverse stakeholders to identify care quality benchmarks 

for women and children in Medicaid and CHIP as well as fund new 

and existing maternity and infant care quality collaboratives. 

These collaboratives bring together local stakeholders such as 

doctors and nurse midwives to best share the best practices in improved care for patients, and I am grateful to both the ACOG and 

March of Dimes for supporting this legislation. 

And let me ask you, finally, both—let me ask perhaps Ms. Stewart. I will ask you this. Wouldn’t you agree that we should be 

measuring and evaluating performances of Medicaid and CHIP caring for America’s moms and babies as well as investing in perinatal 

quality collaboratives which work to implement maternal mortality 

review committee recommendations at the state level? 

Ms. STEWART. Congressman, we are very involved across the 

country in perinatal collaboratives and they are very effective and 

we would very much support them. And I would just add at this 

point which is that 60 percent of all births are covered by Medicaid 

and that is a lot of women and a lot of babies. 

And whatever we can do to make sure that the quality of care 

exists for those women as it does for women in the private insurance market to make sure we are collecting the kind of data to understand what is effective and what is not and that we are sharing 

that data across states, we would firmly support that. 

Mr. ENGEL. Thank you. Thank you very much. Thanks, Mr. 

Chairman. 

Mr. BURGESS. And the gentleman’s time has expired. 

94 

1The information has been retained in committee files and can be found at: https:// 

docs.house.gov/meetings/IF/IF14/20180927/108724/HHRG-115-IF14-20180927-SD022.pdf. 2The information has been retained in committee files and can be found at: https:// 

docs.house.gov/meetings/IF/IF14/20180927/108724/HHRG-115-IF14-20180927-SD023.pdf. 3The information has been retained in committee files and can be found at: https:// 

docs.house.gov/meetings/IF/IF14/20180927/108724/HHRG-115-IF14-20180927-SD004.pdf. 

Seeing no additional members wishing to ask questions, I want 

to thank all of our witnesses again for being here today. I have 

some documents I need to read into the record, a statement for the 

record from Sean Blackwell, M.D.; momsrising.org; and Alexis Joy 

Foundation. I also have the September report for the Maternal 

Mortality and Morbidity Task Force from the state of Texas 1; a letter from Dr. Gary Hankins who participated in one of our 

roundtables—Dr. Hankins is from the University of Texas Medical 

Branch in Galveston; and Dr. Ca ́ rdenas had mentioned the Obstetric Hemorrhage Toolkit in California 2 and I do have a copy of that 

I am going to submit for the record. 

Also, documents from the March for Moms; Postpartum Support 

Virginia; Association of Maternal & Child Health Programs; Heart 

Safe Motherhood; Massachusetts Child Psychiatry Access Program; 

a letter signed by 1,000 Days and other patient groups; Americans 

United for Life; Alexis Joy Foundation; Nurse-Family Partnership; 

Preeclampsia Foundation; Society for Maternal and Fetal Medicine; 

a letter from Timoria McQueen Saba; American College of Surgeons; KSM Consulting 3; more California PPH; SAP America; and 

Forbes Insight Study. 

[The information appears at the conclusion of the hearing.] 

And just to end on a somewhat positive note, my grandfather 

was an OB/GYN, an academic OB/GYN at McGill University in 

Montreal and practiced obstetrics during the decade of the 1930s 

when the maternal mortality fell from all-time highs to all-time 

lows, certainly indicative that if we put our minds to it, it has happened before, it can happen again. 

Pursuant to committee rules, I remind members they have 10 

business days to submit additional questions for the record. I ask 

the witnesses to submit their responses within 10 business days 

upon receipt of the questions. Without objection, the subcommittee 

is adjourned. 

[Whereupon, at 12:23 p.m., the subcommittee was adjourned.] 

[Material submitted for inclusion in the record follows:] 

95 


36730.047

MomsRising .org 

Where moms and people who love them go to change our world 

MomsRising HR 1318 Preventing Maternal Death Acts Hearing Testimony 

Hello, my name is Smita Nadia Hussain. I am the Maternal Justice Campaign Director at 

Moms Rising, a national organization of over a million members, with members in every state in 

the country, who organize and advocate around issues that impact mothers, children, and 

families. As Director of our Maternal Justice campaign, I work on grassroots organizing and 

advancing policy efforts to address the maternal mortality/morbidity issues in our country, 

concentrating on the disparities Black women experience. In fact, Black women, no matter their 

education or income level, are 3-4 time more likely to experience maternal mortality and 

morbidity, one of the widest disparities in ali of women's health. 

I urge you to move HR 1318 The Preventing Maternal Deaths Act forward in today's 

Subcommittee on Health hearing to enable this important piece of legislation to go to a vote by 

the House of Representatives. 

Why is this legislation important? The ability to protect the health of mothers and babies in 

childbirth is a basic measure of a society's development. Yet, currently, the United States holds 

the worst record for maternal and infant mortality in the developed world, and maternal mortality 

continues to rise. Every year in the U.S., 700 to 900 women die from pregnancy or childbirthrelated causes, and some 65,000 nearly die. 

American women are more likely to die from pregnancy-related complications than women in 45 

other countries including the United Kingdom and much poorer nations like Libya and 

Kazakhstan. Additionally the data reveal major racial disparities in maternal mortality rates: 

Black women are three to four times more likely to die from pregnancy complications than white 

women, independent of age, parity, or education in our nation. 

This legislation would establish a program to help states review maternal deaths; establish and 

sustain a maternal mortality review committee; develop a plan for health care provider education 

to improve maternal care, and improve information collection on maternal deaths to provide 

public disclosure of information on maternal mortality. It will help enable health systems to 

address the factors leading to the disproportionate deaths of Black mothers and put 

recommendations in place to begin addressing racial disparities that have been present and 

unchanged for decades. 

These are some of the critical solutions needed to address our nation's maternal mortality and 

morbidity crisis. 

We can fix this; women don't have to die from childbirth. According to a recent analysis by the 

CDC Foundation, nearly 60 percent of maternal deaths in the U.S. are preventable. Sixtypercent. If we are able to decrease that number by even a fraction, thousands of mothers' lives 

could be saved. 

At Moms Rising, we have repeatedly heard the stories of women who've almost lost their 

lives and from those who've lost loved ones to childbirth related causes. Stories such as 

Carissa, from Olympia, WA. 
96 


36730.048

"After 40 hours of labor and 6 hours pushing, [my daughter] was in fetal distress and I had to 

have an emergency c-section. If we hadn't had access to a good doctor, and appropriate care, 

we both would have died. As it is, she is my miracle, and I am so thankful we are here! Good 

prenatal care and access to the childbirth center are not optional. We live in the wealthiest 

country in history, and there is no excuse for moms and babies to die needlessly." 

We can and must do better to ensure that births are as safe and healthy as possible for all 

mothers. We must all work to ensure that the health of women and their children are made a 

priority. Thank you very much for your time. 
97 


36730.049

September 17, 2018 

Chairman Michael C. Burgess, M.D. 

Ranking Member Gene Green 

Subcommittee on Health 

Committee on Energy and Commerce 

2125 Rayburn House Office Building 

Washington, DC 20515-6115 

RE: "Better Data and Better Outcomes: Reducing Maternal Mortality in the U.S." 

Dear Chairman and Ranking Member Green: 

l write to you on behalf of the upcoming hearing scheduled for September 27, 2018 

on Maternal Mortality. !lost my wife Alexis joy in 2013 due to postpartum suicide, 

and I deeply believe that Congress needs to be aware of this ongoing crisis. 

On August 30th, 2013 my wife Alexis and I had our first child, a beautiful healthy 

baby girl we named Adriana Joy. 

August 30th, 2013 was supposed to be the happiest day of our lives. Rather, it was 

the most challenging, eye opening, brutal reality we had never been prepared 

for. Our daughter's delivery was a code blue delivery. This was the beginning of 

the end of our perfect life as I knew it. Alexis was diagnosed with PTSD from the 

delivery. Breastfeeding proved way more challenging than either of us would have 

thought. Baby Adriana cried, a lot. This did not help our situation. 

Alexis was diagnosed with PTSD. She started worrying over everything. "Our 

perfect baby might be damaged", Alexis thought. Alexis was convinced Adriana had 

brain damage and we took the baby in for testing on her brain. She was fine. This 

was an answer my wife couldn't accept. Her fears seemed to grow daily. Each day 

she became more irrational, paranoid, and cried more. She would push food 

around on her plate but never took a bite. 

She had been calling her ObGYN, psychiatrist, and pediatrician during this entire 

period of time. Each one said "Don't worry, it's just the baby blues. It will 

pass. You're fine. Just relax and enjoy this time." 
98 


36730.050

l watched my wife lose nearly 50 pounds in 30 days. One doctor in an emergency 

psychiatric unit pulled me aside and said "Your wife's not crazy. She will be 

fine. She just needs her family and friends. But, just in case there's only two ways 

women as pretty as her commit suicide. They either asphyxiate themselves in the 

garage or overdose on pills. just get rid of the car keys at your house and any 

prescription pills she could take. Women like her would never commit suicide in a 

"sloppy" way. They would never want to be remembered not looking their best." 

In our struggles to find help for my wife Alexis, we we!lJ:_ t()_7~jJf~nmtho_wit<ll~ or 

uisis c_e[ltersinner Ia!itUc:I<!Y~· 

On the morning of October 8th, 2013 I woke up to our Maltese puppy named Lucy, 

frantically barking to wake me up. Something seemed off. The air was stale, it was 

almost as if time had stopped. It's a feeling you have to experience to really 

know. In that moment I knew. I jumped out of bed. Ran downstairs screaming 

Alexis name. No response. I could hear my daughter crying. I ran down to the 

kitchen, no Alexis. The dining room, family room, office· no Alexis. Outside on the 

deck, not there either. Downstairs to the garage, not there. In the basement, not 

there either. By this point I'm literally crazed, panicking screaming at the top of my 

lungs. I run back upstairs to find my daughter strapped to her changing table and 

crying. Still no Alexis. l run back downstairs to look again. As l look to the back of 

the basement there was my beautiful, perfect, love of my life. Lifeless hanging by TV 

cable from my basement ceiling. I called 911 screaming for them to help me save 

her. I remember going through the chest compressions and mouth to mouth 

bargaining with God please, please bring her back. Suddenly, paramedics and cops 

were everywhere. They pulled me from her and started working on her. This was 

only probably 7 minutes. The craziest 7 minutes nobody should ever go through. 

These 7 minutes that paled in comparison to the 5 1/2 weeks of hell my wife had to 

endure. 7 minutes that pale in comparison to the eternity I will spend missing my 

best friend. 7 minutes that pale in comparison to the lifetime my daughter will 

spend wondering who her mom was. 7 minutes that pale in comparison to the 

times I spend coming up with answers to my daughter's questions about why her 

mommy died. Will my daughter blame herself someday? Will she do the same 

thing when she has a baby someday? Will she even want to have a baby 

someday? 7 minutes that pale in comparison to the anxiety I get when my reality 

sets in that I have to do this parenting thing all alone. 
99 


36730.051

All of this for no good reason. 

Since my wife lost her battle with postpartum suicide, Pittsburgh has decided to not 

wait for another tragedy and to do something about it. Moms in Pittsburgh can now 

see a psychiatrist in under 48 hours because of Allegheny Health Network and 

Highmark Blue Cross Blue Shield and the Alexis Joy Foundation. I'm confident in the 

near future it will be under 24 hours. 

PPD is not a women's health issue, it is a family health issue. I firmly believe we 

owe it to our children to fix this preventable and treatable problem. I know I will do 

my part to make sure my daughter gets the care she deserves if needed, someday. 

As Congress takes into consideration the escalating rise in maternal mortality and 

the need to figure out "Why are Mothers dying in this great country", I implore 

Congress to take a look at the mental health aspect of this issue. Perhaps if there 

was enough information on maternal mental health, its risks and evidenced based 

treatment options, my wife would be here with me and our daughter, today. 

I thank you for your time. 

Sincerely, 

Steven !J)'~cfii((e 

Steven D'Achille, Founder 

The Alexis Joy Foundation 

2010 Lake Marshall Drive 

Gibsonia, PA 15044 

wwvv~al~xisjqyfolilldatiop.org 

412.606.0065 
100 


36730.052
101 


36730.053

September 17, 2018 

Chairman Michael C. Burgess, M.D. 

Ranking Member Gene Green 

Subcommittee on Health 

Committee on Energy and Commerce 

2125 Rayburn House Office Building 

Washington, DC 20515-6115 

RE: "Better Data and Better Outcomes: Reducing Maternal Mortality in the U.S." 

Dear Chairman and Ranking Member Green: 

I write to you on behalf of the upcoming hearing scheduled for September 27, 2018 

on Maternal Mortality. !lost my wife Alexis joy in 2013 due to postpartum suicide, 

and I deeply believe that Congress needs to be aware of this ongoing crisis. 

On August 30th, 2013 my wife Alexis and I had our first child, a beautiful healthy 

baby girl we named Adriana joy. 

August 30th, 2013 was supposed to be the happiest day of our lives. Rather, it was 

the most challenging, eye opening, brutal reality we had never been prepared 

for. Our daughter's delivery was a code blue delivery. This was the beginning of 

the end of our perfect life as I knew it. Alexis was diagnosed with PTSD from the 

delivery. Breastfeeding proved way more challenging than either of us would have 

thought. Baby Adriana cried, a lot. This did not help our situation. 

Alexis was diagnosed with PTSD. She started worrying over everything. "Our 

perfect baby might be damaged", Alexis thought. Alexis was convinced Adriana had 

brain damage and we took the baby in for testing on her brain. She was fine. This 

was an answer my wife couldn't accept. Her fears seemed to grow daily. Each day 

she became more irrational, paranoid, and cried more. She would push food 

around on her plate but never took a bite. 

She had been calling her ObGYN, psychiatrist, and pediatrician during this entire 

period of time. Each one said "Don't worry, it's just the baby blues. It will 

pass. You're fine. just relax and enjoy this time." 
102 


36730.054

I watched my wife lose nearly 50 pounds in 30 days. One doctor in an emergency 

psychiatric unit pulled me aside and said "Your wife's not crazy. She will be 

fine. She just needs her family and friends. But, just in case there's only two ways 

women as pretty as her commit suicide. They either asphyxiate themselves in the 

garage or overdose on pills. just get rid of the car keys at your house and any 

prescription pills she could take. Women like her would never commit suicide in a 

"sloppy" way. They would never want to be remembered not looking their best" 

In our struggles to find help for my wife Alexis, we w-tmJ_to 7 _difmr:~nt h9~I!H<IJs_Qf 

!;ri~ili~ItteJ"s 1» b~rJ;~st.1~Ji<Iys. 

On the morning of October 8th, 2013 I woke up to our Maltese puppy named Lucy, 

frantically barking to wake me up. Something seemed off. The air was stale, it was 

almost as if time had stopped. It's a feeling you have to experience to really 

know. In that moment I knew. I jumped out of bed. Ran downstairs screaming 

Alexis name. No response. I could hear my daughter crying. I ran down to the 

kitchen, no Alexis. The dining room, family room, office- no Alexis. Outside on the 

deck, not there either. Downstairs to the garage, not there. In the basement, not 

there either. By this point I'm literally crazed, panicking screaming at the top of my 

lungs. I run back upstairs to find my daughter strapped to her changing table and 

crying. Still no Alexis. I run back downstairs to look again. As I look to the back of 

the basement there was my beautiful, perfect, love of my life. Lifeless hanging by TV 

cable from my basement ceiling. I called 911 screaming for them to help me save 

her. I remember going through the chest compressions and mouth to mouth 

bargaining with God please, please bring her back Suddenly, paramedics and cops 

were everywhere. They pulled me from her and started working on her. This was 

only probably 7 minutes. The craziest 7 minutes nobody should ever go through. 

These 7 minutes that paled in comparison to the 5 1/2 weeks of hell my wife had to 

endure. 7 minutes that pale in comparison to the eternity I will spend missing my 

best friend. 7 minutes that pale in comparison to the lifetime my daughter will 

spend wondering who her mom was. 7 minutes that pale in comparison to the 

times I spend coming up with answers to my daughter's questions about why her 

mommy died. Will my daughter blame herself someday? Will she do the same 

thing when she has a baby someday? Will she even want to have a baby 

someday? 7 minutes that pale in comparison to the anxiety I get when my reality 

sets in that l have to do this parenting thing all alone. 
103 


36730.055

All of this for no good reason. 

Since my wife lost her battle with postpartum suicide, Pittsburgh has decided to not 

wait for another tragedy and to do something about it. Moms in Pittsburgh can now 

see a psychiatrist in under 48 hours because of Allegheny Health Network and 

Highmark Blue Cross Blue Shield and the Alexis joy Foundation. I'm confident in the 

near future it will be under 24 hours. 

PPD is not a women's health issue, it is a family health issue. I firmly believe we 

owe it to our children to fix this preventable and treatable problem. I know I will do 

my part to make sure my daughter gets the care she deserves if needed, someday. 

As Congress takes into consideration the escalating rise in maternal mortality and 

the need to figure out "Why are Mothers dying in this great country", I implore 

Congress to take a look at the mental health aspect of this issue. Perhaps if there 

was enough information on maternal mental health, its risks and evidenced based 

treatment options, my wife would be here with me and our daughter, today. 

I thank you for your time. 

Sincerely, 

Steven 1Y~cfii((e 

Steven D'Achille, Founder 

The Alexis joy Foundation 

2010 Lake Marshall Drive 

Gibsonia, PA 15044 

www,al~Jd~joyf91lndi!Jimu:Jrg 

412.606.0065 
104 


36730.056
105 


36730.057

Statement for the Record 

September 27, 2018 

House Energy & Commerce Committee 

Health Subcommittee Hearing 

Better Data and Better Outcomes: Reducing Maternal Mortality in the U.S. 

Submitted by: 

Sean Blackwell, MD 

President, Society for Maternal Fetal Medicine 

409 l2'h Street SW Suite 601 

Washington, DC 20024 

Contact: Katie Schubert, Chief Advocacy Officer (202) 517-61221 kschubert@smfm.org 
106 


36730.058

Thank you for the opportunity to provide a statement for the record in support of bipartisan 

efforts to reduce a rising national maternal mortality rate in the United States. I submit this 

statement for the record on behalf of the Society for Maternal-Fetal Medicine, or SMFM. 

SMFM was founded in 1977 as the medical professional society for high-risk obstetricians. 

Maternal-fetal medicine specialists treat high-risk pregnant women women who have 

underlying medical conditions and become pregnant, women who develop life-threatening 

medical conditions as a result of becoming pregnant, or women whose fetuses do not develop 

normally and, in some cases, may become unviable. MFMs are obstetricians who have an 

additional three years of training and are on the front lines of these complicated pregnancy cases. 

Because we sec these cases every day we are deeply concerned with our country's rising 

maternal morbidity and mortality rates. 

Unfortunately, there is still much we do not know about why so many women are dying in 

childbirth or as a result of or following pregnancy. What we do know is that maternal mortality is 

just the tip of the iceberg and as many as half are potentially preventable. For each maternal 

death, there are numerous other women who suffer serious complications, what we refer to as 

severe maternal morbidities. We are working to understand more and do more to prevent these 

tragic outcomes. 

What we do know is that we can do better. Despite advances in obstetrical care, the United 

States still trails the developed world in its maternal mortality rate. While the rate of maternal 

mortality has fallen in most developed nations, it is rising here. In a 2015 study, the United 

States had the highest maternal mortality rate at 26.4 deaths for every 100,000 live births, 

followed by the United Kingdom at 9.2 deaths for every 100,000 live births. That translates into 

2 to 3 women dying each day in the United States at a time that should be one of the happiest in 

their lives and the lives of their families. 

When obstetrical care is standardized- when all women receive certain interventions when 

faced with complications- outcomes improve. The state of California has demonstrated 

remarkable improvements in pregnancy outcomes by reviewing the death records of pregnancy 

and postpartum women and standardizing care and working systematically to implement 

standardized care based on what they learned. Specifically, the California Maternal Quality Care 

Collaborative, via the use of state-wide outreach collaboratives, has been able to reduce severe 

maternal morbidity by 20.8 percent between 2014 and 2016 among the hospitals that participate 

in maternal hemorrhage and preeclampsia best practices. 1

Thc United Kingdom has long had 

what is known as the Confidential Inquiry into Maternal Deaths. As a result of that program, 

standardized interventions were developed and implemented that have had a dramatic impact on 

reducing maternal deaths from conditions like venous thromboembolism. 

We also know that with standardized data collection and review of maternal death cases, we can 

improve care and save lives. To assist with this, in September 2016, SMFM and the American 

College of Obstetricians and Gynecologists (ACOG) published an Obstetric Care Consensus 

outlining a process for identifying maternal cases that should be reviewed. We need better, more 

standardized data surrounding maternal mortality so that we can accurately attribute its causes 

1 https:(/www.cmgcc.org/gi-initiatives/obstetric-hemorrhage/hemorrhage-collaboratives 

2 
107 


36730.059

and prevent it wherever possible. There are some new tools available to share knowledge for 

example, with the support of the CDC Foundation, the Association of Maternal and Child Health 

Programs (AMCHP) created a web portal highlighting performing maternal mortality reviews so 

that states that have maternal mortality review committees can share information about best 

practices with states that are interested in setting up review committees. The National Network 

of Perinatal Quality Collaboratives sponsored by the Centers for Disease Control and Prevention 

and the March of Dimes was recently launched to provide support to state Perinatal Quality 

Collaboratives so that they can improve maternal and infant health outcomes. However, to 

accomplish this, they need more information about the problem that they are attacking. 

Once we have data it will be important to translate that data into actionable recommendations 

that can be implemented on a state level. This last piece is critical if we truly want to move the 

needle on reducing maternal morbidity and mortality in the United States and ensuring healthy 

births, morns and babies. With technical assistance and support from the CDC, as provided for in 

HR 1318, the Preventing Maternal Deaths Act, states can expertly create and sustain maternal 

mortality review committees. 

There is more that we can do together to reduce maternal mortality and severe maternal 

morbidity as healthcare providers. The establishment of maternal mortality review committees is 

just the first step. As an example, a focus on care coordination and the importance of considering 

social determinants of health in all of our solutions cannot be stated enough. 

SMFM has endorsed HR 1318 and appreciates Representatives Herrera Beutler, DeGette and 

Costello's leadership on this important issue. With the bipartisan support and further leadership 

of Chairman Burgess, Ranking Member Green and the entire Health Subcommittee, as well as 

Chairman Walden, Ranking Member Pallone and the full Energy and Commerce Committee, we 

can take the first step in reducing maternal mortality. 

No woman goes into pregnancy fearing a significant complication or death. Having a child 

should be a joyous time - but far too often complications arise and these impact not just the 

woman-but also her baby and her entire family. We can do more, and we must do more. With 

a state-based review process, better data, actionable recommendations and a focus on policies 

that are informed by findings from state-based review process and evidence, we can and will 

make a big difference. We urge you to support HR 1318 and move it forward to House floor 

action. Thank you again for providing me the opportunity to speak and for shining a light on this 

important issue. 

3 
108 


36730.060

.Health 

SCHOOL OF MEDICINE 

DEPARTMENT OF OBSTETRICS & GYNECOLOGY 

MEMORANDUM 

Date: September 12, 2018 

To: Congressman Michael Burgess 

From: Gary D.V. Hankins, MD 

Chairman, Department ofOB/GYN 

RE: Maternal Mortality Testimony 

Gary O.V. Hankins, MD 

Garland D Anderson, MD 

Distinguished University 

Chair in Obstetrics and Gynecology 

Professor and Chairman 

3.400 John Sealy Annex 

301 University Blvd 

0 409.772.1957 F 409.772.0974 

E ghankins@utmb.edu 

I greatly appreciate Congressman Michael Burgess providing me the opportunity to submit written 

testimony to the Health Subcommittee of the United States Congress. By way of introduction, I am 

currently the Chai1man of Obstetrics and Gynecology at the University of Texas Medical Branch in 

Galveston, Texas where I have practiced for the last 22 years. Prior to coming to UTMB I was on 

active duty in the United States Air Force for 22 years, again serving a practicing obstetrician 

gynecologist. I am trained both as an OBGYN physician as well as having subspecialty training in 

Maternal Fetal Medicine and in Critical Care medicine. Additionally, I most recently served as Vice 

Chair for the state of Texas Maternal Morbidity and Mortality Review Committee. 

Having spent considerable time looking at maternal mortality in the United States, it is clear that 

substantial improvement is needed and should be accomplished. The mortality within the United 

States is more than twice tl1at in other areas of the industrialized world and greater than 6 times that 

in Sweden. While it is unlikely that we could ever achieve the maternal mortality in the United 

States that can be achieved in a country as small as Sweden, it is clear to me that concentrating in 

the three areas that I will detail below, would substantially (I estimate by at least 50%) reduce 

maternal mortality in the United States. 

1. Interprcgnancy care; The provision of healthcare to many pregnant women within the United 

States, particularly those on government programs such as Medicaid, is episodic. That care 

begins only with the diagnosis of pregnancy and ends within a relatively short period following 

the conclusion of pregnancy. As such, women often enter into the pregnancy with uncontrolled 

or only partially controlled diabetes, hypertension, thyroid disease, and many other medical 

conditions. It is these complications of pregnancy which translate not only to a poor outcome for 

the women but also a poor outcome for the baby, often to include potential fetal malformations 

utmb.edu Working trJgether to work wonders:' The University of Texas Medu.:;at Branch Member; Texas Metticaf Centet'f' 
109 


36730.061

as well as premature deliveries. The cost burden of not providing pregnancy care and control of 

these chronic conditions is staggering and would greatly exceed the cost to control these diseases 

and conditions before the woman ever enters into pregnancy. As a specific example, failure to 

control Diabetes Mellitus carries a substantial risk that the fetus will have either a midline CNS 

developmental defect i.e., cleft lip, cleft palate, spina bifida, or a cardiac anomaly. These fetal 

malformations can be reduced to near zero if the diabetes is controlled prior to pregnancy. This 

is but one example of where dollars could be very well spent. The return on investment on 

quality oflife and a reduction on long-term expenditures are very substantial. 

2. Regionalization. The fact that regionalization of medical care to concentrate getting the patient 

to the appropriate level facility works has been demonstrated by the pediatricians and 

neonatologists for at least 30 years. It is largely through regionalization that the neonatal survival 

rates have been markedly increased at the same time that long term morbidity has been 

decreased for premature infants. This same model is applicable to pregnancy and the transfer of 

women with substantial complications to regional centers with the appropriate staffing! By way 

of one example, major maternal cardiac conditions should be sent to centers with specialized 

ability to provide care for these highly complex and complicated women. Such care is available 

through the input of teams of physicians with expertise to include maternal fetal medicine 

specialists, cardiologists, and intensivists to name a few. As an immediate first step towards 

reducing maternal mortality, the combination of providing interpregnancy care and 

regionalization of the care system hold the promise of significant immediate improvement in 

maternal mortality & morbidity. 

3. Mental Health Services. In the review on the state of Texas Maternal Morbidity and Mortality 

Committee it was a surprise to me as a clinician that almost half of the deaths occurring were as 

a result of either a drug overdose or suicides/homicides. In the majority of these cases the 

women had either not been referred for mental health services or had not gained access to 

facilities capable of providing mental health services. It was clearly my misperception that the 

overwhelming majority of maternal deaths were as a result of the classic issues of obstetric 

hemorrhage, poorly controlled hypertension and/or infection as is still taught in many medical 

schools. To the contrary, almost half of maternal deaths relate to the mental health of the 

woman. Accordingly, while the first two strategies that I've outlined above would make a 

significant impact on the actual medical conditions, that would (at max) affect only about half of 

maternal deaths during pregnancy. Attention to provision of mental healthcare when needed is 

essential. 

I would conclude by briefly addressing the disparity in outcomes based upon race and ethnicity. 

There can be no debate but that the healthcare outcomes for the Native American population and for 

the African American population is far worse than for the Caucasian population. Similarly, the 

outcome for Hispanics, especially if first generation, actually exceeds that of Caucasians in the 

United States. Accordingly, specific populations are readily identified where a greater impact on the 

outcome certainly should be able to be achieved. I'd also point out that throughout the United States 

even in those states with the lowest maternal mortality, this disparity in outcomes persist and 

sometimes is even worse. Finally & sadly, the disparities in these outcomes based upon race and 

ethnicity is the absolute worst in our Nation's Capital. 
110 


36730.062

I want to thank Dr. Burgess and the committee for allowing me to express my thoughts on this issue. 

I commend you for undertaking this difficult task and stand ready to assist you in any fashion I 

might. 

Regards, 

~ fY( J h._)~ 0 

GaryD~MD 
111 


36730.063

September 11, 2018 

TO: US House Energy & Commerce Committee 

Written Testimony of the March for Moms Association at a Hearing of the House Committee on 

Energy and Commerce Subcommittee on Health on the "Maternal Mortality Act" (H.R. 1318) 

Dear Committee Members, 

On behalf of the March for Moms Association Board of Directors, we value your time and our 

opportunity to highlight key issues related to maternal mortality in the United States. March for 

Moms Association, now in its second year, is a growing, multi-stakeholder coalition sharing likeminded urgency to improve the wellbeing of mothers in the US. 

We established March for Moms in 2017 to address a widespread crisis among American 

families during the universally vulnerable period that stretches from pregnancy through 

delivery of a baby to early parenthood. Right now, Americans who are starting or growing their 

families face starkly greater risks than their parents did. 

In just one generation, the odds of an American mother dying from a pregnancyrelated cause has increased by more than 50%, a risk that is consistently three to four 

times higher for black mothers than white mothers. 

For every death, there are 100 mothers who experience life-threatening injuries. For 

every injury, there are tens of thousands of mothers who experience avoidable 

suffering in the form of physical or mental illness, professional disruption, and/ar 

wider societal disempowerment. 

Our inclusion of two graphs depict the current state and worsening trend of maternal health 

childbirth in our country. The first graph published this month from AHRQ illustrates severe 

maternal morbidity from 2006-2015. Severe maternal morbidity is defined as including 

unexpected outcomes of labor and delivery that result in significant short- or long-term 

consequences to a woman's health. Often called near-misses, deliveries involving severe 

maternal morbidity generally include life-threatening conditions, such as acute myocardial 

infarction, pulmonary embolism, or sepsis. Severe maternal morbidity disproportionately 

affects minority and low-income pregnant women, especially non-Hispanic Black women and 

those with Medicaid coverage. 
112 


36730.064

figure 1. Trends In ctetiv.ry h0$plt1Untion• fnvoMnv MVere mat~tntal morbidity, 2086-201$ 

,., 

lUI 

Oltmsevemmatem!llmo~btdity 

{'ol'ilhor~bloodtnmm~nl'" 

24PtiCOf'll 

ln«en~t ~ 

" .. ,,, 

200tl 2001 ;?008 1009 2010 lt'IH l011" 201:1 ~14 2015 

Ye~u 

Fingar KF (IBM Watson Health), Hambrick MM (AHRQ), Heslin KC (AHRQ), Moore JE (Institute for Medicaid 

Innovation). Trends and Disparities in Delivery Hospitalizations Involving Severe Maternal Morbidity, 2006-2015. 

HCUP Statistical Brief #243. September 2018. Agency for Healthcare Research and Quality, Rockville, 

MD. www.hcup-us.ahrq.goy/reports/statbrlefs/sb243-Severe-Maternai-Morbldity-Delivery-Trends-Disparities.pdf. 

The next graph depicts maternal death. American women are more than three times as likely to 

die in the maternal period and six times as likely to die as Scandinavians. In every other highincome country, many less affluent than the US, maternal mortality rates have been falling. 

But in the US, maternal deaths increased from 2000-2005, with the CDC estimating nearly 

60% of such deaths are preventable. 

Maternal Mortality Is Rlsing in the U.S. As It Declines 

Elsewhere 

U.S.A. (26.4) 

U.K..(9.2} 

f'c«tJtal{9) 

O•rmai"IY\9) 

Fnnco{7,S) 

C•nada (7.3) 

Nllftt.ffilnd• (f!.7) 

Spaln{S..6) 

AUl!talili!S!l) 

lfefand(4.1J 

Sweden {4.4} 

ttaly{4/l) 

Oenmatk {11.2) 

finland(3.8} 

'(lliJ.tW,tllll!f..,.,<,MOrmillfllll !!!r;."!l(~clmll~!l><»'t.ll''? lru)G ?I'll"; ;.l>~"'~'l'l'i'>klflllll't'llo!W~>'IW'<I!l)-w 

Stu<l}o~l~." II!>! Lit~(+' 011-)'dWIW'\100 ~-Ml$WU!IWCI!oa•ll'l~t$A'diWI<)I.',..; 
113 


36730.065

Going forward we envision a society where every person can start or grow their family with 

dignity by accessing childbirth care that is safe, supportive and empowering. In the current 

state, maternal health is dangerously fragmented and riddled with inequity. The quality of care 

for women and moms can swing wildly from one woman to the next based on the accident of 

her geography, the color of her skin, or the size of her paycheck. Families, healthcare providers 

and policy makers must come together to shed light on where we are failing and how we can 

do better. 

We are pleased H.R. 1318 enjoys bipartisan support in the House and Senate. We applaud the 

Senate HELP Committee for advancing S. 1112, the Maternal Health Accountability Act this past 

June, and for taking a significant step toward fighting maternal mortality and improving 

maternal health. This legislation will help reverse our country's rising maternal mortality rate by 

assisting states to establish or improve multidisciplinary committees that will track, analyze and 

identify local solutions to prevent maternal deaths. These are known as maternal mortality 

review committees (MMRCs). And we are also pleased they raised the funding level available 

for these state MMRCs from $7 million to $12 million each year for five years. This increased 

investment will allow the CDC to robustly support state MMRCs so they can provide a 

comprehensive picture of why these deaths are occurring, and come up with actionable 

solutions. 

Advancement of H.R. 1318 today shows House leadership in addressing this public health crisis, 

a first step in ending preventable maternal mortality. 

Thank you for your consideration of this legislation on September 14th, 2018. We urge this 

Subcommittee and House to pass without delay. Feel free to contact either of us with any 

questions. 

Respectfully, 

Ginger 

~~ Breedlove, PhD, CNM, FACNM 

President, March for Moms 

maternitycaremarch@gmail.com 

Dr. Nee! Shah, MD, MPP, FACOG 

Vice-President, March for Moms 

neel@post.harvard.edu 
114 


36730.066

September u, 20:1.8 

House of Representatives 

Committee on Energy and Commerce 

2:1.25 Rayburn House Office Building 

Washington DC 205:1.5 

Dear Members of the Committee, 

Having a new baby is supposed to be the happiest time in a woman's life. Not always. 

New mothers in the United States are dying at increasing numbers. In fact, the United States has the 

highest rate of maternal mortality than any other developed country, and this rate continues to rise in our 

country as it declines elsewhere around the globe. 

What is going on in the United States? Why are at least 700 new mothers dying each year? 

Why has the rate of maternal mortality in the United States DOUBLED since 2ooo? 

The only way to answer these questions is to review each and every maternal death through statewide 

maternal mortality review committees (MMRCsl. groups of maternal-child health experts and advocates 

who identify, review, and analyze maternal deaths and then disseminate information and act on the 

findings. Unfortunately, not all states have MMRCs, nor do the existing MMRCs gather data uniformly and 

consistently. 

One of the leading causes of death for women in the first year after having a baby is SUICIDE. The United 

Kingdom and Japan both report suicide as the LEADING CAUSE of maternal mortality. Because we don't 

track this information in the United States, we are not sure of the suicide rate. But we know that 

postpartum depression and related mental health issues affect at least 1 in 5 women during pregnancy or 

first year postpartum. And we know that women like She lane Gaydos, Allison Goldstein, and Brittany 

Butts (see next page for more about each of these lovely young mothers) are taking their lives. We need 

better systems to help these women and to identify why and how new mothers are dying. 

Please vote for full funding of maternal mortality review committees in all so states. 

Why? Because children need their mothers. 

Sincerely, 

Adrienne Griffen 

Founder and Executive Director 

P.O. Box 7521 Arlington VA 22207 • 703-829-7152 www.postpartumva.org 
115 


36730.067

Shelane Dawn Gaydos 

6/1.2{2015 

Allison Mathews Goldstein 

6/28/2016 

P.O. Box 7521 

Sample -- Maternal Deaths By Suicide 

She lane was a strong, energetic, intelligent and warm woman. She had a hearty, 

infectious laugh and a bright smile. She was a loving and supportive wife to her 

husband, Brian, and a devoted mother to her three beautiful daughters, Nadia(?), 

Sofia (5) and Olivia (2). She truly lived for her girls and dedicated a lot of time and 

energy into making their lives extra speciaL On that beautiful sunny afternoon, 

after she made sure all the girls were safely at home and comfortable watching 

the T.V. she made an irreversible split minute decision to go into the next room, 

close the door and end her life. 

Shelane was a Fairfax County police officer. Her family launched Shelane's Run sK and Kids 

Fun Run in 2016 to raise awareness about PMADs. Learn more at www.shelanesrun. orq. 

No star shone brighter, no smile was sweeter than Allison Goldstein. She was a 

wonderful Mother, a devoted wife, and remarkable daughter and sister, a special 

aunt to two nephews and a niece, five cousins and countless friends. Amidst all 

the joy and love she shared with the world, Allison silently suffered from 

postpartum depression. Allison is survived by her loving husband, Maj. Justin 

Goldstein, and her infant daughter, Ainslee Parker. 

Allison's family has taken on the issue of maternal suicide through a foundation they 

launched named Allison's Reach and by speaking publicly and openly about their loss. 

Allison's story has been featured in local news outlets and shared worldwide via social media. 

Brittany loved being on the sled running with her Siberian Huskies, or showing 

them in the conformation ring. Mother to her son Teige, with husband Jeff, she 

was aspiring to be a sports veterinarian. Brittany was the spark in the room that 

made lasting impressions with everyone. She was loved by her family and friends. 

Yet none of us really knew the depth of her despair or the many questions that 

would be left unanswered. 

Brittany's mother1 Natalie Velasquez, participated in PMAD Advocacy Day in 2016. Natalie is 

a psychiatrist who lived in Northern Virginia for many years and now lives in Alaska 

Arlington VA 22207 • 703-829-7152 www.postpartumva.org 
116 


36730.068

House Energy & Commerce Committee Health Subcommittee Hearing on 

Better Data and Better Outcomes: Reducing Maternal Mortality in the U.S. 

September 27, 2018 

Testimony for the Record 

Submitted by Susan Chacon, MSW, LISW 

President, Association of Maternal & Child Health Programs (AMCHP) 

Chairman Burgess, Ranking Member Green and distinguished members of the subcommittee, 

thank you for this opportunity to submit testimony in support ofH.R. 1318, the Preventing 

Maternal Deaths Act. I would also like to especially thank Representatives Jaime Herrera 

Beutler (R-WA) and Diana DeGette (D-CO) as well as their stafffor their diligent work to 

introduce and refine this bill. 

My name is Susan Chacon and I currently serve as the President of the Board of the Association 

of Maternal & Child Health Programs (AMCHP). For 16 years, AMCHP has collaborated with 

national partners to build the capacity of state- and jurisdiction-based teams to conduct maternal 

mortality and morbidity surveillance, including establishing and sustaining maternal mortality 

review committees. As an organization representing state maternal and child public health 

leaders, many of our members directly oversee the maternal mortality review committee process 

in their own states. 

I am proud that my state of New Mexico, where I currently serve as the Children and Youth with 

Special Health Care Needs Director, has been conducting maternal mortality review in some 

form since 1980 and by a multidisciplinary committee since 1993. The mission of our maternal 

mortality review committee is to identify and review maternal deaths caused by pregnancy 

complications and other factors, to identify remediable problems contributing to maternal deaths, 

and to develop interventions to reduce these deaths. 

This process is time consuming and resource intensive. Currently there is no dedicated federal 

source of funding for maternal mortality review committees and therefore most states cobble 

together funding from a combination of their Title V Maternal and Child Health Services Block 

Grant, fluctuating state funding allotments, private grants and volunteered time. Today, only 35 

states (as well as 3 large cities) have maternal mortality review committees, which means they 

have the capacity to understand why mothers are dying and what can be done to prevent these 

tragedies. This capacity is fragile and easily influenced by shifting state public health priorities 

and funding constraints and must be nurtured to ensure adherence to best practices. The 

remaining one-third of states are in varying stages of forming a maternal mortality review 

committee and may be struggling in building political and social will or finding adequate funding 

and staff support to put a review committee into practice. Because these committees operate 

independently of one another and are governed by individual state laws and/or regulations, they 

are also vulnerable to inconsistent methods of collecting, analy-Ling, and reporting data, thereby 

hindering our ability to tell a complete national story about maternal mortality in the U.S. 
117 


36730.069

H.R. 1318 would take a critical step forward by providing federal support to build and sustain the 

work of state maternal mortality review committees and advance efforts to standardize the 

review process and the collection and analysis of data. With this support, we can continue to 

work together to turn that data into action in order to save women's lives. 

About AMCHP: The Association of Maternal & Child Health Programs is a national resource, 

partner and advocate for state public health leaders and others working to improve the health of 

women, children, youth and families, including those with special health care needs. 
118 


36730.070

Heart Safe Motherhood at Penn Medicine (University of Pennsylvania Health System) 

Website: https://hcalthcareinnovation.upenn.edulprojects/heart-safe-motherhood 

Preeclampsia is a disorder of pregnancy characterized by high blood pressure and high levels of protein in 

the urine. Hypertension is the leading cause of maternal morbidity and mortality in the U.S., and while 

risk factors are known, previously no strategy existed for effective, reliable blood pressure surveillance 

for at-risk patients. With poor maternal outcomes on the rise in Philadelphia and across the country and 

new guidelines on postpartum care issued by the American College of Obstetricians and Gynecologists 

this spring, there is a clear call to action and an audience eager for a solution. 

A Penn Medicine team, led by providers and researchers in Maternal Fetal Medicine, has designed a 

common-sense approach to care that answers an important challenge. Their solution, Heart Safe 

Motherhood {HSM), is an evidence-based care model with real-world data that's bolstering the promise 

of connected health, and by its focus on convenient care for women, speaks to the growing attention being 

paid to women as a vital demographic in the dual eras of population health and health care consumerism. 

At the start of the HSM project, blood pressure monitoring required patients to attend a one-time, inperson appointment. However, professional association guidelines published by ACOG in 2014 

recommended two points of monitoring: 72 hours and seven to ten days post-discharge. 

As part of the project, the team developed and tested a text-based intervention for hypertension. They 

enrolled patients in a remote blood pressure monitoring program during the first seven days postdischarge from the Labor and Delivery floor at HUP. 

Over the course of seven iterative pilots, over 30 patients were discharged with digital blood pressure 

monitors and sent reminders via text message to check their blood pressure twice daily. Once submitted 

by the patient, blood pressure results were reviewed and responded to by an Ob/Gyn physician. 

After the conclusion of the pilot, the team received funding from the Penn PCORI Grant and Penn 

Presbyterian Harrison Fund to conduct a randomized controlled trial of the intervention. The team was 

recognized for their leadership with a first prize award in the American Heart Association's Philadelphia 

Heart Science Forum Innovation Challenge, Digital Health Category, and first place in the Council on 

Patient Safety in Women's Health National Improvement Challenge on Hypertension in Pregnancy. 

Heart Safe Motherhood continues to make postpartum remote blood pressure monitoring easy so that 

providers can catch rising blood pressure earlier and keep patients safe at home. 

Our journey to spread Heart Safe Motherhood has just begun. Heart Safe Motherhood can become a 

national model for reducing the burden of preeclampsia on maternal morbidity and mortality. Through 

text message-based remote monitoring, we have transformed our ability at one hospital to provide high 

quality, convenient, and safe care for women with pregnancy-related hypertension in the immediate 

postpartum period. We have developed knowledge about how to identify and enroll patients for 

engagement and how to capture and act on blood pressure remotely for clinical impact, providing the 

right care to the right patient at the right time. We have learned to think outside conventional medicine 
119 


36730.071

and listen to our patients. In fact, the American College of Obstetrics and Gynecology recently 

acknowledged our work in their May, 2018 Committee Opinion on Redefining the postpartum visit. 

Through Heart Safe Motherhood, we can transform our ability to monitor hypertension remotely. The 

Heart Safe Motherhood program allows us to provide patient-centered postpartum care for women with 

preeclampsia who are at risk of devastating complications while simultaneously engaging them in their 

future health. 

Program Results: 

Nine months ago, the team implemented Heart Safe Motherhood for patients with known pregnancyrelated hypertension at the Hospital of the University of Pennsylvania. Since then, they have been able to 

obtain blood pressures remotely at the two time points recommended by ACOG in 80 percent of patients, 

intervene and start medications from home before development of morbidity, and continue to have strong 

patient and provider satisfaction. The team's readmission rate has dropped from 5 percent for postpartum 

patients monitored for hypertensive issues prior to Heart Safe Motherhood to I percent with the program 

at scale. Hypertension is no longer the leading cause of seven-day obstetrical readmissions at the Hospital 

of the University of Pennsylvania. 

Additional proof points and tangible results include: 

Results of the pilot program showed there were no seven-day readmissions among enrolled 

patients, compared to a 5 percent readmission rate among women monitored through in-person 

visits. The percent of patients to report at least one blood pressure reading in the first week postdischarge jumped from 15 percent pre-intervention to 84 percent among all enrolled patients. 

The percent of patients to report blood pressure readings on five of seven days in the first week 

post-discharge jumped from 0 percent pre-intervention to 69 percent among all enrolled patients. 

At the conclusion of the RCT, the team saw the platform's ability to meet ACOG guidelines on 

postpartum blood monitoring leap from 0 percent to 82 percent compared to in-person office 

visits and seven-day readmissions from hypertension drop from 3 percent to 0 percent. 

Heart Safe Motherhood is now the standard of care for obstetrics patients at HUP with plans to scale to 

other Penn Medicine locations in 2018. The team is also partnering with health systems, payers, and 

vendors to evaluate the ability to scale the program for national impact. 
120 


36730.072

September 27,2018 

The Honorable Greg Walden 

Chairman 

Committee on Energy & Commerce 

U.S. House of Representatives 

Washington, DC 20515 

The Honorable Michael Burgess 

Chairman 

Subcommittee on Health 

Committee on Energy & Commerce 

U.S. House of Representatives 

Washington, DC 20515 

The Honorable Frank Pallone 

Ranking Member 

Committee on Energy & Commerce 

U.S. House of Representatives 

Washington, DC 20515 

The Honorable Gene Green 

Ranking Member 

Subcommittee on Health 

Committee on Energy & Commerce 

U.S. House of Representatives 

Washington, DC 20515 

Dear Chairman Walden, Ranking Member Pallone, Chairman Burgess and Ranking Member Green: 

Our organizations commend you for holding today's hearing, "Better Data and Better Outcomes: 

Reducing Maternal Mortality in the U.S." We would like to express our support for the discussion draft 

of H.R. 1318, the Preventing Maternal Deaths Act, sponsored by Representatives Jaime Herrera Beutler 

(R-WA), Diana DeGette (D-CO) and Ryan Costello (R-PA) that is being considered today, which 

mirrors S. 1 112, the Maternal Health Accountability Act, as recently advanced by the Senate HELP 

Committee. 

Our nation faces a growing crisis in maternal health. More women die from pregnancy-related 

complications in the United States than in any other developed country, and the rate of maternal deaths 

continues to rise. Major disparities in maternal mortality exist, with black women three to four times 

more likely than white women to die during pregnancy or shortly after birth. Moreover, for every 

maternal death that occurs, an estimated I 00 other women suffer severe complications of pregnancy or 

childbirth. We must act now to reverse this trend and save mothers' lives. 

We urge the Subcommittee to address maternal mortality by supporting the work of state maternal 

mortality review committees (MMRCs) through the Centers for Disease Control and Prevention (CDC). 

MMRCs are multidisciplinary groups of local experts in maternal, infant, and public health that examine 

cases of maternal death. Maternal mortality review is a cyclical process that does not end by simply 

counting and characterizing deaths, but must be followed with action by putting the recommendations of 

the committee to work in hospitals, communities, or policies. 

While these efforts take place at the state or jurisdiction level, federal support will accelerate progress 

toward ensuring that every state has a high-functioning MMRC. This legislation will also advance 

efforts among states to standardize the collection and analysis of data. With better data and information, 

we can develop a national understanding of why mothers are dying and what we collectively can do to 

reverse this tragic trend. 

We look forward to continuing to work together to see this bipartisan bill move forward in Congress and 

enacted into law. 
121 


36730.073

Sincerely, 

1,000 Days 

2020Mom 

AFE Foundation 

American Academy of Family Physicians 

American Academy of Pediatrics 

American College of Nurse-Midwives 

American College of Obstetricians and Gynecologists 

American College of Physicians 

American College of Surgeons 

American Medical Women's Association 

American Psychological Association 

American Public Health Association 

American Society for Reproductive Medicine 

Amnesty International USA 

APS Foundation of America, Inc. 

Association for Prevention Teaching and Research 

Association of Maternal & Child Health Programs 

Association of Public Health Laboratories 

Association of Schools and Programs of Public Health 

Association of State and Territorial Health Officials 

Association of State Public Health Nutritionists (ASPHN) MCH Nutrition Council 

Association of Women's Health, Obstetric and Neonatal Nurses 

Children's Defense Fund 

Choices in Childbirth 

Every Child By Two 

Every Mother Counts 

Genetic Alliance 

Hand to Hold 

HER Foundation 

Heroes for Moms 

Lamaze International 

March of Dimes 

Maternal Safety Foundation 

Medicines360 

MomsRising 

NAPHSIS 

National Association of County and City Health Officials 

National Association of Nurse Practitioners in Women's Health 

2 
122 


36730.074

National Association of Pediatric Nurse Practitioners 

National Association of Perinatal Social Workers 

National Black Women's HIV/AIDS Network 

National Blood Clot Alliance 

National Health Law Program 

National Partnership for Women & Families 

National Perinatal Association 

National WIC Association 

New York State Birth Center Association 

Nurse-Family Partnership 

Organization of Teratology Infonnation Specialists 

Patient Safety Movement Foundation 

PCOS Challenge: The National Polycystic Ovary Syndrome Association 

Power to Decide, the campaign to prevent unplanned pregnancy 

Preeclampsia Foundation 

Preemie World, LLC 

Safe States Alliance 

Save the Mommies Inc. 

Society for Maternal Fetal Medicine 

Society for Public Health Education 

Spina Bifida Association 

The 2 Degrees Foundation 

The National Accrcta Foundation 

The National Alliance to Advance Adolescent Health 

The Shane Foundation 

The Tara Hansen Foundation 

The Tatia Oden French Memorial Foundation 

Trust for America's Health 

United Methodist Women 

ZERO TO THREE 

3 
123 


36730.075

A AMERICANS Cl UNITED ~ '''' FORLIFE 

Written Testimony of Catherine Glenn Foster 

President and CEO, Americans United for Life 

Regarding the Subcommittee Hearing 

Better Data and Better Outcomes: Reducing Maternal Mortality in the U.S. 

Submitted to the House Energy and Commerce Subcommittee on Health 

Thursday, September 27, 2018 

Chairman Burgess, Ranking Member Green, and distinguished Members of the Committee: 

Americans United for Life (AUL) urges the Committee to recognize that not all maternal 

mortality is the same and to include specific statistical data collection and reporting on abortionrelated mortality in the Preventing Maternal Deaths Act of2018. Founded in 1971, Americans 

United for Life, the legal architect of the prolife movement, is a national law and policy 

nonprofit organization with a specialization in abortion and bioethics law. 

The current United States system for reporting abortion-related maternal mortality is 

deeply flawed, and there is currently no reliable source of data. For the sake of women's health, 

this Committee should take steps to remedy that problem. 

Abortion data reporting in the U.S. is entirely voluntary. This skews both the statistics 

and resulting analysis. For the reporting that does occur, maternal mortality due to abortion is 

often underreported as many maternal deaths are attributed to some other cause-like "sepsis," 

or "infcction"-rather than the true underlying cause, termination of the pregnancy. This means 

that most studies are based on abortion "estimates" and "reported" deaths. 1 Additional studies 

show that I out of 16 women who have an abortion will visit an emergency room within six 

1 See. e.g., Elizabeth G. Raymond & David A. Grimes, The Comparative Safety of Legal induced Abortion and 

Childbirth in the United States, ll9 Obstetrics & Gynecology 215 (2012). 
124 


36730.076

Page 2 of3 

weeks after the abortion, 2 which, due to data collection methodology, should be considered a 

floor and not a ceiling. 

Abortion-related maternal deaths are not systemically collected. There are two national 

reporting organizations: the Alan Guttmacher Institute (AGI) and the Centers for Disease Control 

and Prevention (CDC). AGI collects its data from abortion providers that report voluntarily. The 

CDC collects its data from the states, which report data haphazardly. For example, Californiawhere reportedly one-third to one-half of all abortions in the U.S. are performed-has not 

reported its data to the CDC for several years. The numbers of annual abortions reported by AGI 

and the CDC differ by 15% or more. 

The deeply flawed state of abortion-related maternal health data collection and reporting 

is a direct risk to the health of women. It deprives doctors of accurate data, which in tum 

prevents them from providing accurate information about abortion-related maternal mortality and 

morbidity to women. This is even more problematic considering the vast majority of abortions 

are elective and not medically indicated. 

With the current data and reporting regime, it is impossible for a woman considering 

undergoing an abortion to receive the information she needs to voluntarily consent. Women need 

more than "estimates" or "guesses" on abortion-related maternal mortality to make an informed 

decision. They need complete and accurate data, and the U.S. has a responsibility to care for 

women's health by providing this data through public health reports. 

Such a dysfunctional system of abortion-related maternal health data collection and 

reporting in the U.S. is unnecessarily substandard. In contrast, the collection and reporting of 

births and other gynecological procedures in the U.S. is systematic and thorough. Unlike 

2 Ushma D. Upadhyay et al., Incidence of Emergency Department Visits and Complications After Abortion, 125 

Obstetrics & Gynecology 175, 175 (2015). 

AMERICANS UNITED FOR LIFE AULORG 202.289. 1478 

2101 WILSON BLVD., STE. 525, ARLINGTON. VA 22201 
125 


36730.077

Page 3 of3 

maternal mortality from natural causes, abortion-related maternal mortality can be directly linked 

to either an invasive surgical procedure or a chemically-induced response. Given that this 

unnatural impact to pregnancy is man-made, it stands to reason that there should exist a robust 

methodology to track its impact. Currently, there is not. 

In conclusion, this Committee should add data collection and reporting on abortionrelated maternal mortality specifically in the Preventing Maternal Deaths Act of2018. 

AMERICANS UNITED FOR LIFE 

Sincerely, 

c~ Catherine Glenn Foster, M.A., J.D. 

President and CEO 

Americans United for Life 

AUL.ORG 202.289. 1478 

2101 WILSON BLVD .. STE 525. ARLINGTON. VA 22201 
126 


36730.078

2018 

1900 Grant SUe€t, 4th Floor 1 

on this 

kgis1ation. 

I nursef&mJlypartnershlp.org 
127 


36730.079

CLAMPSIA 

foundation 

House Energy & Commerce Committee Health Subcommittee Hearing on 

"Better Data and Better Outcomes: Reducing Maternal Mortality in the U.S." 

September 27, 2018 

Testimony for the Record 

Submitted by Eleni Tsigas 

Chief Executive Officer, Preeclampsia Foundation 

Chairman Burgess, Ranking Member Green, and distinguished members of the subcommittee, 

thank you for holding today's hearing to address "Better Data and Better Outcomes: Reducing 

Maternal Mortality in the U.S." I am Eleni Tsigas, Chief Executive Officer of the Preeclampsia 

Foundation, and I am so pleased for the opportunity to submit testimony for this hearing in 

support of the discussion draft of H.R. 1318, the Preventing Maternal Deaths Act. I would also 

like to recognize the hard work of Representatives Jaime Herrera Beutler (R-WA) and Diana 

DeGette (D-CO) for their efforts to address the crisis of maternal mortality in the U.S. and to 

introduce and advance this important legislation. 

Preeclampsia is one of the leading causes of mothers dying from pregnancy-related issues. It is a 

hypertensive disorder of pregnancy characterized by high blood pressure, protein in the urine, 

and sometimes failure of the kidneys, liver and other organs. It can affect up to one in 12 

pregnancies, and there is no cure, only management. 

Nineteen years ago, I held the still warm body of my baby daughter in my arms and kissed her 

desperately, trying to will her back to life. My kidneys had failed. I had lost half of my body's 

blood volume when I delivered her because of an undetected placental abruption due to 
128 


36730.080

.ECLAMPSIA 

foundation 

preeclampsia, and I almost died. So many other women like me have faced similar 

circumstances, but sadly, many of them did not survive and cannot offer their testimony here 

today. 

As an organization, the Preeclampsia Foundation is focused on educating patients, their families 

and health care providers to recognize the preeclampsia warning signs and ensure that timely 

care is provided so no woman dies during pregnancy, delivery, or during the postpartum period. 

Moving this agenda forward has required solid data proving that a lack of patient knowledge of 

preeclampsia is a factor in a large percentage of preventable deaths. We have been able to obtain 

much of this data from existing state maternal mortality review committees, but much more data 

is needed. The data from state maternal mortality review committees is utilized to ensure 

healthcare providers accept and adopt the Preeclampsia Foundation's call to action to educate 

women about the signs and symptoms of preeclampsia and appropriately respond with timely 

diagnosis and accurate clinical management when they do. 

Thanks to the work of existing maternal mortality review committees, the Foundation is sending 

out hundreds of thousands of pieces of patient education materials every year that are used in 

hospitals, and often in prenatal care settings. We strive to push out millions of educational 

materials, and women should be getting them at every prenatal visit, but unfortunately, too many 

states have not yet been able to - or understood how to - appropriately collect and assess their 

maternal mortality data that is linked to hypertensive disorders of pregnancy or other pregnancyrelated complications. 
129 


36730.081

ECLAMPSIA 

foundation 

The Preeclampsia Foundation ultimately strives to prevent maternal mortality and severe 

maternal morbidity and help states and communities establish protocols that save lives. We view 

this as a data-to-action initiative. There is so much to be learned from maternal mortality reviews 

that can improve healthcare practices today. For example, in Florida, based on their maternal 

mortality reviews, the state found that hospitals were taking too long to treat pregnant women 

that had severe high blood pressure. These women were dying from stroke and other preventable 

sequelae. Armed with data, new standards and protocols were set. In less than a year, 90 percent 

of women with persistent new onset severe hypertension were treated within one hour in 

hospitals using a new hypertension in pregnancy protocol. Before that time, only 20 percent were 

being treated within one hour. 

Another example of where data can impact care is in addressing postpartum preeclampsia. One 

of the most common myths associated with this disorder is that "delivery is the cure for 

preeclampsia." This is not true. Women are still at risk from preeclampsia and related 

hypertensive disorders following delivery, sometimes for weeks, particularly as most care is 

directed to the baby. Analyses from some states' data has reinforced this by reviewing the 

number of mothers that die after they have returned home post delivery. We need far better 

postpartum surveillance, and we need to train emergency departments for when these women 

present with signs of preeclampsia-related distress. We cannot let up after delivery. There are 

states to learn from that have successfully begun to address postpartum preeclampsia. The 

legislation the Committee is reviewing here today would do much to support this type of 

information exchange to share best practices with other states. 
130 


36730.082

CLAMPSIA 

foundation 

Preeclampsia costs the U.S. health care system $2.18 billion dollars a year- about half due to 

maternal health care costs and halffor the care of the infants born to those mothers. To put that 

into perspective, these preeclampsia-related costs comprise about 1/3 of the costs for these entire 

pregnancies in just one year. The long-term costs associated with prematurity and long-term 

maternal health consequences are not included in these numbers. 

A long time health activist, Mary Lasker, once said, "Research is expensive, but disease is 

more!" In the case of maternal mortality reviews, the research that is collected, assessed, and 

released by the state committees almost immediately leads to health care improvements and is 

nowhere near as expensive as the health conditions and complexities we would otherwise face. 

There are system factors, patient factors and provider factors that contribute to maternal 

mortality and severe morbidity today: We can do so much more with a small investment of time 

and resources for states and ultimately improve outcomes for thousands of lives. This must be a 

public health priority. Maternal health is the building block upon which all other health issues 

are based. We need compelling, instructive data to move healthcare providers and institutions to 

action and to support patient and family engagement in their health care. 

Support the H.R. 1318 Discussion Draft 

Mr. Chairman, Ranking Member Green and members of the Subcommittee, the discussion draft 

ofH.R. 1318, The Preventing Maternal Deaths Act, sponsored by Representatives Jaime Herrera 

Beutler (R-WA), Diana DeGctte (D-CO), and Ryan Costello (R-PA) mirrors S. 1112, the 
131 


36730.083

E.ECLAMPSIA 

foundation 

Maternal Health Accountability Act, as recently passed by the Senate Committee on Health, 

Education, Labor and Pensions. 

This legislation will help support state efforts to get at solutions- affordable and actionable 

efforts that can save lives. The bill, with the support and expertise of the Centers for Disease 

Control and Prevention (CDC) will help states understand how to identify local problems that 

contribute to rising rates of maternal mortality and derive local solutions. It will also help states 

that have been unable to get a maternal mortality review committee launched or operating. 

Despite the pockets of successful committees, the fact remains that today no state has a fully 

functioning maternal mortality review committee; even the best of them are handicapped by 

inadequate information, resources or know-how. For too many, the investment that has been 

made to date in databases, training, and tools will have been wasted if we cannot create a 

sustainable maternal mortality review system and thereby demonstrate what we value most: our 

mothers. 

The Preeclampsia Foundation believes the discussion draft ofH.R. 1318 will work to put an end 

to the rising rate of maternal mortality in the United States, protecting our mothers and saving 

health care resources. On behalf of the Foundation and all of the families we represent, we urge 

the Committee to prioritize this legislation and for Congress to pass it this year. 
132 


36730.084

September 24, 2018 

Statement 

OF Timoria McQueen Saba 

Survivor of a near fatal postpartum hemorrhage, Commissioner for the Commonwealth 

of Massachusetts, Senator Ellen Story Special Commission on Postpartum Depression 

BEFORE THE SUBCOMMITTEE ON HEALTH COMMITTEE ON ENERGY AND 

COMMERCE U.S. HOUSE OF REPRESENTATIVES 

"BETTER DATA AND BETTER OUTCOMES: REDUCING MATERNAL MORTALITY IN 

THE U.S." 

Dear Mr. Chairman, Ranking Member Green, members of the committee: My name is 

Timoria McQueen Saba. 

I am an African-American mother of two daughters, Graison Joyce and Harper Elle. I've 

waited many years to see a bill like this get passed. On April19, 2010, I started 

hemorrhaging after giving birth to Graison. My uterus wouldn't contract after the birth, 

known as a uterine atony. Doctors told me that they would try to save my uterus and 

ovaries by performing a procedure called an embolization. If that was not successful, 

they would have to give me a hysterectomy. If the bleeding continued after receiving a 

hysterectomy, I was told that I would die. 

My pregnancy with Graison can best be described as "normal". I had no preexisting conditions and am fortunate to have great health insurance. I had a relatively 

easy, but long (twenty-seven hour) labor. Once I was fully dilated, delivery was fast and 

easy- I remember thinking it was almost too easy. Ten pushes and twenty minutes 
133 


36730.085

later, my beautiful daughter was born. As I held Graison in my arms for a few moments, 

1 could feel a shift in the mood of the hospital staff in the room. Before I knew it, the 

serenity of the room was tainted by the sounds of warning beeps from the machines I 

was hooked up to. Next, the room became flooded with strangers. 

Enter emergency personnel. My husband, Robert, and Graison were rushed out 

of the room and taken into the nursery. I watched blood pour out of my vagina through 

the reflection from an overhead television screen. My body was weak, and I struggled to 

keep my eyes open, feeling deep down that if I allowed them to close they would never 

open again. After a three-hour long surgery {during which I was fully conscious), I was 

left in critical condition. Instead of staying in intensive care alone, my Ob/Gyn insisted 

that I be reunited with Graison and Robert in the labor and delivery ward. 

I was told not to move a muscle, which included nursing or holding my new baby. 

I lay awake all night in pain. I was afraid to sleep, afraid to move, afraid that every 

breath I took might shake loose whatever was keeping me together. I stared at Graison 

all night. Her big, round, brown eyes peered through the bassinet. I made a promise to 

her that I would be live- she would not be a motherless child. I survived and the three 

of us went home five days later. 

I was diagnosed with PTSD {Post Traumatic Stress Disorder) several weeks 

after giving birth. Because of what happened, I was afraid to leave the house. This was 

a very new feeling to me. At the time, I was a professional make-up artist and loved 

traveling with my clients to destinations near and far. I had never been afraid to go 
134 


36730.086

anywhere! After the traumatic birth, I was easily startled and wrought with anxiety that 

something might happen to me, my daughter or my husband. 

It became increasingly difficult to sleep at night. Every time I closed my eyes, I 

saw the blood pouring from my body and other reminders of the ordeal! had suffered 

through. Due to the demands of motherhood, I tried to push my negative feelings aside. 

I was excited to be a mom and savored the days I spent with Graison. I challenged 

myself to get out of the house. I joined a hospital support group for new moms and 

signed up for "Mommy and Me" baby music classes. As I met more new moms I felt a 

common bond among us as we talked about breastfeeding, sleep schedules and baby 

gear. We also shared intimate details of our lives that you would never think possible to 

share with strangers. I made great friends through joining that group. Despite my 

outgoing nature and positive outlook on life, deep inside I remained a traumatized victim 

of a near fatal postpartum hemorrhage. No other mom I met back then had experienced 

a postpartum hemorrhage. My feelings about the hemorrhage and the surgery never 

went away. My emotions cycled through anger, guilt, fear and sadness. 

Thirteen months after Graison was born, I had a miscarriage which resulted in 

another hemorrhage. This occurred in front of several people while I was in a frozen 

yogurt shop. The miscarriage triggered the difficult emotions from the hemorrhage I 

suffered the year prior. I underwent an emergency D &C and returned home the next 

day. Yet again- I was sad, angry and afraid that I might bleed to death at any moment. 
135 


36730.087

I knew that I could not be the only woman who experienced these types of 

harrowing birth and pregnancy complications. While looking for answers, I realized that 

resources and support for mothers and families who had survived a near miss or lost a 

loved one due to a birth or pregnancy complication, were scarce. I began sharing my 

story publicly in 2012 and have since connected with thousands of women across 

America who have experienced similar birth and pregnancy complications; and the 

lingering psychological effects. With the help of a therapist who specializes in 

postpartum mental health and birth trauma, I was able to heal. I gave birth to Harper 

Elle in March 2014. I'm happy to report that my birth experience the second time around 

was perfectly "normal." 

I am now a full-time maternal health advocate, speaker and writer with a focus on 

mental and physical trauma due to childbirth and pregnancy. I am also the coordinator 

of resources and support for Postpartum Support International (PSI) in the Boston Metro 

West and Central areas. In this role, I connect women suffering from postpartum mood 

disorders and their families to local therapists and support groups. I'm also a member of 

the PSI President's Advisory Council. Twice per month, I facilitate a free peer-to-peer 

mother's support group, Emotional Wellbeing After Baby, at Milford Regional Hospital in 

Milford, MA. In 2017, I was honored to be appointed by MA State Rep. James O'Day 

(D-14 Worcester) to a House chair seat on the Senator Ellen Story Special Commission 

on Postpartum Depression. 
136 


36730.088

Every day I think about how fortunate I am. I survived two hemorrhages due to birth and 

pregnancy complications. Statistics show that black mothers die during childbirth at 

three to four times the rate of white mothers. 

Statistically speaking, I shouldn't be alive. 

But because I survived, it is my duty and a privilege to be a voice for mothers who 

struggle to cope with the mental and physical effects of a near fatal birth trauma, and 

also honor those who tragically, have died. 

Passing HR 1318: Preventing Maternal Mortality Act of 2017 is imperative to the health 

of all mothers and families in the United States. Individual states will be able to learn the 

exact causes of deaths due to childbirth and pregnancy complications, therefore helping 

healthcare providers to identify the proper preventions or the best emergency response 

plans. 

It is our responsibility to care for a// mothers in America. Legislators, healthcare 

providers, advocates and patients must work together to give mothers the healthcare 

they deserve. By passing this bill and working together to understand the disparities in 

outcomes, we will prevent mothers from dying and save entire generations from 

suffering. 

Thank you for allowing me the opportunity to share my story with you. 
137 


36730.089

OFFfCERS h:rtfd!IIJt 

Barbau L B~ss, Mfr, fACS !-h:.uston,TX 

BOARD OF REGENTS Chair 

l.<llghA.Nemn~y.Jr, MD, fACS Tutcll!l.AZ 

BOARD OF GOVERNORS Ctmir man-a Lfa1mer,MO.FAl~S 

Sau~tnti!lhl, CA 

AMERICAN COLLEGE OF SURGEONS 

r;;;j,iri-;;g(iu;ii;y;- 0 

Highest Standards, Better Outcomes 

June 27, 2018 

Chicago Headquarters 

633 N_ Saint C!air Street 

Chlca.go, !l60611<!211 

Voice: 312-202-5000 

Fax: 312-202·5001 

E-mail: pos1master@facs.org 

Washington Office 

20 F Street, NW Suite 1000 

Washington, DC 20001 

Voice; 202·337-2701 

Fax: 202·337·4271 

E-mail: ahp®faC$.org 

facs.org 

The Honorable Jaime Herrera Beutler 

U.S. House of Representatives 

The Honorable Ryan Costello 

1107 Longworth House Office Building 

Washington, DoC. 20515 

The Honorable Diana DeGette 

U.S. House of Representatives 

2111 Rayburn House Office Building 

Washington, DoC. 20515 

U.S. House of Representatives 

326 Cannon House Office Building 

Washington, D.C. 20515 

Dear Representatives Herrera Beutler, Costello, and DeGette: 

On behalf of the more than 80,000 members of the American College of Surgeons 

(ACS). I would like to express our support for the Preventing Maternal Deaths Act, 

H.R. 1318. This bipartisan legislation is an important step in addressing disparities in 

pregnancy-related mortality and identifYing ways to make pregnancy safer. 

The U.S. is the only industrialized nation with a rising maternal mortality rate. The 

U.S. saw a 26% increase in the maternal mortality rate from 18.8 deaths per 100,000 

live births in 2000 to 23.8 in 20141• Considerable racial disparities in pregnancyrelated mortality exist. According to the Centers for Disease Control and Prevention's 

Pregnancy Mortality Surveillance System, during 2011-2013, the pregnancy-related 

mortality ratios were 12.7 deaths per 100,000 live births for white women compared 

to 43.5 deaths per 100,000 live births for black women. 

According to the CDC Foundation, the leading causes of pregnancy-related death 

include seven causes accounting for 72.2% of all pregnancy~re!ated deaths. The 

leading underlying causes of pregnancy-related death are hemorrhage, 

cardiovascular and coronary conditions, cardiomyopathy, infection, embolism, 

mental health conditions, and preeclampsia. Variations amongst the leading causes 

exist among states, race~ethnicity, and age. Determining methods to address 

1 MacOorman, M., Declercq, E., Cabral, H., Morton, C., "!s the United States Maternal Mortality Rate 

Increasing? Disentangling trends from measurement issues: Short title: U.S. Maternal MortatityTrends." 

Journal of Obstetrics and Gynecology. September, 2016 

FOUNDED BY SURGEONS OF THE UNITED STATES AND CANADA, 1913 

The American Col/ega of Surgeons ts an Equal Opportunity!Affirmativ& Action Employer 
138 


36730.090

Chicago Headquarters. 

633 N. Saint Clair Street 

Chicago, ll $.0611-32:11 

W.a&hington Office 

2:0 F Street, NW Sulte 1000 Washington, DC 20001 

Volce: 2-o.:i!~337·2.i'01 

Fax; 2:02-337~421"1 

E.'"rnail: ahp@facs..org 

facs,org 

AMERICAN COLLEGE OF SURGEONS 

Inspiring Quality: 

Highest Standards, Better Outcomes 

disparities amongst different populations by providing high quality care will help to 

improve health outcomes. 

Currently, 33 states are studying local maternal death cases through maternal 

mortality review committees (MMRCs) to identify opportunities for prevention and 

ways to make pregnancy safer for all women. The authorization of a Department of 

Health and Human Services (HHS) grant program through the Centers for Disease 

Control and Prevention (CDC) for states to establish, maintain, or expand MMRCs is 

critical for improving health outcomes and reducing disparities in pregnancy-related 

care. 

The ACS also strongly supports the provision directing HHS to research disparities in 

maternal health outcomes and expand access to health care services that improve 

quality and outcomes of maternity care for vulnerable populations. The 

establishment of a demonstration project to compare the effectiveness of and 

implement effective interventions to reduce disparities in maternity care is vital to 

efforts to reduce preventable pregnancy-related mortality. 

Again, thank you for your leadership in introducing the Preventing Maternal Deaths 

Act. We look forward to working with you as this important legislation moves 

through Congress. 

Sincerely, 

David B. Hoyt, MD, FACS 

Executive Director, American College of Surgeons 
139 


36730.091

The Honorable Michael C. Burgess, MD 

Chairman 

Subcommittee on Health 

Committee on Energy & Commerce 

U.S. House of Representatives 

Washington DC 20515 

The Honorable Gene Green 

Ranking Member 

Subcommittee on Health 

Committee on Energy & Commerce 

U.S. House of Representatives 

Washington DC 20515 

September 28, 2018 

SAP America, Inc. 

1399 New York Avenue, NW 

Suite 800 

Washington, DC 20005 

T 202.312.3500 

F 202.312.3501 

www.sap.com 

RE: Submission Request for the Record of the Health Subcommittee's hearing entitled "Better Data 

and Better Outcomes: Reducing Maternal Mortality in the U.S.," being held on September 27,2018 

Dear Mr. Chairman and Ranking Member Green: 

On behalf of SAP America Inc. (SAP), I write to respectfully request this letter and its accompanying 

attachments be entered into the Record of the Health Subcommittee's hearing entitled "Better Data and 

Better Outcomes: Reducing Maternal Mortality in the U.S.," being held on September 27, 2018. 

SAP is the world's largest provider of enterprise application software serving over 400,000 customers and 

100,00 partners in 180 countries. We develop and produce software for a wide range of customers, in both 

the public and private sectors, around the world. Seventy-seven percent of all global commercial 

transactions run through SAP software. 

The extraordinary grow1h in the amounts of data available to governments presents both great challenges 

and significant opportunities. SAP has significant experience in translating those challenges to successful 

outcomes allowing governments to take advantage of the opportunities data and the analysis of the wealth 

of data at governments' fingertips present Weaving together publicly held data sets holds great potential 

for making government more effective at serving the public. 

In March 2014, then-Governor Pence of Indiana established the Indiana Management Performance Hub 

(MPH). Among the purposes of the MPH is to collect data from all Indiana state agencies and analyze the 

data to produce "continuous process improvements" by providing recommendations to the Governor on 

"[o]pportunities to use data ... to drive innovation and efficiency .... " See Goldberg, "Analy1ics Paves the 

Way for Better Government," Forbes Insights, Sept 2014, enclosed with this letter. SAP provides the 

software that performed the data analysis conducted by the MPH. 

Of direct relevance to the Subcommittee's hearing on maternal mortality is the initial area of inquiry 

conducted in 2014 by the MPH. That initial study was focused on reducing infant mortality in Indiana. The 

report produced as a result of the study by KSM Consulting, entitled "A Summary of Findings and 

Quantitative Investigation Targeted at: Reducing Infant Mortality in Indiana," is attached for the 

Subcommittee's review and consideration, insofar as it may be relevant to the related subject of this 

hearing, the reduction in maternal mortality. 

DC: 68290 14·1 
140 


36730.092

The Honorable Michael C. Burgess, MD 

The Honorable Gene Green 

September 27, 2018 

Page 2 

As a result of the data analysis performed in connection with the MPH's review of infant mortality, Indiana 

was able to develop a set of predictive algorithms and put in place programs to address identify the most 

at-risk populations and ensure the delivery of services to this population by the Indiana State Department 

of Health. 

SAP believes that programs like the Indiana MPH can and should be established at the state and local 

levels with federal support. The wider establishment of programs like the MPH can be a basis for the 

widespread improvement nationally on addressing maternal mortality rates. 

The potential for emerging technologies to enable data-driven policy and practice is well articulated by the 

Commission on Evidence-based Policymaking: " ... the Commission envisions a future in which rigorous 

evidence is created efficiently, as a routine part of government operations, and used to construct effective 

public policy. Advances in technology and statistical methodology, coupled with a modern legal framework 

and a commitment to transparency, make it possible to do this while simultaneously providing stronger 

protections for the privacy and confidentiality of the people, businesses, and organizations from which the 

government collects information. Addressing barriers to the use of already collected data is a path to 

unlocking important insights for addressing society's greatest challenges" 1 

SAP would be pleased to brief the Subcommittee members and staff on the MPH and the potential for data 

analytics in tackling many of government's most pressing problems. 

Respectfully submitted, 

Kevin M. Richards 

Vice President, Head of US Government Relations 

SAP America, Inc. 

T-202.312.3638 

M-202-578-8726 

E- k.richards@sap.com 

Enclosures 

1 Commission on Evidence~based Pollcymaking (https://www.cep.gov/content/dam/cep/report/cep~fina!~report.pdf). 
141 


36730.093

Analytics Paves the Way for 

Better Government 

The State of 

Indiana is 

applying datadriven insights 

to improve 

outcomes for 

citizens and 

make public 

sector 

performance 

more 

transparent. 

BY MICHAELS. 

GOLDBERG 

SEPTEMBER 2014 

© Copynght 2014. 

Forbes Insights. 

All rights reserved. 

M anaging state government often 

requires impassioned debate about 

the best way to allocate resources, dellver 

services to citizens and build budgets that 

reflect elected leaders' and citizens' 

priorities. The State of Indiana is bringing 

data~driven insights to these discussions 

through its use of ana!ytics. 

Public sector organizations globally are fertile 

ground tor po!icymakers' vision of more effective, 

timely decisions. Every agency, department and 

bureau has years' worth of data that has been 

collected in compliance with documented 

procedures, subJeCt to oversight and accessible via 

information systems. Citizens, in fact, increasingly 

expect government agencies to manage and analyze 

their voluminous data sets in ways that benefit the 

public and enable government transparency. 

Government leaders, from the European Commission 

to the White House, have called for investment in big 

data analytics capabl!ities to modernize government 

serw:es and aid their economies. Deeper insights 

from government data offer more than the 

possibility for better-informed policy decisions. 

Businesses may also use these insights to create new 

data-driven products and services using government 

data (see F1gure l, "Data That Serves thn Public"). In 

fact, McKinsey & Co. estimates that by digitiZing 

information, disseminating public data sets and 

applying analytics to improve decision-making, 

governments around the world can act as catalysts 

for more than $3 trillion in economic value} 

In the State of Indiana, data is at the center of Gov. 

Mike Pence's long~ term vision for improving the 

management and effectiveness of government 

""""' Data That Serves the Public 

Improve soc1al and welfare ser.;1ces 

4'1 S1reng1hen collaboration among countries 

.JN Improve educat1on 

Improve ClhZen serv1ces • 

+M Improve hecalthcare 

a.a Improve transparency ard accountablilly 

ta 

Help st~mulate economic grovvttl 

lmprovementstosnt:laJservicesandco!!aborationarethetop 

2013-http:I!\?OO.I}II)(aeLOI> - benefitstouslngblgdata.(percentoftespondents) 

programs and making Indiana a leader ln data-driven 

decision-making. In March 2014, a year after taking 

office, Pence ordered state agencies to share data 

and partner with the state Office of Management and 

Budget (OMS, which oversees state finances and 

agency performance management), the Indiana 

Office of Technology (lOT) and outside experts ln a 

centralized effort "to improve and strengthen 

services, maximize the utilization of available 

resources and ensure that state services are 

available to all." As in many public sector settingswhere systems and tools have become available to 

more easily analyze large, diverse data sets-data 

sharing had not, until recently, been a common 

practice in states, 

Overseen by the OMB, the data~sharing mandate is 

setting the stage for an enterprisewide solution that 

wi11 put key performance indicators (KP!s) in front 

FORBES lNSIGHTS 
142 


36730.094

By augmenting 

existing 

research efforts, 

analytics have 

the potential to 

uncover new 

approaches to 

stubborn 

problems. 

of decision-makers and the public, The solution 

will also apply both descriptive and predictive 

analytics to cntica! problems. 

DATA SHARING SERVES POLICY GOALS 

lndwna's initiative allgns with the administration's 

six-pronged roadmap that emphasizes economic 

growth. education and the well-bemg of families 

(see Figure 2, "Data-Driven Progress"). "This 

project is enabling state government to service 

those goals and achieve outcomes,' says OMS 

Director Chris Atkins. 

Each of Indiana's 92 agencies and departments has a 

role to play, Using Gov. Pence's data-sharing order as 

a lever, Atkins and his colleagues are working with 

the lOT and the other agency heads to collect data 

for analysis. Part of Atkins' job !S communicating the 

end-goal. "We're trymg to help the agencies see the 

value m this project,'' he says. "A culture of datasharing means a more successful enterprise." 

Data sharing is more than a technical issue, as Jaws 

and regulations restrict the handling of certain types 

of data. So another essential element for Atkins was 

to hire several legal experts who could answer 

questions about the rules for using different data 

sets. Federal or state privacy laws may require 

agencies to remove personal information, for 

example. "We hired counsel to help the agencies 

work through these data security issues so they 

don't have to task their own legal teams," he says. 

"We're dofng it for them, in concert with their 

leadership" (see Figure 3, "Breaking Down Barriers"). 

ANALYTICS FOR SAVING LIVES 

The data collection effort supports a four-point 

program to deliver more insights to government 

poltcymakers and the public. One segment, recently 

begun, targets a vital public policy problem; the 

rate of infant morta!lty in Indiana, which at 7.6 

percent in 2010 ranked higher than the national 

average of 6.1 percent. 

The project pilots Indiana's recently acquired 

in-memory computing platform, which supports 

predictive analytics -capabilities. An in-memory 

FIGURE2 Data-Driven Progress 

SilUro~: lnd>s.na Manasement and P~rlormanc~ Hub. htt;J://gco.g!l15u6}'j 

Insights from analyUcs w!!l help Indiana pursue six public 

policy goals. 

platform enables organizations to consolidate 

extremely large volumes of data from multiple sources 

into one database and answers any question almost 

instantly. Indiana is now able to collect data sets from 

many different state agendes for rapid~fire, iterative 

queries. That ability, in turn, enables analysts to test 

out hypotheses and answer questions using a range of 

techniques and algorithms. 

By scrutinizing combinations of these data sourcesand adding new data sources to the mix-analysts are 

working to identify correlations that provide signals 

about the possible causes of the infant mortality 

problem. The signals may relate to demographics, 

mothers' health conditions or unexpected relationships 

among other vanabtes that influence babies' health. 

The pilot so far is demonstrating the value of both the 

cooperat1on of state agencies (the shared data sets arc 

useful in the prediCtive models) and the in-memory 

platform that provides fast response times to analysts' 

quenes. Atkins says the work to date has shown 

promising results, but it's not finished. "We know as we 

add more data, we will see more results," he adds. 

The findings are expected to drive the development of 

new programs or the updating of existing ones, so that 

the state can improve Indiana's performance-and 

reduce the number of infant deaths in Indiana. Charlie 

Brandt, managmg director at KSM Consulting, a 

technology, management and data ana!ytics 

Consultancy that has been working with the state, says 

predictive ana!ytics has the potential to elevate public 

policy decis1on·making as leaders are provided 

FORBES INSIGHTS 
143 


36730.095

CASE STUDY 

HA culture of 

data-sharing 

means a more 

successful 

enterprise." 

-CHRIS ATKINS, 

DIRECTOR, 

INDIANA OFFICE 

OF MANAGEMENT 

AND BUDGET 

knowledge of drivers of transformation instead of 

reports sharing insights on past performance. 

By augmenting existing research efforts, analytks has 

the potentia! to uncover new approaches to stubborn 

problems. "People have been trying to improve 

performance and outcomes related to the public 

sector, and m particular, in areas !ike human services," 

continues Brandt. They do research, take the best of it 

and use it to model policy changes. "Analytics gives 

us the opportunity to show that data is a powerful 

-component to be used," he says, ''to make decisions 

and to improve outcomes:' 

Atkins says the state is now developing additional 

predictive analytics proJects related to achieving the 

goals that Gov. Pence set out in his roadmap. 

TRANSFORMING SERVICE DELIVERY 

Three other projects in the state's data analyt1cs 

program aim to improve transparency, so that 

policymakers and the public ahke are able to more 

easHy see govemment oerformance. Indiana is using 

the in~memory platform and data visualization tools 

to make data more visible. For one project, the OMB 

is working w1th agency leaders to collect data for 

specific KPis tied to each state agency's performance. 

Another involves developing an executive dashboard 

system that will enable state leaders to scan these 

metrics and know when they change. 

A related project includes the launch, in July 2014, of 

an or>!ine Management and Performance Hub (MPH) 

to share performance data in sectors tied to Gov. 

Pence's roadmap, including private sector 

employment. elementary students' reading skills and 

the percentage of children who are at risk of going 

hungry. The measures are posted on the MPH Web 

site, with graphs and charts that set baselines for 

comparison as data is added or updated, 

Taken as a whole, these moves have attracted the 

attention of government innovation watchers like 

Stephen Goldsmith, a former Indianapolis mayor who ls 

a professor at Harvard's Kennedy School ot Government 

Goldsmith wntes: "With the launch of MPH and strong 

"•"'" Breaking Down Barriers 

II Federal • State 

2013.1ltlp:/lgoo.g!IXacLDh 

U.S.techno!ogyoffic!alsv!ewptlvacyandotherpolicyissuesasa 

topobstacletousingblgdata.(percentofrespondents) 

centra! leadership, Indiana stands to become a model for 

other governments looking to embed data throughout their 

operations and tap the power of data ana!ytics to save 

money and transform service de!ivety."l • 

ABOUT FORBES INSIGHTS 

combinedmediapropertiesreachnear!y50milllonbusinessdecisionmakerswor!dwideonamonthlybas!s. 

Bruce Rogers 

CHIEF INSIGfiTS OFFICER 

Brian McLeod 

DIRECTOR, NORTH AMERICA 

FORBES INSIGHTS 
144 


36730.096

CASE STUDY 

SPONSOR'S 

STATEMENT 

nwe're unloCking 

the true potential 

for innovation 

through new 

business 

processes and 

models: real·time 

innovation.~' 

-STEVE LUCAS, 

PRESiDENT, 

PLATFORM 

SOlUTIONS, SAP SE 

Real-Time Organizations Make 

Decisions in the Moment 

Forbes Insights interviewed Steve Lucas, President, Platform Solutions, 

SAP SE, about transforming operations with realMtime insights. 

What does it mean to be a rea1-time organization? 

Being a real-time orgamzation means being aware of the key £:1ctors that will impact your 

decisions and being able to make a dectsion m the moment that matters. ln most public 

sector agenCies today, deds10n-makers have to wait for batch processes to run. When batch 

technology is replaced with realM time processmg, however, organizations can obtain 

in-the-moment policy msights instantaneously. They can me those insights to improve 

performance, deliver services to constituents more etf1ciently and develop innovative 

approach{'s to policy goah. That is why the SAP HANA platform exi.~t~: to enable 

organnatwns do busmess in the moment. 

Where do you see the most value for different organizations? 

The value comes from three main drivers. Fmt, we reduce the complexity of the systems 

req1.1ired to produce your existing results. This was one of the key motivations in des1gning 

SAP HAN A: massive IT simplification. You C"an use the platform to feed data from all 

different sources into one system. Second, we enable agilny by giving customers the ability 

to get re::~l-timc insight for decision-makmg. Third, we're unlocking the true potential fOr 

mnovation through new business processes and models: the real-time innovatiOn. 

As you look ahead, what new ways of serving constituents do you envision? 

Our SAP HANA pb.tform not only can enable customers to make decisions for today, but 

it also prov1des a powerful predictive engine. Mmt organizations make decision~ by 

looking in tht: rearview mirror. But the rearview mirror is tiny compared to the 

windshield looking forward. Organizations will start to build forvvard-!ooking decision.<> 

into their operating models. 

What is your best advice to organizations that want to start their rea1·time 

transfQrmation? 

It is not just about the technology. SAP HANA is extraordinarily innovative, but the first 

thing we do is look at where the opportunities nre to tr~nsform business processes. Then 

we spend time with customers rethinking how those processes are designed, and how to 

remodel them. You have to start at zero: What would you do if you didn't have to wait for 

informatwn? If you don't have to wait, there's an opportunity for massive remverttion and 

value creation across mdustries. 

To learn more about uomg SAP Analytics, visit www.sap.com/analytics 

To learn more ~bom SAP's Public Sector offenngs, visit 

www.sap.com/solution!industry/public-sector.html 
145 

Æ 


36730.097

~~ 

Jane M. Adams 

Vice President 

U.S. Federal Government Affairs 

September27, 2018 

The Honorable Greg Walden 

2125 Rayburn House Office Building 

Washington, DC 20515 

Dear Chairman Walden, 

SERVICES. INC. 

1350 Eye Street, N.W. 

Suite 1210 

Washington, DC 20005-3305 

Telephone: (202) 589·1000 

[am writing to you on behalf of Johnson & Johnson in support of the Preventing Maternal Deaths Act and to 

thank the Energy and Commerce Health Subcommittee for holding the hearing, "Better Data and Better 

Outcomes: Reducing Maternal Mortality in the U.S.,'' to call attention to this complex and wide-ranging 

problem. We believe this hearing is a positive step forward to help address a worsening health crisis affecting 

families across the country. 

In just 14 years (2000 to 20!4), America has suffered a staggering 26 percent increase in its maternal mortality 

rate, many of which occur from mostly preventable causes like preeclampsia and obstetric hemorrhage. Of 

nations with advanced economies, the United States stands alone in experiencing increases in mortality rates. 

Other countries also seeing increases are South Sudan and the Democratic Republic of the Congo. 

Along with the American College of Obstetricians and Gynecologists, the American College ofNurseMidwives, and the March of Dimes, Johnson & Johnson believes that a crucial part of the U.S. solution to this 

problem includes utilizing higher quality data, and expert review of maternal death cases by effective maternal 

mortality review committees (MMRCs). MMRCs study local maternal death cases with the goal ofidentifYing 

ways to make pregnancies safer, prevent loss oflife, and ultimately save families from this tragedy. 

Congress can advance the health of mothers and families by working for swift passage of the Preventing 

Maternal Deaths Act, which will commit $58 million through the Public Health Service Act to support states 

and to establish and improve maternal mortality review committees helping to prevent pregnancy related 

deaths and reduce disparities in care. 

We are pleased to support this legislation, because Johnson & Johnson is committed to changing the trajectory 

of health for humanity and believe good health is the foundation of vibrant lives, thriving communities and 

forward progress. That's why for more than 130 years, Johnson & Johnson has aimed to keep people well at 

every age and every stage oflife. Today, as the world's largest and most broadly-based health care company, 

we are committed to using our reach and size for good. Working together, we can work to reduce the number 

of maternal mortality deaths in the U.S. Please don't hesitate to reach out to me for further information. 

Sincerely, 

Jane M. Adams 

Vice President, U.S. Federal Affairs