II Calendar No. 70 117th CONGRESS 1st Session S. 1491 IN THE SENATE OF THE UNITED STATES April 29, 2021 Ms. Smith (for herself, Ms. Murkowski , Mr. King , Ms. Ernst , Mrs. Gillibrand , Ms. Stabenow , Mr. Luján , Mrs. Capito , and Ms. Collins ) introduced the following bill; which was read twice and referred to the Committee on Health, Education, Labor, and Pensions June 8, 2021 Reported by Mrs. Murray , with an amendment Strike out all after the enacting clause and insert the part printed in italic A BILL To amend the Public Health Service Act to improve obstetric care in rural areas.

1. Short title This Act may be cited as the Rural Maternal and Obstetric Modernization of Services Act or the Rural MOMS Act . 2. 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 striking sociocultural contexts and inserting sociocultural (race, ethnicity, language, class, income) contexts (including among American Indians and Alaska Natives, as such terms are defined in section 4 of the Indian Health Care Improvement Act), and geographic contexts . (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 health 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 redesignating paragraphs (4) through (9) as paragraphs (5) through (10), respectively; (B) by inserting after paragraph (3) the following: (4) carry out paragraphs (1) and (2) with respect to pregnancy, with priority given to deaths related to pregnancy; ; and (C) in paragraph (5) (as so redesignated), by striking through (3) and inserting through (4) ; and (2) in subsection (d)(4)(A)(iv), by inserting , including maternal mortality and other maternal morbidity outcomes before the semicolon. 3. Rural Obstetric Network Grants The Public Health Service Act is amended by inserting after section 317L–1 ( 42 U.S.C. 247b–13a ) the following: 317L–2. Rural Obstetric Network Grants (a) In general For the purpose of enabling the Secretary (through grants, contracts, or otherwise), acting through the Administrator of the Health Resources and Services Administration, to establish collaborative improvement and innovation networks (referred to in this section as rural obstetric networks ) to improve outcomes in birth and maternal morbidity and mortality, there is appropriated to the Secretary, out of any money in the Treasury not otherwise appropriated, $3,000,000 for each of fiscal years 2021 through 2025. Such amounts shall remain available until expended. (b) Use of funds Amount appropriated under subsection (a) shall be used for the establishment of collaborative improvement and innovation networks to improve maternal health in rural areas by improving outcomes in birth and maternal morbidity and mortality. Rural obstetric networks established in accordance with this section shall— (1) assist pregnant women and individuals in rural areas connect with prenatal, labor and birth, and postpartum care to improve outcomes in birth and maternal mortality and morbidity; (2) identify successful prenatal, labor and birth, and postpartum health delivery models for individuals in rural areas, 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 health unit and health facilities that do not have an obstetric health unit; (4) provide training and guidance for health facilities that do not have obstetric health units; (5) collaborate with academic institutions that can provide regional expertise and research on access, outcomes, needs assessments, and other identified data; and (6) measure and address inequities in birth outcomes among rural residents, with an emphasis on Black and American Indians and Alaska Native residents, as such terms are defined in section 4 of the Indian Health Care Improvement Act. (c) Requirements (1) Establishment Not later than October 1, 2021, the Secretary shall establish rural obstetric health networks in at least 5 regions. (2) Definitions In this section: (A) 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. (B) Indian tribe The term Indian tribe has the meaning given such term in section 4 of the Indian Health Care Improvement Act. (C) Native Hawaiian health care system The term Native Hawaiian Health Care System has the meaning given such term in section 12 of the Native Hawaiian Health Care Improvement Act. (D) Region The term region means a State, Indian tribe, rural area, or frontier area. (E) Rural area The term rural area has the meaning given that term in section 1886(d)(2)(D) of the Social Security Act. (F) Tribal organization The term tribal organization has the meaning given such term in the Indian Self-Determination Act. (G) State The term State has the meaning given that term for purposes of title V of the Social Security Act. . 4. 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)(3), by adding at the end the following: (M) Providers of maternal, including prenatal, labor and birth, and postpartum care services and entities operation obstetric care units. ; (2) in subsection (h)(1)(B), by inserting labor and birth, postpartum, before or prenatal ; and (3) in subsection (j)(1)(B), by inserting , including equipment useful for caring for pregnant women and individuals, including ultrasound machines and fetal monitoring equipment before the semicolon. 5. Rural maternal and obstetric care training demonstration Part D of title VII of the Public Health Service Act is amended by inserting after section 760 ( 42 U.S.C. 294k ) the following: 760A. 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 licensed and accredited nurse practitioners, physician assistants, certified nurse midwives, certified midwives, certified professional midwives, home visiting nurses, or non-clinical professionals such as doulas and community health workers, 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) Academic units or programs A recipient of a grant under subsection (a)(3) shall enter into a partnership with organizations such as an education accrediting organization (such as the Liaison Committee on Medical Education, the Accreditation Council for Graduate Medical Education, the Commission on Osteopathic College Accreditation, the Accreditation Commission for Education in Nursing, the Commission on Collegiate Nursing Education, the Accreditation Commission for Midwifery Education, or the Accreditation Review Commission on Education for the Physician Assistant) to carry out activities under subsection (a)(3). (4) 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 include instruction on— (A) maternal mental health, including perinatal depression and anxiety and postpartum depression; (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); (F) a health center operated by the Indian Health Service, an Indian tribe, a tribal organization, 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); or (G) an entity with a demonstrated record of success in providing academic training for nurse practitioners, physician assistants, certified nurse-midwives, certified midwives, certified professional midwives, home visiting nurses, or non-clinical professionals, such as doulas and community health workers. (3) Academic units or programs To be eligible to receive a grant under subsection (a)(3), an entity shall be a school of medicine or osteopathic medicine, a nursing school, a physician assistant training program, an accredited public or nonprofit private hospital, an accredited medical residency program, a school accredited by the Midwifery Education and Accreditation Council, or a public or private nonprofit 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) Duration Grants awarded under this section shall be for a minimum of 5 years. (e) 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 Congress 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. (f) Authorization of appropriations There are authorized to be appropriated to carry out this section, $5,000,000 for each of fiscal years 2021 through 2025. . 6. GAO report Not later than 1 year after the date of enactment of this Act, the Comptroller General of the United States shall submit to the appropriate committees of Congress a report on the maternal, including prenatal, labor and birth, and postpartum care in rural areas. Such report shall include the following: (1) The location of gaps in maternal and obstetric clinicians and health professionals, including non-clinical professionals such as doulas and community health workers. (2) The location of gaps in facilities able to provide maternal, 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 recommendations to standardize the format on collecting data related to maternal mortality and morbidity. (4) The gaps in maternal health by race and ethnicity in rural communities, with a focus on racial inequities for Black residents and among Indian Tribes and American Indian and Alaska Native rural residents (as such terms are defined in section 4 of the Indian Health Care Improvement Act). (5) A list of specific activities that the Secretary of Health and Human Services plans to conduct on maternal, including prenatal, labor and birth, and postpartum care. (6) A plan for completing such activities. (7) An explanation of Federal agency involvement and coordination needed to conduct such activities. (8) A budget for conducting such activities. (9) Other information that the Comptroller General determines appropriate.

1. Short title This Act may be cited as the Rural Maternal and Obstetric Modernization of Services Act or the Rural MOMS Act . 2. Improving rural maternal and obstetric care data (a) Maternal mortality and morbidity activities Section 301(e) of the Public Health Service Act ( 42 U.S.C. 241 ) is amended by inserting , preventable maternal mortality and severe maternal morbidity, after delivery . (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 striking and sociocultural contexts, and inserting sociocultural (including among American Indians, Native Hawaiians, and Alaska Natives), and geographical contexts, . (c) Safe motherhood Section 317K of the Public Health Service Act ( 42 U.S.C. 247b–12 ) is amended— (1) in subsection (a)(2)(A), by inserting , including improving disaggregation of data (in a manner consistent with applicable State and Federal privacy laws) before the period; and (2) in subsection (b)(2)— (A) in subparagraph (L), by striking and at the end; (B) by redesignating subparagraph (M) as subparagraph (N); and (C) by inserting after subparagraph (L) the following: (M) an examination of the relationship between maternal health and obstetric services in rural areas and outcomes in delivery and postpartum care; and . (d) Office of Research on Women's Health Section 486(d)(4)(A)(iv) of the Public Health Service Act ( 42 U.S.C. 287d(d)(4)(A)(iv) ) is amended by inserting , including preventable maternal mortality and severe maternal morbidity before the semicolon. 3. 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 shall award grants or cooperative agreements to eligible entities to establish collaborative improvement and innovation networks (referred to in this section as rural obstetric networks ) to improve maternal and infant health outcomes and reduce preventable maternal mortality and severe maternal morbidity by improving maternity care and access to care in rural areas, frontier areas, maternity care health professional target areas, or jurisdictions of Indian Tribes and Tribal organizations. (b) Use of funds Grants or cooperative agreements awarded pursuant to this section shall be used for the establishment or continuation of collaborative improvement and innovation networks to improve maternal and infant health outcomes and reduce preventable maternal mortality and severe maternal morbidity by improving prenatal care, labor care, birthing, and postpartum care services in rural areas. Rural obstetric networks established in accordance with this section may— (1) develop a network to improve coordination and increase access to maternal health care and assist pregnant women in the areas described in subsection (a) with accessing and utilizing prenatal care, labor care, birthing, and postpartum care services to improve outcomes in birth and maternal mortality and morbidity; (2) identify and implement evidence-based and sustainable delivery models for providing prenatal care, labor care, birthing, and postpartum care services, including home visiting programs and culturally appropriate care models that reduce health disparities; (3) develop a model for maternal health care collaboration between health care settings to improve access to care in areas described in subsection (a), which may include the use of telehealth; (4) provide training for professionals in health care settings that do not have specialty maternity care; (5) collaborate with academic institutions that can provide regional expertise and help identify barriers to providing maternal health care, including strategies for addressing such barriers; and (6) assess and address disparities in infant and maternal health outcomes, including among racial and ethnic minority populations and underserved populations in such areas described in subsection (a). (c) Definitions In this section: (1) Eligible entities The term eligible entities means entities providing prenatal care, labor care, birthing, and postpartum care services in rural areas, frontier areas, or medically underserved areas, or to medically underserved populations or 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 Tribes; Tribal organization The terms Indian Tribe and Tribal organization have the meanings given the terms Indian tribe and tribal organization in section 4 of the Indian Self-Determination and Education Assistance Act. (4) Maternity care health professional target area The term maternity care health professional target area has the meaning described in section 332(k)(2). (d) Report to Congress Not later than September 30, 2025, the Secretary shall submit to Congress a report on activities supported by grants awarded under this section, including— (1) a description of activities conducted pursuant to paragraphs (1) through (6) of subsection (b); and (2) an analysis of the effects of rural obstetric networks on improving maternal and infant health outcomes. (e) Authorization of appropriations There are authorized to be appropriated to carry out this section $3,000,000 for each of fiscal years 2022 through 2026. . 4. 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)(3), by adding at the end the following: (M) Providers of prenatal, labor care, birthing, and postpartum care services, including hospitals that operate obstetric care units. ; and (2) in subsection (h)(1)(B), by striking or prenatal care for high-risk pregnancies and inserting prenatal care, labor care, birthing care, or postpartum care . 5. Rural maternal and obstetric care training demonstration Subpart 1 of part E of title VII of the Public Health Service Act ( 42 U.S.C. 294n et seq.) is amended by adding at the end the following: 764. Rural maternal and obstetric care training demonstration (a) In general The Secretary shall award grants to accredited schools of allopathic medicine, osteopathic medicine, and nursing, and other appropriate health professional training programs, to establish a training demonstration program to support— (1) training for physicians, medical residents, fellows, nurse practitioners, physician assistants, nurses, certified nurse midwives, relevant home visiting workforce professionals and paraprofessionals, or other professionals who meet relevant State training and licensing requirements, as applicable, to reduce preventable maternal mortality and severe maternal morbidity by improving prenatal care, labor care, birthing, and postpartum care in rural community-based settings; and (2) developing recommendations for such training programs. (b) 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. (c) Activities (1) Training for health care professionals A recipient of a grant under subsection (a)— (A) shall use the grant funds to plan, develop, and operate a training program to provide prenatal care, labor care, birthing, and postpartum 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 program requirements The recipient of a grant under subsection (a) shall ensure that training programs carried out under the grant are evidence-based and address improving prenatal care, labor care, birthing, and postpartum care in rural areas, and such programs may include training on topics such as— (A) maternal mental health, including perinatal depression and anxiety; (B) substance use disorders; (C) social determinants of health that affect individuals living in rural areas; and (D) improving the provision of prenatal care, labor care, birthing, and postpartum care for racial and ethnic minority populations, including with respect to perceptions and biases that may affect the approach to, and provision of, care. (d) Evaluation and report (1) Evaluation (A) In general The Secretary shall evaluate the outcomes of the demonstration program under this section. (B) Data submission Recipients of a grant under subsection (a) shall submit to the Secretary performance metrics and other related data in order to evaluate the program for the report described in paragraph (2). (2) Report to Congress Not later than January 1, 2025, the Secretary shall submit to Congress a report that includes— (A) an analysis of the effects of the demonstration program under this section on the quality, quantity, and distribution of maternal health care services, including prenatal care, labor care, birthing, 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 continued. (e) Authorization of appropriations There are authorized to be appropriated to carry out this section $5,000,000 for each of fiscal years 2022 through 2026. .

June 8, 2021 Reported with an amendment