Existing law establishes the State Department of Public Health and sets forth its powers and duties, as specified. Existing law requires the department to maintain a program of maternal, child, and adolescent health.

Existing law establishes the State Department of Public Health and sets forth its powers and duties, as specified. Existing law requires the department to maintain a program of maternal, child, and adolescent health.

This bill would require the department to prepare, prepare and submit to the Legislature, and post to the departments Internet Web site Legislature an annual report on maternal mortality and morbidity in California. The bill also would require the department to include in the report California, including an in-depth analysis of maternal deaths and pregnancy-related complications, and severe maternal morbidity. The bill would also require the department, in order to develop the most accurate reports, to support efforts of private-public collaboration to collect necessary data and complete the report. reports in a resource-efficient manner, to consider existing resources, including, among others, opportunities for partnerships with other entities and use of physician volunteers.

Existing law establishes the State Department of Public Health and sets forth its powers and duties, as specified. Existing law requires the department to maintain a program of maternal and child health. maternal, child, and adolescent health.

This bill would require the department to prepare and publish prepare, submit to the Legislature, and post to the departments Internet Web site an annual report on maternal mortality and morbidity in California. The bill also would require the department to include in the report an in-depth analysis of maternal deaths and pregnancy-related complications, and would require the department, in order to develop the most accurate reports, to support efforts of private-public collaboration to collect necessary data and complete the report.

Existing law establishes the State Department of Public Health and sets forth its powers and duties, as specified. Existing law requires the State Department of Public Health to develop a coordinated state strategy for addressing the health-related needs of women, including implementation of goals and objectives for womens health. department to maintain a program of maternal and child health.

Existing law establishes the State Department of Public Health and sets forth its powers and duties, as specified. Existing law requires the State Department of Public Health to develop a coordinated state strategy for addressing the health-related needs of women, including implementation of goals and objectives for womens health.

This bill would establish within the State Department of Public Health, the California Maternal Quality Care Collaborative. The bill would require the collaborative to establish a statewide system for purposes of collecting and maintaining data related to, among other things, pregnancy-related maternal deaths. The bill would require any hospital in this state that provides obstetrical services to provide to the department, on a monthly basis, information relating to maternal mortality, as specified.

ASSEMBLY THIRD READING

ATR Bill Id:AB 508

Author:(Cristina Garcia)

As Amended Ver:January 25, 2016

Majority vote

SUMMARY: Requires the California Department of Public Health (DPH) to prepare and publish an annual report regarding the frequencies of maternal mortality and severe maternal morbidity. Specifically, this bill:

1. Requires DPH to publish annual reports regarding all maternal deaths which includes a case review of each death and an analysis of patient demographics, contributing factors, and underlying causes.
2. Requires the report to also include an analysis of all cases of severe maternal morbidity, for which data collection is practicable, which includes analysis of patient demographics and underlying causes.
3. Requires DPH, in order to develop accurate reports in a cost efficient manner, to consider existing resources including opportunities for partnership with entities engaged in maternal care quality measurement or improvement.

EXISTING LAW: Establishes DPH to optimize the health and well-being of the people in California and authorizes DPH to study births, deaths, marriages, and divorces, in order to provide a continuing analysis of trends to state agencies and the Legislature.

FISCAL EFFECT: According to the Assembly Appropriations Committee:

1. In absence of another fund source, there would be General Fund (GF) costs to the Maternal, Child, and Adolescent Health (MCAH) division of DPH to complete the annual study, likely in hundreds of thousands of dollars annually. The robustness and cost of implementation would depend on administrative and legislative decisions about resource availability for this purpose.
2. DPH may also incur, on a one-time basis, some level of infrastructure capacity enhancement in order to process and store data. For example, new databases, automated processes or new computer hardware may be required. The level of one-time costs would increase commensurate with the complexity of the effort. Higher one-time costs — for example, to automate certain processes — could also potentially reduce ongoing personnel costs, depending on the approach chosen. Alternatively, costs may be avoided if existing resources could be leveraged — for example, if it was possible to partner with a nonprofit entity that currently has a data collection infrastructure.
3. Depending on the availability and approval of federal Title V funds for this purpose, federal funds could potentially be used instead of GF. Approximately $39 million in federal Title V funds are available to California annually. Funding decisions are based partially on a federally required needs assessment, and these monies currently fund other maternal, child, and adolescent health priorities, including $8 million for state operations and $31 million for local assistance annually.

COMMENTS: According to the author, Californians have given birth to more than 500,000 babies each year over the last two decades. The author notes the maternal death rate increased from 1999 to 2010, with substantially higher rates for African-American women, three to four times that of other groups. Although due to concerted efforts, California has been able to reverse the overall trend, unlike the rest of the United States where the numbers continue to escalate.

The author contends, through the data and reports that would be provided by this bill, significant practice variations that exist amongst the 260 obstetrical hospitals in California could be exposed. And, once exposed these variations and disparities could be eliminated by creating the tools for systemic change, such as quality improvement programs developed and implemented with demonstrated positive outcomes. The author also notes this bill will build on existing infrastructure and private-public partnerships, which are the likely cause of the dramatic improvement in California's maternal outcomes, while the situation for the rest of the United States continues to decline.

The author concludes, not only will these efforts save the lives and quality of life of many California women and their babies, but health care dollars spent directly by the state for Medi-Cal births (approximately half of the half million plus births annually are paid for by Medi-Cal) should be reduced by fewer complications.

According to a May 2015 MCAH bulletin, rates of maternal deaths in California have dropped to a low three-year moving average of 6.9 deaths per 100,000 live births in 2011-13. However racial and ethnic disparities persist. While mortality rates for African-American women are the lowest they have been since 1999, African-American women continue to have a three-to four-fold higher risk of maternal mortality compared to white women.

Analysis Prepared by: Lara Flynn / HEALTH / (916) 319-2097 FN: 0002575

Date of Hearing: January 21, 2016

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Jimmy Gomez, Chair

ABPCA Bill Id:AB 508

Author:(Cristina Garcia) – As Amended Ver:January 13, 2016

Urgency: No State Mandated Local Program: No Reimbursable: No

SUMMARY:

This bill requires the California Department of Public Health (CDPH) to annually publish a report on maternal mortality and morbidity, and specifies factors the department must analyze.

It also requires the department to support efforts of private-public collaboration to collect and analyze data and complete the report.

FISCAL EFFECT:

1. In absence of another fund source, there would be significant GF costs to the Maternal, Child, and Adolescent Health division of CDPH to complete this annual study, likely in the range of several hundred thousand dollars to the low millions annually. The low end of the range would assume use of publicly available data and a lower level of analytical depth, while the high end would assume significant costs for novel data collection and higher analytical complexity. The bill is fairly broad in its requirements, so the robustness and cost of implementation would depend on administrative and legislative decisions about resource availability for this purpose.
2. CDPH would also likely incur, on a one-time basis, some level of infrastructure capacity enhancement in order to process and store data. For example, new databases, automated processes or new computer hardware may be required. The level of one-time costs would increase commensurate with the complexity of the effort as described above. Higher one-time costs— for example, to automate certain processes— could also potentially reduce ongoing personnel costs, depending on the approach chosen.
3. Depending on the availability and approval of federal Title V funds for this purpose, federal funds could potentially be used instead of GF. Approximately $39 million in federal Title V funds are available to California annually. Funding decisions are based partially on a federally required needs assessment, and these monies currently fund other maternal, child, and adolescent health priorities, including $8 million for state operations and $31 million for local assistance annually.

COMMENTS:

1. Purpose. According to the author, although California's trends are among the best in the country, maternal mortality and morbidity remain unacceptably high. The author points to past successes in reducing maternal mortality by CDPH's attention to the issue, analysis of data, and collaborative problem-solving with the health care delivery system. The author believes the annual report required by this bill will assist the state to further reduce dangerous complications from pregnancy and childbirth.
2. Background. The CDPH administers the California Pregnancy-Associated Mortality Review (CA-PAMR) in collaboration with private sector efforts. CA-PAMR reviews information related to maternal deaths and translates findings into quality improvement projects.

The department regularly reports trends in maternal mortality, but no longer conducts case review of each maternal death. The most recent report notes a sustained decline in maternal mortality from 2008 until 2013, while national rates rose. The national rate is nearly three times California's rate, although health disparities persist in the state. Notably, African-American women in California are three to four times more likely to die from maternal causes than whites.

CDPH efforts appear to focus on mortality, not morbidity. According to the World Health Organization (WHO), maternal death (mortality) is defined as "the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by pregnancy or its management but not from accidental or incidental causes. "Pregnancy-related death" is also used in this field to indicate the same, but it refers to death while pregnant or within one year of the termination of pregnancy.

In addition to maternal mortality, this bill requires study of morbidity, including study of all instances of complications from pregnancy. Pregnancy-related complications and maternal morbidity are fairly broad terms. The WHO Maternal Morbidity Working Group defines maternal morbidity as "any health condition attributed to, and/or aggravated by, pregnancy and childbirth that has a negative impact on the woman’s wellbeing." The Center for Disease Control and Prevention (CDC) idenifies "severe maternal morbidity" through delivery hospitalization data and medical codes that indicate a potentially life-threatening maternal condition or complication. Severe postpartum hemorrhage is an example of severe maternal morbidity. The CDC lists the following as potential pregnancy complications: obesity and weight gain, high blood pressure, gestational diabetes, mental health conditions, anemia, and urinary tract infections.

1. Staff Comment. There is surely merit in analyzing various pregnancy complications and all types of maternal morbidity for their potential effects on women's health, but if the intent is to concentrate resources on the conditions with the greatest potential for harm or loss of life, the author may wish to consider narrowing the bill somewhat. For example, the bill could be narrowed to require study of severe maternal morbidity instead of maternal morbidity and pregnancy complications generally. Another alternative is to require study of factors contributing to pregnancy-related deaths as defined above, instead of all complications. Yet another option would be to require a baseline study that includes review of all complications, but require an annual or biennial study to focus on those complications with the greatest potential for severe health outcomes. Narrowing the bill could provide more direction to the department about what is most important to study, as well as reduce costs.

Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081

Date of Hearing: January 12, 2016

ASSEMBLY COMMITTEE ON HEALTH

Rob Bonta, Chair

ABPCA Bill Id:AB 508

Author:(Cristina Garcia) – As Amended Ver:January 4, 2016

SUBJECT: Public health: maternal care

SUMMARY: Requires the California Department of Public Health (DPH) to prepare and publish an annual report regarding the frequencies of maternal mortality and severe maternal morbidity. Specifically, this bill:

1. Requires DPH to publish annual reports regarding all maternal deaths and instances of complications related to pregnancy which includes all of the following:
   
   1. Patient demographics;
      
   2. Underlying causes;
      
   3. Contributing factors; and,
      
   4. Suggestions for improvements in care.
      
2. Requires DPH, in order to develop the most accurate reports, to support efforts of private-public collaboration to collect and analyze the necessary data and complete the report.

EXISTING LAW:

1. Establishes DPH to optimize the health and well-being of the people in California and authorizes DPH to study births, deaths, marriages, and divorces, in order to provide a continuing analysis of trends to state agencies and the Legislature.
   
2. Establishes the Office of Statewide Health Planning and Development (OSHPD) and requires each organization that operates, conducts, or maintains a health facility to make and file with OSHPD certain specified reports, including a hospital discharge abstract data record that currently includes 19 elements of data per admission that are required to be included.
   
3. Authorizes the release of OSHPD confidential patient data for research, public health, and healthcare operations to the federal Centers for Disease Control and Prevention (CDC) and the Agency for Healthcare Research and Quality and to California-licensed hospitals, local public health departments, and local public health officers.

FISCAL EFFECT: This bill has not yet been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, Californians have given birth to more than 500,000 babies each year over the last two decades. The author notes the maternal death rate increased from 1999 to 2010, with substantially higher rates for African-American women, three to four times that of other groups. Although due to concerted efforts, California has been able to reverse the overall trend, unlike the rest of the United States where the numbers continue to escalate.
   
   The author contends, through the data and reports that would be provided by this bill, significant practice variations that exist amongst the 260 obstetrical hospitals in California could be exposed. And, once exposed these variations and disparities could be eliminated by creating the tools for systemic change, such as quality improvement programs developed and implemented with demonstrated positive outcomes. The author also notes this bill will build on existing infrastructure and private-public partnerships, which are the likely cause of the dramatic improvement in California’s maternal outcomes, while the situation for the rest of the United States continues to decline.
   
   The author concludes, not only will these efforts save the lives and quality of life of many California women and their babies, but health care dollars spent directly by the state for Medi-Cal births (approximately half of the half million plus births annually are paid for by Medi-Cal) should be reduced by fewer complications.
2. BACKGROUND. In 2004, the Maternal, Child and Adolescent Health Division (MCAH) at DPH started the California Pregnancy-Associated Mortality Review (CA-PAMR) project to investigate the rise in maternal deaths. CA-PAMR identified maternal deaths using enhanced surveillance methodology and conducted in-depth reviews of the medical records with an expert panel of maternity care and public health professionals. The major goals of the project were to identify pregnancy-related deaths, causes and associated risks, and then recommend improvements in the quality of maternity care.
   
   To accomplish this CA-PAMR worked with the California Maternal Quality Care Collaborative (CMQCC), founded at Stanford University in 2006 with a mission to end preventable morbidity, mortality, and racial disparities in California maternity care and drive maternity quality improvement throughout the state. The CMQCC represents a partnership of more than 40 public and private agencies, programs, professional groups, health systems, and universities. Initial funding was provided by MCAH. DPH-MCAH contracted with CMQCC to run patient case review committee meetings and the Public Health Institute to obtain and summarize medical records.
   
   In 2011 CA-PAMR published a statewide report identifying cardiovascular disease, preeclampsia, and obstetric hemorrhage as the leading causes of pregnancy-related deaths, and CMQCC developed quality improvement toolkits, and sponsored learning collaboratives for the maternity care community to improve the recognition and response to obstetric hemorrhage and preeclampsia.
   
   DPH focused the review on the time period corresponding to the rise in maternal mortality (2002-07), but because since 2006 California has experienced an overall decrease in maternal deaths, DPH has not planned any additional meetings since the last in-person mortality case review meeting on November 7, 2014. DPH is still working in collaboration with the review committee and is planning to release another report in early 2016. DPH also plans to convene a case review committee again in late 2016 to review the 2002-07 pregnancy related deaths due to suicide, homicides, and drug overdose.
   
   According to a May 2015 MCAH bulletin, rates of maternal deaths in California have dropped to a low three-year moving average of 6.9 deaths per 100,000 live births in 2011-13. However racial and ethnic disparities persist. While mortality rates for African-American women are the lowest they have been since 1999, African-American women continue to have a three-to four-fold higher risk of maternal mortality compared to white women. Among the CA-PAMR report recommendations were to continue CA-PAMR committee reviews in order to thoroughly investigate the years with the greatest rise in maternal deaths (2005-06) and to explore methods for capturing data regarding social determinants of health that may contribute to maternal deaths.
   
   According to DPH they have access to most of the data that would be needed to develop the annual report required by this bill. DPH routinely collects data from vital statistics (birth and maternal and fetal death certificates), and coroner, autopsy, and toxicology reports. DPH also routinely obtains the OSHPD hospital discharge data set, however DPH is currently not obtaining full medical records for deceased women, although they have the authority to do so. However, DPH notes that there would likely be a one-to two-year lag in the report's production because of the timing of release of public datasets and that most likely, a report on deaths occurring in 2016 would be available for release in 2018.
3. SUPPORT. The American Congress of Obstetricians and Gynecologists, District IX (ACOG) is the sponsor of this bill and states it will enhance CMQCC’s ongoing efforts by requiring DPH to continually gather data to analyze and create continuous quality improvement programs. According to ACOG, during the very first maternal death review project of CMQCC they found that 40% of hospitals did not have a protocol in place for when a woman was hemorrhaging during or after birth, even though hemorrhage was the leading cause of maternal death. ACOG contends, by collaboratively putting best practices into place, hemorrhage now ranks third, a dramatic change due to determining and standardizing best practices. ACOG continues, once hemorrhages were reduced, CMQCC worked on reducing early elective deliveries, and then expanded their focus to include the next largest cause of maternal death and complication, preeclampsia. ACOG points to an April 14, 2015 article in the Obstetrics and Gynecology Green Journal reports that a good to strong chance that 41% of maternal deaths could be prevented. ACOG concludes that this bill keeps us on course to achieve this goal.
4. POLICY COMMENT. As noted in the background above, DPH contends there would likely be a one-to two-year lag in the production of the report’s required by this bill because of the timing of the release of public datasets and that most likely, a report on deaths occurring in 2016 would not be available for release until 2018. As this bill moves forward the author may want to work with DPH to coordinate the required timing of the reports' release with the availability of public datasets.
5. TECHNICAL AMENDMENT. Existing law requires that reports to the Legislature comply with specified requirements in the Government code. The Committee recommends including this provision in the bill as follows:

(c) A report submitted to the legislature pursuant to this section shall be submitted in compliance with Section 9795 of the Government code.

REGISTERED SUPPORT / OPPOSITION:

Support

American Congress of Obstetricians and Gynecologists, District IX (sponsor)
Unexpected Project

Opposition

None on file.

Analysis Prepared by: Lara Flynn / HEALTH / (916) 319-2097