I 117th CONGRESS 1st Session H. R. 1212 IN THE HOUSE OF REPRESENTATIVES February 23, 2021 Ms. Adams (for herself, Ms. Underwood , Mr. Khanna , Ms. Velázquez , Mrs. McBath , Mr. Smith of Washington , Ms. Scanlon , Mr. Lawson of Florida , Mrs. Hayes , Mr. Butterfield , Ms. Moore of Wisconsin , Ms. Strickland , Mr. Ryan , Mr. Schiff , Mr. Johnson of Georgia , Mr. Horsford , Ms. Wasserman Schultz , Ms. Barragán , Mr. Deutch , Mr. Blumenauer , Mr. Moulton , Mr. Soto , Mr. Nadler , Mr. Trone , Ms. Clarke of New York , Ms. Schakowsky , Ms. Bass , Ms. Pressley , Mr. Evans , Ms. Blunt Rochester , Ms. Castor of Florida , Ms. Sewell , and Ms. Williams of Georgia ) introduced the following bill; which was referred to the Committee on Energy and Commerce A BILL To end preventable maternal mortality and severe maternal morbidity in the United States and close disparities in maternal health outcomes, and for other purposes.

1. Short title This Act may be cited as the Kira Johnson Act . 2. Investments in community-based organizations to improve Black maternal health outcomes (a) Awards Following the 1-year period described in subsection (c), the Secretary of Health and Human Services (in this section referred to as the Secretary ) shall award grants to eligible entities to establish or expand programs to prevent maternal mortality and severe maternal morbidity among Black pregnant and postpartum individuals. (b) Eligibility To be eligible to seek a grant under this section, an entity shall be a community-based organization offering programs and resources aligned with evidence-based practices for improving maternal health outcomes for Black pregnant and postpartum individuals. (c) Outreach and technical assistance period During the 1-year period beginning on the date of enactment of this Act, the Secretary shall— (1) conduct outreach to encourage eligible entities to apply for grants under this section; and (2) provide technical assistance to eligible entities on best practices for applying for grants under this section. (d) Special consideration (1) Outreach In conducting outreach under subsection (c), the Secretary shall give special consideration to eligible entities that— (A) are based in, and provide support for, communities with high rates of adverse maternal health outcomes or significant racial and ethnic disparities in maternal health outcomes, to the extent such data are available; (B) are led by Black women; and (C) offer programs and resources that are aligned with evidence-based practices for improving maternal health outcomes for Black pregnant and postpartum individuals. (2) Awards In awarding grants under this section, the Secretary shall give special consideration to eligible entities that— (A) are described in subparagraphs (A), (B), and (C) of paragraph (1); (B) offer programs and resources designed in consultation with and intended for Black pregnant and postpartum individuals; and (C) offer programs and resources in the communities in which the respective eligible entities are located that— (i) promote maternal mental health and maternal substance use disorder treatments and supports that are aligned with evidence-based practices for improving maternal mental and behavioral health outcomes for Black pregnant and postpartum individuals; (ii) address social determinants of maternal health for pregnant and postpartum individuals; (iii) promote evidence-based health literacy and pregnancy, childbirth, and parenting education for pregnant and postpartum individuals; (iv) provide support from perinatal health workers to pregnant and postpartum individuals; (v) provide culturally congruent training to perinatal health workers; (vi) conduct or support research on maternal health issues disproportionately impacting Black pregnant and postpartum individuals; (vii) provide support to family members of individuals who suffered a pregnancy-associated death or pregnancy-related death; (viii) operate midwifery practices that provide culturally congruent maternal health care and support, including for the purposes of— (I) supporting additional education, training, and certification programs, including support for distance learning; (II) providing financial support to current and future midwives to address education costs, debts, and other needs; (III) clinical site investments; (IV) supporting preceptor development trainings; (V) expanding the midwifery practice; or (VI) related needs identified by the midwifery practice and described in the practice’s application; or (ix) have developed other programs and resources that address community-specific needs for pregnant and postpartum individuals and are aligned with evidence-based practices for improving maternal health outcomes for Black pregnant and postpartum individuals. (e) Technical assistance The Secretary shall provide to grant recipients under this section technical assistance on— (1) capacity building to establish or expand programs to prevent adverse maternal health outcomes among Black pregnant and postpartum individuals; (2) best practices in data collection, measurement, evaluation, and reporting; and (3) planning for sustaining programs to prevent maternal mortality and severe maternal morbidity among Black pregnant and postpartum individuals after the period of the grant. (f) Evaluation Not later than the end of fiscal year 2026, the Secretary shall submit to the Congress an evaluation of the grant program under this section that— (1) assesses the effectiveness of outreach efforts during the application process in diversifying the pool of grant recipients; (2) makes recommendations for future outreach efforts to diversify the pool of grant recipients for Department of Health and Human Services grant programs and funding opportunities related to maternal health; (3) assesses the effectiveness of programs funded by grants under this section in improving maternal health outcomes for Black pregnant and postpartum individuals, to the extent practicable; and (4) makes recommendations for future Department of Health and Human Services grant programs and funding opportunities that deliver funding to community-based organizations that provide programs and resources that are aligned with evidence-based practices for improving maternal health outcomes for Black pregnant and postpartum individuals. (g) Authorization of appropriations To carry out this section, there is authorized to be appropriated $10,000,000 for each of fiscal years 2022 through 2026. 3. Investments in community-based organizations to improve maternal health outcomes in underserved communities (a) Awards Following the 1-year period described in subsection (c), the Secretary of Health and Human Services (in this section referred to as the Secretary ) shall award grants to eligible entities to establish or expand programs to prevent maternal mortality and severe maternal morbidity among underserved groups. (b) Eligibility To be eligible to seek a grant under this section, an entity shall be a community-based organization offering programs and resources aligned with evidence-based practices for improving maternal health outcomes for pregnant and postpartum individuals. (c) Outreach and technical assistance period During the 1-year period beginning on the date of enactment of this Act, the Secretary shall— (1) conduct outreach to encourage eligible entities to apply for grants under this section; and (2) provide technical assistance to eligible entities on best practices for applying for grants under this section. (d) Special consideration (1) Outreach In conducting outreach under subsection (c), the Secretary shall give special consideration to eligible entities that— (A) are based in, and provide support for, communities with high rates of adverse maternal health outcomes or significant racial and ethnic disparities in maternal health outcomes, to the extent such data are available; (B) are led by individuals from racially, ethnically, and geographically diverse backgrounds; and (C) offer programs and resources that are aligned with evidence-based practices for improving maternal health outcomes for pregnant and postpartum individuals. (2) Awards In awarding grants under this section, the Secretary shall give special consideration to eligible entities that— (A) are described in subparagraphs (A), (B), and (C) of paragraph (1); (B) offer programs and resources designed in consultation with and intended for pregnant and postpartum individuals from underserved groups; and (C) offer programs and resources in the communities in which the respective eligible entities are located that— (i) promote maternal mental health and maternal substance use disorder treatments and support that are aligned with evidence-based practices for improving maternal mental and behavioral health outcomes for pregnant and postpartum individuals; (ii) address social determinants of maternal health for pregnant and postpartum individuals; (iii) promote evidence-based health literacy and pregnancy, childbirth, and parenting education for pregnant and postpartum individuals; (iv) provide support from perinatal health workers to pregnant and postpartum individuals; (v) provide culturally congruent training to perinatal health workers; (vi) conduct or support research on maternal health outcomes and disparities; (vii) provide support to family members of individuals who suffered a pregnancy-associated death or pregnancy-related death; (viii) operate midwifery practices that provide culturally congruent maternal health care and support, including for the purposes of— (I) supporting additional education, training, and certification programs, including support for distance learning; (II) providing financial support to current and future midwives to address education costs, debts, and other needs; (III) clinical site investments; (IV) supporting preceptor development trainings; (V) expanding the midwifery practice; or (VI) related needs identified by the midwifery practice and described in the practice’s application; or (ix) have developed other programs and resources that address community-specific needs for pregnant and postpartum individuals and are aligned with evidence-based practices for improving maternal health outcomes for pregnant and postpartum individuals. (e) Technical assistance The Secretary shall provide to grant recipients under this section technical assistance on— (1) capacity building to establish or expand programs to prevent adverse maternal health outcomes among pregnant and postpartum individuals from underserved groups; (2) best practices in data collection, measurement, evaluation, and reporting; and (3) planning for sustaining programs to prevent maternal mortality and severe maternal morbidity among pregnant and postpartum individuals from underserved groups after the period of the grant. (f) Evaluation Not later than the end of fiscal year 2026, the Secretary shall submit to the Congress an evaluation of the grant program under this section that— (1) assesses the effectiveness of outreach efforts during the application process in diversifying the pool of grant recipients; (2) makes recommendations for future outreach efforts to diversify the pool of grant recipients for Department of Health and Human Services grant programs and funding opportunities related to maternal health; (3) assesses the effectiveness of programs funded by grants under this section in improving maternal health outcomes for pregnant and postpartum individuals from underserved groups, to the extent practicable; and (4) makes recommendations for future Department of Health and Human Services grant programs and funding opportunities that deliver funding to community-based organizations that provide programs and resources that are aligned with evidence-based practices for improving maternal health outcomes for pregnant and postpartum individuals. (g) Definition In this section, the term underserved groups refers to pregnant and postpartum individuals— (1) from racial and ethnic minority groups (as such term is defined in section 1707(g)(1) of the Public Health Service Act ( 42 U.S.C. 300u–6(g)(1) )); (2) whose household income is equal to or less than 150 percent of the Federal poverty line; (3) who live in health professional shortage areas (as such term is defined in section 332 of the Public Health Service Act ( 42 U.S.C. 254e(a)(1) )); (4) who live in counties with no hospital offering obstetric care, no birth center, and no obstetric provider; or (5) who live in counties with a level of vulnerability of moderate-to-high or higher, according to the Social Vulnerability Index of the Centers for Disease Control and Prevention. (h) Authorization of appropriations To carry out this section, there is authorized to be appropriated $10,000,000 for each of fiscal years 2022 through 2026. 4. Respectful maternity care training for all employees in maternity care settings Part B of title VII of the Public Health Service Act ( 42 U.S.C. 293 et seq.) is amended by adding at the end the following new section: 742. Respectful maternity care training for all employees in maternity care settings (a) Grants The Secretary shall award grants for programs to reduce and prevent bias, racism, and discrimination in maternity care settings and to advance respectful, culturally congruent, trauma-informed care. (b) Special consideration In awarding grants under subsection (a), the Secretary shall give special consideration to applications for programs that would— (1) apply to all maternity care providers (as defined in section 8 of the Kira Johnson Act ) and any employees who interact with pregnant and postpartum individuals in the provider setting, including front desk employees, sonographers, schedulers, health care professionals, hospital or health system administrators, security staff, and other employees; (2) emphasize periodic, as opposed to one-time, trainings for all birthing professionals and employees described in paragraph (1); (3) address implicit bias, racism, and cultural humility; (4) be delivered in ongoing education settings for providers maintaining their licenses, with a preference for trainings that provide continuing education units; (5) include trauma-informed care best practices and an emphasis on shared decision making between providers and patients; (6) include antiracism training and programs; (7) be delivered in undergraduate programs that funnel into health professions schools; (8) be delivered in settings that apply to providers of the special supplemental nutrition program for women, infants, and children under section 17 of the Child Nutrition Act of 1966; (9) integrate bias training in obstetric emergency simulation trainings or related trainings; (10) include training for emergency department employees and emergency medical technicians on recognizing warning signs for severe pregnancy-related complications; (11) offer training to all maternity care providers on the value of racially, ethnically, and professionally diverse maternity care teams to provide culturally congruent care; or (12) be based on one or more programs designed by a historically Black college or university or other minority-serving institution. (c) Application To seek a grant under subsection (a), an entity shall submit an application at such time, in such manner, and containing such information as the Secretary may require. (d) Reporting Each recipient of a grant under this section shall annually submit to the Secretary a report on the status of activities conducted using the grant, including, as applicable, a description of the impact of training provided through the grant on patient outcomes and patient experience for pregnant and postpartum individuals from racial and ethnic minority groups and their families. (e) Best practices Based on the annual reports submitted pursuant to subsection (d), the Secretary— (1) shall produce an annual report on the findings resulting from programs funded through this section; (2) shall disseminate such report to all recipients of grants under this section and to the public; and (3) may include in such report findings on best practices for improving patient outcomes and patient experience for pregnant and postpartum individuals from racial and ethnic minority groups and their families in maternity care settings. (f) Definitions In this section: (1) The term postpartum means the one-year period beginning on the last day of an individual’s pregnancy. (2) The term culturally congruent means in agreement with the preferred cultural values, beliefs, world view, language, and practices of the health care consumer and other stakeholders. (3) The term racial and ethnic minority group has the meaning given such term in section 1707(g)(1). (g) Authorization of appropriations To carry out this section, there is authorized to be appropriated $5,000,000 for each of fiscal years 2022 through 2026. . 5. Study on reducing and preventing bias, racism, and discrimination in maternity care settings (a) In general The Secretary of Health and Human Services shall seek to enter into an agreement, not later than 90 days after the date of enactment of this Act, with the National Academies of Sciences, Engineering, and Medicine (referred to in this section as the National Academies ) under which the National Academies agree to— (1) conduct a study on the design and implementation of programs to reduce and prevent bias, racism, and discrimination in maternity care settings and to advance respectful, culturally congruent, trauma-informed care; and (2) not later than 24 months after the date of enactment of this Act— (A) complete the study; and (B) transmit a report on the results of the study to the Congress. (b) Possible topics The agreement entered into pursuant to subsection (a) may provide for the study of any of the following: (1) The development of a scorecard or other evaluation standards for programs designed to reduce and prevent bias, racism, and discrimination in maternity care settings to assess the effectiveness of such programs in improving patient outcomes and patient experience for pregnant and postpartum individuals from racial and ethnic minority groups and their families. (2) Determination of the types and frequency of training to reduce and prevent bias, racism, and discrimination in maternity care settings that are demonstrated to improve patient outcomes or patient experience for pregnant and postpartum individuals from racial and ethnic minority groups and their families. 6. Respectful maternity care compliance program (a) In general The Secretary of Health and Human Services (referred to in this section as the Secretary ) shall award grants to accredited hospitals, health systems, and other maternity care settings to establish as an integral part of quality implementation initiatives within one or more hospitals or other birth settings a respectful maternity care compliance program. (b) Program requirements A respectful maternity care compliance program funded through a grant under this section shall— (1) institutionalize mechanisms to allow patients receiving maternity care services, the families of such patients, or perinatal health workers supporting such patients to report instances of racism or evidence of bias on the basis of race, ethnicity, or another protected class; (2) institutionalize response mechanisms through which representatives of the program can directly follow up with the patient, if possible, and the patient’s family in a timely manner; (3) prepare and make publicly available a hospital- or health system-wide strategy to reduce bias on the basis of race, ethnicity, or another protected class in the delivery of maternity care that includes— (A) information on the training programs to reduce and prevent bias, racism, and discrimination on the basis of race, ethnicity, or another protected class for all employees in maternity care settings; (B) information on the number of cases reported to the compliance program; and (C) the development of methods to routinely assess the extent to which bias, racism, or discrimination on the basis of race, ethnicity, or another protected class are present in the delivery of maternity care to patients from racial and ethnic minority groups; and (4) develop mechanisms to routinely collect and publicly report hospital-level data related to patient-reported experience of care; and (5) provide annual reports to the Secretary with information about each case reported to the compliance program over the course of the year containing such information as the Secretary may require, such as— (A) de-identified demographic information on the patient in the case, such as race, ethnicity, gender identity, and primary language; (B) the content of the report from the patient or the family of the patient to the compliance program; (C) the response from the compliance program; and (D) to the extent applicable, institutional changes made as a result of the case. (c) Secretary requirements (1) Processes Not later than 180 days after the date of enactment of this Act, the Secretary shall establish processes for— (A) disseminating best practices for establishing and implementing a respectful maternity care compliance program within a hospital or other birth setting; (B) promoting coordination and collaboration between hospitals, health systems, and other maternity care delivery settings on the establishment and implementation of respectful maternity care compliance programs; and (C) evaluating the effectiveness of respectful maternity care compliance programs on maternal health outcomes and patient and family experiences, especially for patients from racial and ethnic minority groups and their families. (2) Study (A) In general Not later than 2 years after the date of enactment of this Act, the Secretary shall, through a contract with an independent research organization, conduct a study on strategies to address— (i) racism or bias on the basis of race, ethnicity, or another protected class in the delivery of maternity care services; and (ii) successful implementation of respectful care initiatives. (B) Components of study The study shall include the following: (i) An assessment of the reports submitted to the Secretary from the respectful maternity care compliance programs pursuant to subsection (b)(5). (ii) Based on such assessment, recommendations for potential accountability mechanisms related to cases of racism or bias on the basis of race, ethnicity, or another protected class in the delivery of maternity care services at hospitals and other birth settings. Such recommendations shall take into consideration medical and non-medical factors that contribute to adverse patient experiences and maternal health outcomes. (C) Report The Secretary shall submit to the Congress and make publicly available a report on the results of the study under this paragraph. (d) Authorization of appropriations To carry out this section, there is authorized to be appropriated such sums as may be necessary for fiscal years 2022 through 2027. 7. GAO report (a) In general Not later than 2 years after the date of enactment of this Act and annually thereafter, the Comptroller General of the United States shall submit to the Congress and make publicly available a report on the establishment of respectful maternity care compliance programs within hospitals, health systems, and other maternity care settings. (b) Matters included The report under paragraph (1) shall include the following: (1) Information regarding the extent to which hospitals, health systems, and other maternity care settings have elected to establish respectful maternity care compliance programs, including— (A) which hospitals and other birth settings elect to establish compliance programs and when such programs are established; (B) to the extent practicable, impacts of the establishment of such programs on maternal health outcomes and patient and family experiences in the hospitals and other birth settings that have established such programs, especially for patients from racial and ethnic minority groups and their families; (C) information on geographic areas, and types of hospitals or other birth settings, where respectful maternity care compliance programs are not being established and information on factors contributing to decisions to not establish such programs; and (D) recommendations for establishing respectful maternity care compliance programs in geographic areas, and types of hospitals or other birth settings, where such programs are not being established. (2) Whether the funding made available to carry out this section has been sufficient and, if applicable, recommendations for additional appropriations to carry out this section. (3) Such other information as the Comptroller General determines appropriate. 8. Definitions In this Act: (1) Culturally congruent The term culturally congruent , with respect to care or maternity care, means care that is in agreement with the preferred cultural values, beliefs, worldview, language, and practices of the health care consumer and other stakeholders. (2) Maternity care provider The term maternity care provider means a health care provider who— (A) is a physician, physician assistant, midwife who meets at a minimum the international definition of the midwife and global standards for midwifery education as established by the International Confederation of Midwives, nurse practitioner, or clinical nurse specialist; and (B) has a focus on maternal or perinatal health. (3) Maternal mortality The term maternal mortality means a death occurring during or within a one-year period after pregnancy, caused by pregnancy-related or childbirth complications, including a suicide, overdose, or other death resulting from a mental health or substance use disorder attributed to or aggravated by pregnancy-related or childbirth complications. (4) Perinatal health worker The term perinatal health worker means a doula, community health worker, peer supporter, breastfeeding and lactation educator or counselor, nutritionist or dietitian, childbirth educator, social worker, home visitor, language interpreter, or navigator. (5) Postpartum and postpartum period The terms postpartum and postpartum period refer to the 1-year period beginning on the last day of the pregnancy of an individual. (6) Pregnancy-associated death The term pregnancy-associated death means a death of a pregnant or postpartum individual, by any cause, that occurs during, or within 1 year following, the individual’s pregnancy, regardless of the outcome, duration, or site of the pregnancy. (7) Pregnancy-related death The term pregnancy-related death means a death of a pregnant or postpartum individual that occurs during, or within 1 year following, the individual’s pregnancy, from a pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy. (8) Racial and ethnic minority group The term racial and ethnic minority group has the meaning given such term in section 1707(g)(1) of the Public Health Service Act ( 42 U.S.C. 300u–6(g)(1) ). (9) Severe maternal morbidity The term severe maternal morbidity means a health condition, including mental health conditions and substance use disorders, attributed to or aggravated by pregnancy or childbirth that results in significant short-term or long-term consequences to the health of the individual who was pregnant. (10) Social determinants of maternal health defined The term social determinants of maternal health means non-clinical factors that impact maternal health outcomes, including— (A) economic factors, which may include poverty, employment, food security, support for and access to lactation and other infant feeding options, housing stability, and related factors; (B) neighborhood factors, which may include quality of housing, access to transportation, access to child care, availability of healthy foods and nutrition counseling, availability of clean water, air and water quality, ambient temperatures, neighborhood crime and violence, access to broadband, and related factors; (C) social and community factors, which may include systemic racism, gender discrimination or discrimination based on other protected classes, workplace conditions, incarceration, and related factors; (D) household factors, which may include ability to conduct lead testing and abatement, car seat installation, indoor air temperatures, and related factors; (E) education access and quality factors, which may include educational attainment, language and literacy, and related factors; and (F) health care access factors, including health insurance coverage, access to culturally congruent health care services, providers, and non-clinical support, access to home visiting services, access to wellness and stress management programs, health literacy, access to telehealth and items required to receive telehealth services, and related factors.