II 116th CONGRESS 2d Session S. 4269 IN THE SENATE OF THE UNITED STATES July 22, 2020 Mr. Kaine (for himself and Ms. Murkowski ) introduced the following bill; which was read twice and referred to the Committee on Health, Education, Labor, and Pensions A BILL To amend the Public Health Service Act to improve maternal health and promote safe motherhood.

1. Short title This Act may be cited as the Mothers and Newborns Success Act . 2. Findings and sense of the Senate (a) Findings Congress finds the following: (1) Among developed nations, the United States has disturbingly high rates of maternal and infant mortality. (2) The United States published an official maternal mortality rate from vital statistics for the first time since 2007 in 2018. The United States maternal mortality rate of 17.4 per 100,000 live births, is significantly higher than the Organisation for Economic Co-operation and Development (referred to in this section as the OECD ) average of 14.0 in 2017, according to modeling by the World Bank. (3) The United States infant mortality rate in 2017 was 5.8 per 1,000 live births, while the OECD average was 3.8 per 1,000 live births. (4) In the United States, there are significant maternal mortality and infant mortality inequities. (5) The maternal mortality rate for non-Hispanic Black women in 2018 was 37.1 per 100,000 live births. This rate is more than 2.5 times higher than the maternal mortality rate of 14.7 for non-Hispanic White women and more than 3.1 times higher than the maternal mortality rate of 11.8 for Hispanic women of any race. (6) The Centers for Disease Control and Prevention data from 2007 through 2016 shows that American Indian/Alaska Native women also have significantly higher rates of pregnancy-related deaths than White, Hispanic, and Asian/Pacific Islander women. American Indian/Alaska Native women had a rate of 29.7 pregnancy-related deaths per 100,000 live births from 2007 through 2016, which is 2.3 times higher than the rate of 12.7 deaths per 100,000 live births for White women during the same time period. (7) The mortality rate for infants of non-Hispanic Black women is 11.0 per 1,000 live births and 9.2 per 1,000 live births for infants of American Indian or Alaska Native women. This rate is more than 2.3 times higher than the infant mortality rate of non-Hispanic White infants at 4.7 and more than 2.1 times higher than the infant mortality rate of Hispanic infants of any race at 5.1 per 1,000 live births. (b) Sense of the Senate It is the sense of the Senate that the following should apply: (1) The United States should dramatically reduce maternal and infant mortality, ensure that all infants can grow up healthy and safe, and protect women’s health before, during, and after pregnancy. (2) Any pregnant woman choosing to have a child should be able to do so safely without regard to income, race, ethnicity, employment status, geographic location, ability, or any other socio-economic factor. United States policy should support women’s health so that women thrive and newborns have the maximum chance for a healthy life. (3) The evidence of serious racial inequities in maternal and infant mortality, especially between Black women and White women demonstrates the persistence of racism and racial bias in our society and health care system. A 2015 study funded by the National Institute for Biomedical and Bi­o­en­gi­neering of the National Institutes of Health found that most health care providers appear to harbor negative implicit biases towards people of color. These biases were found to impact patient-provider interactions, treatment decisions, treatment adherence, and patient health outcomes. Therefore, the programs authorized by this Act should be specifically deployed in ways to counter such inequities. (4) In the next 5 years, the United States should aim to reduce its overall maternal and infant mortality rates such that they are no higher than the OECD average. The United States should dramatically reduce the maternal mortality and infant mortality inequities between Black and American Indian/Alaskan Native women and White women. (5) By advancing evidence-based policies to improve maternal and infant health outcomes, the United States can work to reduce and eliminate preventable maternal and infant mortality and severe maternal morbidity. 3. State maternal health innovation Title III of the Public Health Service Act is amended by inserting after section 330M ( 42 U.S.C. 254c–19 ) the following: 330N. State maternal health innovation (a) In general The Secretary, acting through the Administrator of the Health Resources and Services Administration, shall continue in effect the State Maternal Health Innovation Program and the Supporting Maternal Health Innovation Program to award competitive grants to eligible entities for the purpose of assisting States to implement State-specific actions that address racial, ethnic and geographic inequities in maternal health and improve maternal health outcomes, including the prevention and reduction of maternal mortality and severe maternal morbidity. (b) Use of funds An entity receiving a grant under this section may use such funds— (1) to translate recommendations on addressing maternal mortality and severe maternal morbidity into action through activities which may include— (A) establishing a State- or regional multi-State-focused Maternal Health Task Force to create and implement a strategic plan; (B) improving the collection, analysis, and application of State- or regional multi-State-level data on maternal mortality and severe maternal morbidity; and (C) promoting and executing innovation in maternal health service delivery, such as improving access to maternal health care services, identifying and addressing workforce needs, including maternal health provider shortages; identifying and addressing implicit and explicit bias based on race or ethnicity; or supporting postpartum and inter-pregnancy care services; or (2) to provide support to entities receiving assistance under paragraph (1), and other initiatives of the Department of Health and Human Services to improve maternal health outcomes as the Secretary determines appropriate, States, multi-State regions and other stakeholders working to reduce and prevent maternal mortality and severe maternal morbidity through activities which may include— (A) providing capacity-building assistance to such entities to implement innovative and evidence-informed strategies; and (B) establishing or continuing the operation of a resource center to provide national guidance to such entities, States, and key stakeholders to improve maternal health. (c) Alignment of activities An entity carrying out activities under subsection (b)(1) shall coordinate and align such activities with the activities to improve maternal health outcomes carried out by such entities under title V of the Social Security Act. (d) Eligible entities To be eligible for a grant under subsection (a), a domestic public or non-profit private entity, Indian Tribe, or Tribal serving organization, such as a Tribal health department or other organization fulfilling similar functions for the Tribe, shall submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require. In the case of applicants intending to carry out activities described in subsection (b)(1), such applicants shall demonstrate in such application that the entity has a commitment from a State or group of States to collaborate as part of the project on strengthening State-level capacity in achieving the program aims. (e) Report to Congress Not later than January 1, 2024, the Secretary shall submit to the Committee on Health, Education, Labor, and Pensions of the Senate and the Committee on Energy and Commerce of the House of Representatives, and make publicly available, a report concerning the impact of the programs continued under this section on addressing inequities in maternal health and improving maternal health outcomes, including the prevention and reduction of maternal mortality and severe maternal morbidity, together with recommendations on whether to expand such programs to additional recipients and the estimated amount of funds needed to expand such programs. (f) Authorization of appropriations To carry out this section, including carrying out the programs referred to in subsection (a) on a national basis (subject to the availability of appropriations), there is authorized to be appropriated $53,000,000 for each of fiscal years 2021 through 2024. . 4. Safe motherhood Section 317K of the Public Health Service Act ( 42 U.S.C. 247b–12 ) is amended— (1) by redesignating subsections (e) and (f) as subsections (h) and (i), respectively; (2) by inserting after subsection (d) the following: (e) Levels of maternal and neonatal care (1) In general The Secretary, acting through the Director of the Centers for Disease Control and Prevention, shall establish or continue in effect a program to award competitive grants to eligible entities to assist with the classification of birthing facilities based on the level of risk-appropriate maternal and neonatal care such entities can provide in order to strategically improve maternal and infant care delivery and health outcomes. (2) Use of funds An eligible entity receiving a grant under this subsection shall use such funds to— (A) coordinate an assessment of the risk-appropriate maternal and neonatal care of a State, jurisdiction, or region, based on the most recent guidelines and policy statements issued by the professional associations representing relevant clinical specialties, including obstetrics and gynecology and pediatrics; and (B) work with relevant stakeholders, such as hospitals, hospital associations, perinatal quality collaboratives, members of the communities most affected by racial, ethnic, and geographic maternal health inequities, maternal mortality review committees, and maternal and neonatal health care providers and community-based birth workers to review the findings of the assessment made of activities carried out under paragraph (1) and implement changes, as appropriate, based on identified gaps in peri­na­tal services and differences in maternal and neonatal outcomes in the State, jurisdiction, or region for which such an assessment was conducted to support the provision of risk-appropriate care. (3) Eligible entities To be eligible for a grant under this subsection, a State health department, Indian Tribe or other Tribal serving organization, such as a Tribal health department or other organization fulfilling similar functions for the Tribe, shall submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require. (4) Period A grant awarded under this subsection shall be made for a period of 3 years. Any supplemental award made to a grantee under this subsection may be made for a period of less than 3 years. (5) Report to Congress Not later than January 1, 2023, the Secretary shall submit to the Committee on Health, Education, Labor, and Pensions of the Senate and the Committee on Energy and Commerce of the House of Representatives, and make publicly available, a report concerning the impact of the programs established or continued under this subsection. (f) Pregnancy checkbox quality assurance (1) In general The Secretary, acting through the Director of the Centers for Disease Control and Prevention, may establish or continue a program to award competitive grants and provide technical assistance to eligible entities to implement a quality assurance process to improve the validity of the pregnancy checkbox data from death certificates. (2) Use of funds Eligible entities receiving a grant under this subsection shall use grant funds to implement a quality assurance process to improve the validity of the pregnancy checkbox data from death certificates in the State or within the Indian Tribe. Activities funded under the grant may include the following: (A) Reviewing death certificates for women of reproductive age and individuals with a pregnancy checkbox marked. (B) Attempting to confirm the pregnancy of a decedent by searching for a matching birth or fetal death record (or other matching state administrative data source), contacting the death certifier, or reviewing the medical record. (C) Amending death certificates or death record files, as appropriate, and sending the updated file to the National Center for Health Statistics. (D) Providing training to death certifiers about completing the death certificate. (E) Building awareness among death certifiers and health department staff about the pregnancy checkbox. (F) Coordinating quality assurance activities among State maternal and child health programs, State vital records offices, and maternal mortality review committee members and abstractors. (3) Eligible entities To be eligible for a grant under this subsection, a State health department, Indian Tribe, or other Tribal serving organization, such as a Tribal health department or other organization fulfilling similar functions for the Tribe, shall submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require. (4) Report to Congress Not later than January 1, 2023, the Secretary shall submit to the Committee on Health, Education, Labor, and Pensions of the Senate and the Committee on Energy and Commerce of the House of Representatives, and make publicly available, a report concerning the impact of the programs established or continued under this subsection. ; and (3) in subsection (i) (as so redesignated), by striking $58,000,000 for each of fiscal years 2019 through 2023 and inserting $81,000,000 for each of fiscal years 2021 through 2023 . 5. Pregnancy risk assessment monitoring system Section 317K of the Public Health Service Act ( 42 U.S.C. 247b–12 ) is amended by inserting after subsection (f) (as added by section 4) the following: (h) Pregnancy risk assessment monitoring system (1) In general The Secretary, acting through the Director of the Centers for Disease Control and Prevention, may establish or continue activities to collect data on maternal attitudes and experiences during the prepregnancy, pregnancy, labor and delivery, and postpartum periods. The Secretary may expand data collection to all States, Indian Tribes, and territories, and to the extent practicable, compile and publish population-based findings on the health and well-being of women, mothers and infants. (2) Enhanced surveillance activities and technical assistance The Secretary, acting through the Director of the Centers for Disease Control and Prevention may support enhanced surveillance activities and provide technical assistance to States and Indian Tribes to improve data collection and ensure an adequate representation of racial, ethnic and other communities of color in related datasets. . 6. Postpartum care coordination pilot program Title III of the Public Health Service Act is amended by inserting after section 330N (as added by section 3) the following: 330O. Postpartum care coordination pilot program (a) In general The Secretary, acting through the Administrator of the Health Resources and Services Administration, and in consultation with experts representing a variety of clinical specialties, including obstetrics and gynecology, State, Tribal, or local public health officials, , and in coordination with existing efforts to address postpartum care, including activities conducted under section 330H, shall establish a program to award competitive grants to not more than 10 eligible entities for the purpose of— (1) identifying and disseminating best practices to improve care and outcomes for women, including women with chronic health conditions prepregnancy and those with ongoing pregnancy-related conditions, in the postpartum period of at least one year following birth, which may include— (A) information on evidence-based and evidence-informed practices to improve the quality of care; (B) best practices for connecting women to primary or specialized care, including behavioral health services, in the postpartum period; (C) information on addressing social and clinical determinants of health that impact women in the postpartum period; and (D) information on the most appropriate course of care during the postpartum period, including continued access to maternity care providers and ways to strengthen capabilities of primary care providers and specialists, including cardiologists and endocrinologists to recognize and treat conditions that may result from or be exacerbated by pregnancy; (2) collaborating with State-based maternal mortality review committees, State-based perinatal quality care collaboratives and other relevant initiatives to— (A) identify risk factors and systems issues for the development of best practices; and (B) disseminate best practices; (3) providing technical assistance and supporting the implementation of best practices identified in paragraph (1) to entities and providers providing health care and social support services to postpartum women; (4) identifying, developing, and evaluating new models of care that improve maternal health outcomes, which may include the integration of community-based services, behavioral health, and clinical care, including interprofessional education for team-based care; and (5) developing condition-specific consumer materials directed toward women to help them better manage their physical and behavioral health in the postpartum period. (b) Eligible entities To be eligible for a grant under subsection (a), an entity shall— (1) submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require; and (2) demonstrate in such application that the entity is capable of carrying out data-driven maternal safety and quality improvement initiatives in the areas of obstetrics and gynecology or maternal health. (c) Report to Congress Not later than January 1, 2025, the Secretary shall submit to the Committee on Health, Education, Labor, and Pensions of the Senate and the Committee on Energy and Commerce of the House of Representatives, and make publicly available, a report concerning the impact of the programs established or continued under this section. (d) Authorization of appropriations To carry out this section, there is authorized to be appropriated $5,000,000 for each of fiscal years 2021 through 2025. . 7. Maternal health research network Subpart 7 of part C of title IV of the Public Health Service Act ( 42 U.S.C. 285g et seq.) is amended by adding at the end the following: 452H. Maternal health research network (a) Establishment The Secretary, acting through the Director of the National Institutes of Health, shall establish a National Maternal Health Research Network (referred to in this section as the Network ), to more effectively support innovative research to reduce maternal mortality and promote maternal health. (b) Activities The Secretary, acting through the Network, may carry out activities to support mechanistic, translational, clinical, behavioral, or epidemiologic research, as well as community-informed research on structural risk factors to address unmet maternal health research needs specific to the underlying causes of maternal mortality and severe maternal morbidity and their treatment. Such activities should be focused on optimizing improved diagnostics and clinical treatments, improving health outcomes, and reducing inequities. (c) Existing networks In carrying out this section, the Secretary may utilize or coordinate with the Maternal Fetal Medicine Units Network and the Obstetric-Fetal Pharmacology Research Centers Network. (d) Use of funds Amounts appropriated to carry out this section may be used to support the Network for activities related to maternal mortality or severe maternal morbidity that lead to potential therapies or clinical practices that will improve maternal health outcomes and reduce inequities. Amounts provided to such Network shall be used to supplement, and not supplant, other funding provided to such Network for such activities. (e) Authorization of appropriations To carry out this section, there is authorized to be appropriated $50,000,000 for each of fiscal years 2021 through 2025. . 8. Telehealth demonstration program Section 330A of the Public Health Service Act ( 42 U.S.C. 254c ) is amended— (1) by redesignating subsections (h) through (j) as subsections (i) through (k), respectively; and (2) by inserting after subsection (g), the following: (h) Telehealth demonstration program (1) In general The Secretary, acting through the Administrator of the Health Resources and Services Administration, shall continue in effect the Rural Maternity and Obstetrics Management Strategies (RMOMS) Program to award competitive grants to eligible entities for the purpose of improving access to, and continuity of, maternal and obstetrics care in rural communities. (2) Use of funds An entity receiving a grant under this subsection shall use grant funds to develop a sustainable consortium approach to coordinate maternal and obstetrics care within a rural region— (A) through a focus on— (i) rural regional approaches to risk appropriate care; (ii) an approach to coordinating a continuum of care for prepregnancy, pregnancy, labor and delivery, postpartum, and interpregnancy services; (iii) leveraging telehealth and specialty care to enhance case management of higher-risk expectant mothers living in geographically isolated areas; and (iv) demonstrating financial sustainability through improved maternal and neonatal outcomes and potential cost savings; and (B) by testing and improving upon strategies to improve access to, and continuity of, obstetrics care in rural communities and reduce geographic inequities in maternal health through the use of data and outcome measures spanning the continuum of care from prepregnancy through pregnancy, labor, delivery, and the postpartum period. (3) Eligible entities To be eligible for a grant under paragraph (1), a domestic public or non-profit private entity, including Indian Tribes, and Tribal serving organizations such as a Tribal health department or other organization fulfilling similar functions for the Tribe, shall— (A) submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require; (B) propose to carry out activities that exclusively target populations residing in rural counties or rural census tracts in urban counties as designated by the Health Resources and Services Administration; and (C) demonstrate a formal arrangement among a consortium of three or more entities, including the applicant, to build a rural based system of perinatal and maternal care. (4) Report to Congress Not later than January 1, 2023, the Secretary shall submit to the Committee on Health, Education, Labor, and Pensions of the Senate and the Committee on Energy and Commerce of the House of Representatives, and make publicly available, a report concerning the impact of the programs continued under this subsection together with recommendations on whether to expand such programs and the estimated amount of funds needed to expand such programs. (5) Authorization of appropriations To carry out this subsection, there is authorized to be appropriated $12,000,000 for each of fiscal years 2021 through 2023. . 9. Public and provider awareness campaign promoting maternal and child health (a) In general The Secretary of Health and Human Services, acting through the Director of the Centers for Disease Control and Prevention, and in coordination with State, local, territorial, health departments, Indian Tribes, Tribal serving organizations, public health experts and associations, the medical and allied professional community, and minority health organizations, shall award competitive grants to eligible entities to establish a national evidence-based public and provider awareness campaign on the importance of maternal and child health, including identifying and responding to maternal health warning signs and vaccinations for the health of pregnant women and their children, with the goal of increasing vaccination rates among pregnant women and children, reducing racism and racial, ethnic, and geographic inequities in maternal and child health, and reducing maternal mortality and severe maternal morbidity. (b) Use of funds An entity receiving a grant under this section shall use grant funds to supplement, not supplant, any Federal, State, or local funds supporting the establishment of a national evidence-based public and provider awareness campaign with all resources in an accessible format that— (1) increases awareness and knowledge of maternal health warning signs and how to respond to those signs as well as the safety and effectiveness of vaccines for pregnant women and their children; (2) provides targeted evidence-based, culturally and linguistically appropriate resources to pregnant women, particularly in communities with low rates of vaccination and in rural and underserved areas; and (3) provides evidence-based information and resources on the importance of maternal and child health, including maternal health warning signs and the safety of vaccinations for pregnant women and their children to public health departments and health care providers that care for pregnant women. (c) Eligible entities To be eligible for a grant under this section, a public or private entity shall submit to the Secretary of Health and Human Services an application at such time, in such manner, and containing such information as the Secretary may require. (d) Collaboration The Secretary of Health and Human Services shall ensure that the information and resources developed for the campaign under this section are disseminated to other divisions of the Department of Health and Human Services working to improve maternal and child health outcomes. (e) Evaluation Not later than January 1, 2025, the Secretary of Health and Human Services shall establish quantitative and qualitative metrics to evaluate the campaign under this section and shall submit a report detailing the campaign’s impact to the Committee on Health, Education, Labor, and Pensions of the Senate and the Committee on Energy and Commerce of the House of Representatives. (f) Authorization of appropriations To carry out this section, there is authorized to be appropriated $2,000,000 for each of fiscal years 2021 through 2025.