I 116th CONGRESS 1st Session H. R. 4995 IN THE HOUSE OF REPRESENTATIVES November 8, 2019 Mr. Engel (for himself, Mr. Bucshon , Ms. Torres Small of New Mexico , Mr. Latta , Ms. Adams , and Mr. Stivers ) introduced the following bill; which was referred to the Committee on Energy and Commerce A BILL To amend the Public Health Service Act to improve obstetric care and maternal health outcomes, and for other purposes.

1. Short title This Act may be cited as the Maternal Health Quality Improvement Act of 2019 . 2. Table of contents The table of contents for this Act is as follows: Sec. 1. Short title. Sec. 2. Table of contents. Title I—Improving Obstetric Care in Rural Areas Sec. 101. Improving rural maternal and obstetric care data. Sec. 102. Rural obstetric network grants. Sec. 103. Telehealth network and telehealth resource centers grant programs. Sec. 104. Rural maternal and obstetric care training demonstration. Sec. 105. GAO report. Title II—Other Improvements to Maternal Care Sec. 201. Innovation for maternal health. Sec. 202. Training for health care providers. Sec. 203. Study on training to reduce and prevent discrimination. Sec. 204. Perinatal quality collaboratives. Sec. 205. Integrated services for pregnant and postpartum women. I Improving Obstetric Care in Rural Areas 101. Improving rural maternal and obstetric care data (a) Maternal mortality and morbidity activities Section 301 of the Public Health Service Act ( 42 U.S.C. 241 ) is amended— (1) by redesignating subsections (e) through (h) as subsections (f) through (i), respectively; and (2) by inserting after subsection (d), the following: (e) The Secretary, acting through the Director of the Centers for Disease Control and Prevention, shall expand, intensify, and coordinate the activities of the Centers for Disease Control and Prevention with respect to maternal mortality and morbidity. . (b) Office of women’s health Section 310A(b)(1) of the Public Health Service Act ( 42 U.S.C. 242s(b)(1) ) is amended by inserting sociocultural, including among American Indians and Alaska Natives, as such terms are defined in section 4 of the Indian Health Care Improvement Act, geographic, after biological, . (c) Safe motherhood Section 317K(b)(2) of the Public Health Service Act ( 42 U.S.C. 247b–12(b)(2) ) is amended— (1) in subparagraph (L), by striking and at the end; (2) by redesignating subparagraph (M) as subparagraph (N); and (3) by inserting after subparagraph (L), the following: (M) an examination of the relationship between maternal and obstetric services in rural areas and outcomes in delivery and postpartum care; and . (d) Office of research on women’s health Section 486 of the Public Health Service Act ( 42 U.S.C. 287d ) is amended— (1) in subsection (b)— (A) by amending paragraph (3) to read as follows: (3) carry out paragraphs (1) and (2) with respect to— (A) the aging process in women, with priority given to menopause; and (B) pregnancy, with priority given to deaths related to pregnancy; ; and (2) in subsection (d)(4)(A)(iv), by inserting , including maternal mortality and other maternal morbidity outcomes before the semicolon. 102. Rural obstetric network grants The Public Health Service Act is amended by inserting after section 330A–1 of such Act ( 42 U.S.C. 254c–1a ) the following: 330A–2. Rural obstetric network grants (a) Program established The Secretary, acting through the Administrator of the Health Resources and Services Administration, shall award grants to eligible entities to establish collaborative improvement and innovation networks (referred to in this section as rural obstetric networks ) to improve birth outcomes and reduce maternal morbidity and mortality by improving maternity care and access to care in rural areas, frontier areas, maternity care health professional target areas, and Indian country and with Indian Tribes and tribal organizations. (b) Use of funds Rural obstetric networks receiving funds pursuant to this section may use such funds to— (1) assist pregnant women and individuals in areas and within populations referenced in subsection (a) with accessing and utilizing maternal and obstetric care, including preconception, pregnancy, labor and delivery, postpartum, and interconception services to improve outcomes in birth and maternal mortality and morbidity; (2) identify successful delivery models for maternal and obstetric care (including preconception, pregnancy, labor and delivery, postpartum, and interconception services) for individuals in areas and within populations referenced by subsection (a), including evidence-based home visiting programs and successful, culturally competent models with positive maternal health outcomes that advance health equity; (3) develop a model for collaboration between health facilities that have an obstetric care unit and health facilities that do not have an obstetric care unit to improve access to and the delivery of obstetric services in communities lacking these services; (4) provide training and guidance on obstetric care for health facilities that do not have obstetric care units; (5) collaborate with academic institutions that can provide regional expertise and research on access, outcomes, needs assessments, and other identified data and measurement activities needed to inform rural obstetric network efforts to improve obstetric care; and (6) measure and address inequities in birth outcomes among rural residents, with an emphasis on racial and ethnic minorities and underserved populations. (c) Definitions In this section: (1) Eligible entities The term eligible entities means entities providing obstetric, gynecologic, and other maternal health care services in rural areas, frontier areas, or medically underserved areas, or to medically underserved populations or Native Americans, including Indian tribes or tribal organizations. (2) Frontier area The term frontier area means a frontier county, as defined in section 1886(d)(3)(E)(iii)(III) of the Social Security Act. (3) Indian country The term Indian country has the meaning given such term in section 1151 of title 18, United States Code. (4) Maternity care health professional target area The term maternity care health professional target area has the meaning of such term as used in section 332(k)(2). (5) Rural area The term rural area has the meaning given that term in section 1886(d)(2) of the Social Security Act. (6) Indian tribes; tribal organization The terms Indian Tribe and tribal organization have the meaning given such terms in section 4 of the Indian Self-Determination and Education Assistance Act. (d) Authorization of Appropriations There is authorized to be appropriated to carry out this section $3,000,000 for each of fiscal years 2020 through 2024. . 103. Telehealth network and telehealth resource centers grant programs Section 330I of the Public Health Service Act ( 42 U.S.C. 254c–14 ) is amended— (1) in subsection (f)(1)(B)(iii), by adding at the end the following: (XIII) Providers of maternal, including prenatal, labor and birth, and postpartum care services and entities operating obstetric care units. ; and (2) in subsection (i)(1)(B), by inserting labor and birth, postpartum, before or prenatal . 104. Rural maternal and obstetric care training demonstration Subpart 1 of part E of title VII of the Public Health Service Act is amended by inserting after section 760 ( 42 U.S.C. 294n et seq.), as amended by section 202, is amended by adding at the end the following: 764. Rural maternal and obstetric care training demonstration (a) In general The Secretary shall establish a training demonstration program to award grants to eligible entities to support— (1) training for physicians, medical residents, including family medicine and obstetrics and gynecology residents, and fellows to practice maternal and obstetric medicine in rural community-based settings; (2) training for nurse practitioners, physician assistants, nurses, certified nurse midwives, home visiting nurses and non-clinical home visiting workforce professionals and paraprofessionals, or non-clinical professionals, who meet applicable State training and licensing requirements, to provide maternal care services in rural community-based settings; and (3) establishing, maintaining, or improving academic units or programs that— (A) provide training for students or faculty, including through clinical experiences and research, to improve maternal care in rural areas; or (B) develop evidence-based practices or recommendations for the design of the units or programs described in subparagraph (A), including curriculum content standards. (b) Activities (1) Training for medical residents and fellows A recipient of a grant under subsection (a)(1)— (A) shall use the grant funds— (i) to plan, develop, and operate a training program to provide obstetric care in rural areas for family practice or obstetrics and gynecology residents and fellows; or (ii) to train new family practice or obstetrics and gynecology residents and fellows in maternal and obstetric health care to provide and expand access to maternal and obstetric health care in rural areas; and (B) may use the grant funds to provide additional support for the administration of the program or to meet the costs of projects to establish, maintain, or improve faculty development, or departments, divisions, or other units necessary to implement such training. (2) Training for other providers A recipient of a grant under subsection (a)(2)— (A) shall use the grant funds to plan, develop, or operate a training program to provide maternal health care services in rural, community-based settings; and (B) may use the grant funds to provide additional support for the administration of the program or to meet the costs of projects to establish, maintain, or improve faculty development, or departments, divisions, or other units necessary to implement such program. (3) Training program requirements The recipient of a grant under subsection (a)(1) or (a)(2) shall ensure that training programs carried out under the grant are evidence-based and include instruction on— (A) maternal mental health, including perinatal depression and anxiety; (B) maternal substance use disorder; (C) social determinants of health that impact individuals living in rural communities, including poverty, social isolation, access to nutrition, education, transportation, and housing; and (D) implicit bias. (c) Eligible entities (1) Training for medical residents and fellows To be eligible to receive a grant under subsection (a)(1), an entity shall— (A) be a consortium consisting of— (i) at least one teaching health center; or (ii) the sponsoring institution (or parent institution of the sponsoring institution) of— (I) an obstetrics and gynecology or family medicine residency program that is accredited by the Accreditation Council of Graduate Medical Education (or the parent institution of such a program); or (II) a fellowship in maternal or obstetric medicine, as determined appropriate by the Secretary; or (B) be an entity described in subparagraph (A)(ii) that provides opportunities for medical residents or fellows to train in rural community-based settings. (2) Training for other providers To be eligible to receive a grant under subsection (a)(2), an entity shall be— (A) a teaching health center (as defined in section 749A(f)); (B) a federally qualified health center (as defined in section 1905(l)(2)(B) of the Social Security Act); (C) a community mental health center (as defined in section 1861(ff)(3)(B) of the Social Security Act); (D) a rural health clinic (as defined in section 1861(aa) of the Social Security Act); (E) a freestanding birth center (as defined in section 1905(l)(3) of the Social Security Act); or (F) an Indian Health Program or a Native Hawaiian health care system (as such terms are defined in section 4 of the Indian Health Care Improvement Act and section 12 of the Native Hawaiian Health Care Improvement Act, respectively). (3) Academic units or programs To be eligible to receive a grant under subsection (a)(3), an entity shall be a school of medicine, a school of osteopathic medicine, a school of nursing (as defined in section 801), a physician assistant education program, an accredited public or nonprofit private hospital, an accredited medical residency training program, a school accredited by the Midwifery Education and Accreditation Council, by the Accreditation Commission for Midwifery Education, or by the American Midwifery Certification Board, or a public or private nonprofit educational entity which the Secretary has determined is capable of carrying out such grant. (4) Application To be eligible to receive a grant under subsection (a), an entity shall submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require, including an estimate of the amount to be expended to conduct training activities under the grant (including ancillary and administrative costs). (d) Study and report (1) Study (A) In general The Secretary, acting through the Administrator of the Health Resources and Services Administration, shall conduct a study on the results of the demonstration program under this section. (B) Data submission Not later than 90 days after the completion of the first year of the training program, and each subsequent year for the duration of the grant, that the program is in effect, each recipient of a grant under subsection (a) shall submit to the Secretary such data as the Secretary may require for analysis for the report described in paragraph (2). (2) Report to Congress Not later than 1 year after receipt of the data described in paragraph (1)(B), the Secretary shall submit to the Committee on Energy and Commerce of the House of Representatives and the Committee on Health, Education, Labor, and Pensions of the Senate a report that includes— (A) an analysis of the effect of the demonstration program under this section on the quality, quantity, and distribution of maternal (including prenatal, labor and birth, and postpartum) care services and the demographics of the recipients of those services; (B) an analysis of maternal and infant health outcomes (including quality of care, morbidity, and mortality) before and after implementation of the program in the communities served by entities participating in the demonstration; and (C) recommendations on whether the demonstration program should be expanded. (e) Authorization of appropriations There is authorized to be appropriated to carry out this section, $5,000,000 for each of fiscal years 2020 through 2024. . 105. GAO report Not later than 18 months after the date of enactment of this Act, the Comptroller General of the United States shall submit to the Committee on Energy and Commerce of the House of Representatives and the Committee on Health, Education, Labor, and Pensions of the Senate a report on maternal care in rural areas, including prenatal, labor and birth, and postpartum care in rural areas. Such report shall include the following: (1) Trends in data that may identify potential gaps in maternal and obstetric clinicians and health professionals, including non-clinical professionals. (2) Trends in the number of facilities able to provide maternal care, including prenatal, labor and birth, and postpartum care, in rural areas, including care for high-risk pregnancies. (3) The gaps in data on maternal mortality and morbidity and recommendations to standardize the format on collecting data related to maternal mortality and morbidity. (4) The gaps in maternal health outcomes by race and ethnicity in rural communities, with a focus on racial inequities for residents who are racial and ethnic minorities or members of underserved populations. (5) An examination of— (A) activities which the Secretary of Health and Human Services plans to conduct to improve maternal care in rural areas, including prenatal, labor and birth, and postpartum care; and (B) the extent to which the Secretary has a plan for completing these activities, has identified the lead agency responsible for each activity, has identified any needed coordination among agencies, and has developed a budget for conducting such activities. (6) Other information that the Comptroller General determines appropriate. II Other Improvements to Maternal Care 201. Innovation for maternal health The Public Health Service Act is amended— (1) in the section designation of section 330M ( 42 U.S.C. 254c–19 ) by inserting a period after 330M ; and (2) by inserting after such section 330M the following: 330N. Innovation for maternal health (a) In general The Secretary, in consultation with experts representing a variety of clinical specialties, State, tribal, or local public health officials, researchers, epidemiologists, statisticians, and community organizations, shall establish or continue a program to award competitive grants to eligible entities for the purpose of— (1) identifying, developing, or disseminating best practices to improve maternal health care quality and outcomes, eliminate preventable maternal mortality and severe maternal morbidity, and improve infant health outcomes, which may include— (A) information on evidence-based practices to improve the quality and safety of maternal health care in hospitals and other health care settings of a State or health care system, including by addressing topics commonly associated with health complications or risks related to prenatal care, labor care, birthing, and postpartum care; (B) best practices for improving maternal health care based on data findings and reviews conducted by a State maternal mortality review committee that address topics of relevance to common complications or health risks related to prenatal care, labor care, birthing, and post­partum care; and (C) information on addressing determinants of health that impact maternal health outcomes for women before, during, and after pregnancy; (2) collaborating with State maternal mortality review committees to identify issues for the development and implementation of evidence-based practices to improve maternal health outcomes and reduce preventable maternal mortality and severe maternal morbidity; (3) providing technical assistance and supporting the implementation of best practices identified in paragraph (1) to entities providing health care services to pregnant and postpartum women; and (4) identifying, developing, and evaluating new models of care that improve maternal and infant health outcomes, which may include the integration of community-based services and clinical care. (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) Authorization of appropriations To carry out this section, there is authorized to be appropriated $10,000,000 for each of fiscal years 2020 through 2024. . 202. Training for health care providers Title VII of the Public Health Service Act is amended by striking section 763 ( 42 U.S.C. 294p ) and inserting the following: 763. Training for health care providers (a) Grant program The Secretary shall establish a program to award grants to accredited schools of allopathic medicine, osteopathic medicine, and nursing, and other health professional training programs for the training of health care professionals to reduce and prevent discrimination (including training related to implicit and explicit biases) in the provision of health care services related to prenatal care, labor care, birthing, and postpartum care. (b) Eligibility To be eligible for a grant under subsection (a), an entity described in such subsection shall submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require. (c) Reporting requirement Each entity awarded a grant under this section shall periodically submit to the Secretary a report on the status of activities conducted using the grant, including a description of the impact of such training on patient outcomes, as applicable. (d) Best practices The Secretary may identify and disseminate best practices for the training of health care professionals to reduce and prevent discrimination (including training related to implicit and explicit biases) in the provision of health care services related to prenatal care, labor care, birthing, and postpartum care. (e) Authorization of appropriations To carry out this section, there is authorized to be appropriated $5,000,000 for each of fiscal years 2020 through 2024. . 203. Study on training to reduce and prevent discrimination Not later than 2 years after date of enactment of this Act, the Secretary of Health and Human Services (referred to in this section as the Secretary ) shall, through a contract with an independent research organization, conduct a study and make recommendations for accredited schools of allopathic medicine, osteopathic medicine, and nursing, and other health professional training programs, on best practices related to training to reduce and prevent discrimination, including training related to implicit and explicit biases, in the provision of health care services related to prenatal care, labor care, birthing, and postpartum care. 204. Perinatal quality collaboratives (a) Grants Section 317K(a)(2) of the Public Health Service Act ( 42 U.S.C. 247b–12(a)(2) ) is amended by adding at the end the following: (E) (i) The Secretary, acting through the Director of the Centers for Disease Control and Prevention and in coordination with other offices and agencies, as appropriate, shall establish or continue a competitive grant program for the establishment or support of perinatal quality collaboratives to improve perinatal care and perinatal health outcomes for pregnant and postpartum women and their infants. A State, Indian Tribe, or tribal organization may use funds received through such grant to— (I) support the use of evidence-based or evidence-informed practices to improve outcomes for maternal and infant health; (II) work with clinical teams; experts; State, local, and, as appropriate, tribal public health officials; and stakeholders, including patients and families, to identify, develop, or disseminate best practices to improve perinatal care and outcomes; and (III) employ strategies that provide opportunities for health care professionals and clinical teams to collaborate across health care settings and disciplines, including primary care and mental health, as appropriate, to improve maternal and infant health outcomes, which may include the use of data to provide timely feedback across hospital and clinical teams to inform responses, and to provide support and training to hospital and clinical teams for quality improvement, as appropriate. (ii) To be eligible for a grant under clause (i), an entity shall submit to the Secretary an application in such form and manner and containing such information as the Secretary may require. . (b) Authorization of appropriations Section 317K(f) of the Public Health Service Act ( 42 U.S.C. 247b–12(f) ) is amended by striking $58,000,000 for each of fiscal years 2019 through 2023 and inserting $65,000,000 for each of fiscal years 2020 through 2024 . 205. Integrated services for pregnant and postpartum women (a) Grants The Public Health Service Act is amended by inserting after section 330N of such Act, as added by section 201, the following: 330O. Integrated services for pregnant and postpartum women (a) In general The Secretary may award grants for the purpose of establishing or operating evidence-based or innovative, evidence-informed programs to deliver integrated health care services to pregnant and postpartum women to optimize the health of women and their infants, including— (1) to reduce adverse maternal health outcomes, pregnancy-related deaths, and related health disparities (including such disparities associated with racial and ethnic minority populations); and (2) as appropriate, by addressing issues researched under section 317K(b)(2). (b) Integrated services for pregnant and postpartum women (1) Eligibility To be eligible to receive a grant under subsection (a), a State, Indian Tribe, or tribal organization (as such terms are defined in section 4 of the Indian Self-Determination and Education Assistance Act) shall work with relevant stakeholders that coordinate care (including coordinating resources and referrals for health care and social services) to develop and carry out the program, including— (A) State, Tribal, and local agencies responsible for Medicaid, public health, social services, mental health, and substance use disorder treatment and services; (B) health care providers who serve pregnant and postpartum women; and (C) community-based health organizations and health workers, including providers of home visiting services and individuals representing communities with disproportionately high rates of maternal mortality and severe maternal morbidity, and including those representing racial and ethnicity minority populations. (2) Terms (A) Period A grant awarded under subsection (a) shall be made for a period of 5 years. Any supplemental award made to a grantee under subsection (a) may be made for a period of less than 5 years. (B) Preference In awarding grants under subsection (a), the Secretary shall— (i) give preference to States, Indian Tribes, and tribal organizations that have the highest rates of maternal mortality and severe maternal morbidity relative to other such States, Indian Tribes, or tribal organizations, respectively; and (ii) shall consider health disparities related to maternal mortality and severe maternal morbidity, including such disparities associated with racial and ethnic minority populations. (C) Priority In awarding grants under subsection (a), the Secretary shall give priority to applications from up to 15 entities described in subparagraph (B)(i). (D) Evaluation The Secretary shall require grantees to evaluate the outcomes of the programs supported under the grant. (c) Authorization of appropriations To carry out this section, there is authorized to be appropriated $15,000,000 for each of fiscal years 2020 through 2024. . (b) Report on grant outcomes and dissemination of best practices (1) Report Not later than February 1, 2026, the Secretary of Health and Human Services shall submit to the Committee on Energy and Commerce of the House of Representatives and the Committee on Health, Education, Labor, and Pensions of the Senate a report that describes— (A) the outcomes of the activities supported by the grants awarded under the amendments made by this section on maternal and child health; (B) best practices and models of care used by recipients of grants under such amendments; and (C) obstacles identified by recipients of grants under such amendments, and strategies used by such recipients to deliver care, improve maternal and child health, and reduce health disparities. (2) Dissemination of best practices Not later than August 1, 2026, the Secretary of Health and Human Services shall disseminate information on best practices and models of care used by recipients of grants under section 330O of the Public Health Service Act (as added by this section) (including best practices and models of care relating to the reduction of health disparities, including such disparities associated with racial and ethnic minority populations, in rates of maternal mortality and severe maternal morbidity) to relevant stakeholders, which may include health providers, medical schools, nursing schools, relevant State, tribal, and local agencies, and the general public.