Date of Hearing: June 25, 2019

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

SBPCA Bill Id:SB 464

Author:(Mitchell) – As Amended Ver:April 11, 2019

SENATE VOTE: 38-0

SUBJECT: California Dignity in Pregnancy and Childbirth Act.

SUMMARY: Enacts the California Dignity in Pregnancy and Childbirth Act which requires hospitals and alternative birth centers or primary care clinics that provide perinatal care to implement an implicit bias program for all health care providers involved in perinatal care of patients; requires the Department of Public Health (DPH) to track data on maternal death and severe morbidity; and, requires death certificates to indicate whether the decedent was pregnant within specific time periods of the death. Specifically, this bill:

Adds to the information each patient is to required to receive in writing, upon admission to a hospital, the following:
1. The patient’s right to be free of discrimination on the basis of race, color, religion, ancestry, national origin, disability, medical condition, genetic information, marital status, sex, gender, gender identity, gender expression, sexual orientation, citizenship, primary language, or immigration status; and,
2. Information on how to file a discrimination complaint with DPH, the Department of Fair Employment and Housing (DFEH); and, the Medical Board of California.
Requires a hospital, and alternative birth centers or primary care clinics that provide perinatal care, to implement an evidence-based implicit bias program for all health care providers involved in the perinatal care of patients within those facilities.
Requires an implicit bias program to include all of the following:
1. Identification of previous or current unconscious biases and misinformation;
2. Identification of personal, interpersonal, institutional, structural, and cultural barriers to inclusion;
3. Corrective measures to decrease implicit bias at the interpersonal and institutional levels, including ongoing policies and practices for that purpose;
4. Information on the effects, including, but not limited to, ongoing personal effects, of historical and contemporary exclusion and oppression of minority communities;
5. Information about cultural identity across racial or ethnic groups;
6. Information about communicating more effectively across identities, including racial, ethnic, religious, and gender identities;
7. Discussion on power dynamics and organizational decision-making;
8. Discussion on health inequities within the perinatal care field, including information on how implicit bias impacts maternal and infant health outcomes;
9. Perspectives of diverse, local constituency groups and experts on particular racial, identity, cultural, and provider-community relations issues in the community; and,
10. Information on reproductive justice.
Requires a health care provider described in 2) above to complete initial basic training through the implicit bias program based on the components described in 3) above, and, to complete a refresher course under the implicit bias program every two years, or more frequently if deemed necessary by the facility, in order to keep current with changing racial, identity, and cultural trends and best practices in decreasing interpersonal and institutional implicit bias.
Requires DPH to track data on maternal death and severe morbidity, including, but not limited to, all of the following health conditions:
1. Obstetric hemorrhage;
2. Hypertension;
3. Preeclampsia and eclampsia;
4. Venous thromboembolism;
5. Sepsis;
6. Cerebrovascular accident;
7. Amniotic fluid embolism;
8. Other indirect obstetric complications; and,
9. Other complications pertaining to the pregnancy and puerperium period.
Requires the data on maternal severe morbidity described in 5) above to be published after all of the following have occurred:
1. The data has been risk-adjusted pursuant to a valid methodology;
2. The data has been aggregated by state regions with populations of 100,000 to 200,000, inclusive; and,
3. The data has been disaggregated by racial and ethnic identity.
Requires the data on maternal deaths collected pursuant to subdivision 5) above to be published after all of the following have occurred:
1. The data have been aggregated by state regions with populations of 100,000 to 200,000, inclusive; and,
2. The data have been disaggregated by racial and ethnic identity.
Adds information as to whether the decedent was pregnant within 42 days of death, or within 43 to 365 days of death, to the medical and health data included on a death certificate.
Defines the following terms:
1. “Pregnancy-related death” means the death of a person while pregnant or within 365 days of the end of a pregnancy, irrespective of the duration or site of the pregnancy, from any cause related to, or aggravated by, the pregnancy or its management, but not from accidental or incidental causes.
2. “Implicit bias” means a bias in judgment or behavior that results from subtle cognitive processes, including implicit prejudice and implicit stereotypes that often operate at a level below conscious awareness and without intentional control.
3. “Implicit prejudice” means prejudicial negative feelings or beliefs about a group that a person holds without being aware of them.
4. “Implicit stereotypes” are the unconscious attributions of particular qualities to a member of a certain social group. Implicit stereotypes are influenced by experience and are based on learned associations between various qualities and social categories, including race or gender.
5. “Perinatal care” is the provision of care during pregnancy, labor, delivery, and postpartum and neonatal periods.
Finds and declares that every person should be entitled to dignity and respect during and after pregnancy and childbirth; that the United States has the highest maternal mortality rate in the developed world; that in California, since 2006, the rate of maternal death has decreased 55%, however, for women of color, particularly Black women, the maternal mortality rate remains three to four times higher than White women. States that implicit bias is a key cause that drives health disparities in communities of color, and it is the intent of the Legislature to reduce the effect of implicit bias in pregnancy, childbirth and postnatal care so that all people are treated with dignity and respect by their health care providers.

EXISTING LAW:

Establishes DPH and sets forth its powers and duties, including, but not limited to, licensing and regulating health facilities, including hospitals and clinics providing alternative birth center services, and serving as State Registrar relating to vital records and health statistics.
Defines an “alternative birth center” as a clinic that is not part of a hospital that provides comprehensive perinatal services and delivery care to pregnant women who remain less than 24 hours at the facility. Requires alternative birth centers to meet certain requirements of licensure.
Requires hospitals to provide each patient, upon admission, written information regarding the patient’s rights, including the right to participate actively in decisions regarding medical care, and the right to have a friend or family member be provided information about the patients’ continuing health care requirements following discharge.
Requires hospitals to report adverse events to DPH, including maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a facility, including events that occur within 42 days post-delivery.
Requires DPH to implement an internet-based electronic death registration system (the California Electronic Death Registration System, or CA-EDRS) for the creation, storage, and transfer of death registration information. Requires CA-EDRS to protect the proper use of the death registration information created, stored, and transferred within the system.
Requires a certificate of death to contain certain specified information, including any disease or conditions leading directly to death and antecedent causes, as well as information indicating whether the decedent was pregnant at the time of death, or within the year prior to the death, if known, as determined by observation, autopsy, or review of the medical record.

FISCAL EFFECT: According to the Senate Appropriations Committee:

According to DPH: $515,788 (General Fund {GF}) one-time costs in Fiscal Year 2020-21 for 4.0 positions, and $348,000 (GF), in FY 2021-22 and ongoing, for 2.0 Research Scientist III to track and publish data. Overall, costs are to modify the existing vital records systems to store death certificate images, generate copies for issuance, and ongoing administrative funding for positions to track and publish data.
Staff notes unknown, potentially significant ongoing costs (hundreds of thousands GF to low millions GF), for DFEH to investigate additional workload and process complaints. The wide range depends on the unknown number of complaints to be received. According to the DFEH’s 2017 Annual Report, 736 were complaints filed under the Unruh Civil Rights Act. The average cost of an investigative complaint is approximately $5,000 (GF). If there were to be a ten percent increase in total number complaints, the cost to investigate those claims would be around $368,000 (GF).
Staff notes unknown, ongoing costs for the Department of Consumer Affair’s Health Quality Investigation Unit to investigate a discrimination complaint, and if sufficient evidence was found, for the Attorney General’s Office to file a complaint. According to data from the Medical Board of California, from July 1, 2013, to March 26, 2019, there were 145 complaints received with the allegation of “Discrimination – Refused to Treat Patient.”

COMMENTS:

PURPOSE OF THIS BILL. According to the author, the United States is the most dangerous place for a woman to give birth in the industrialized world, and for Black women, the threat of death is three to four times higher. Over the last 20 years, California has led the charge in reducing our maternal mortality and morbidity rate, making us the only state to buck the trend of the rising numbers of pregnancy-related deaths. However, like the rest of the country, California has yet to close the gap in disparities between Black women and the state's average. The author points out that in the county of Los Angeles, between 2004 and 2015, the rate of maternal death for Black women was 65.1 per 100,000 compared to White women as 14.4 per 100,000. Many will point to socioeconomic factors to explain the disproportionate rate of death; however, when controlled for this, the disparities for Black women still exist. There is a growing body of research that shows implicit bias is a major factor in the racial disparities seen in this country and here in this state. However, there are no requirements for perinatal health providers to take any implicit bias training. California has a responsibility to ensure that all her residences can have safe and dignified pregnancy and childbirth. By preparing perinatal medical providers to better care for mothers in some of the most vulnerable moments in their lives, this bill will preserve lives so that childbirth remains a joyful moment for all mothers, and not a life-threatening event for Black mothers.
BACKGROUND.
1. Disparities in maternal morbidity and mortality. Since 1999, the reported maternal mortality data in California shows a persistent three- or four-fold gap between Black mothers and mothers from all other racial groups. According to the California Birth Equity Collaborative (CBEC), an initiative at Stanford University’s California Maternal Quality of Care Collaborative (CMQCC), maternal mortality rates nearly doubled in California between 1999 and 2006. Since CMQCC was founded in 2006, California’s maternal mortality rate has declined by 55% while the national maternal mortality rate has continued to rise. CMQCC developed evidence-based quality improvement toolkits for the leading causes of preventable death and complications for mothers and infants, including toolkits on: Cardiovascular Disease, Early Elective Delivery, Hemorrhage, Maternal Venous Thromboembolism, Preeclampsia, and Supporting Vaginal Birth and Reducing Primary Cesareans. To help California hospitals implement the evidence-based care presented in the toolkits, CMQCC launched large-scale outreach collaboratives. Statewide collaboratives for hemorrhage and preeclampsia were launched individually and then a second time together in 2013 to help hospitals implement both obstetric hemorrhage and preeclampsia patient safety bundles. Maternal morbidity was reduced by 20.8% between 2014 and 2016 among the 126 hospitals participating in the California Partnership for Maternal Safety, the joint hemorrhage and preeclampsia collaborative.
  
  The expectation was that widespread adoption of CMQCC’s clinical safety bundles would reduce the gap in the number of maternal deaths among black women. However, the difference in outcomes for black mothers has persisted.

Data shows that even in the absence of risk factors such as age over 35 years, lack of health insurance, inadequate or no prenatal care, and less than high school education, the U.S. system of health care is not protecting Black mothers. According to CBEC, increasing evidence points to racism within and across multiple levels, and not race, as a key cause of these birth disparities. Data also show variations in the quality of care and outcomes across hospitals in California highlighting opportunities for advancing equity in quality improvement.

In February of 2017, the American Congress of Obstetricians and Gynecologists released a statement of Policy on Racial Bias, which notes, “The racial and ethnic disparities in women’s health (including higher rates of preterm birth, maternal mortality, and breast, cervical, and endometrial cancer deaths among Black women) cannot be reversed without addressing racial bias, both implicit and explicit. We recognize that structural and institutional racism contribute to and exacerbate these biases, which further marginalize women of color in the health care system. Without acknowledging the historical context from which these disparities grew, and examining these disparities through a lens that takes into account race, gender, and class, an equitable health care system that serves all women cannot be realized.”

1. California Pregnancy-Associated Mortality Review (CA-PAMR) and DPH maternal morbidity and mortality reporting. CA-PAMR is a comprehensive statewide maternal mortality examination that aims to identify pregnancy-related deaths during pregnancy or within one year of the end of pregnancy, their causes, factors that contributed to the death, and improvement opportunities in maternity care and support, with the ultimate goal of reducing preventable deaths and associated health disparities. CA-PAMR is a collaborative effort between DPH’s Division of Maternal, Child and Adolescent Health, CMQCC, and the Public Health Institute. Funding comes from the federal Title V Maternal Child Health Block Grant. In a review of maternal deaths from 2002-2007, CA-PAMR found that:
  1. Forty-one percent of pregnancy-related obstetric deaths had a good-to-strong chance of preventability;
  2. Cardiovascular disease is the leading cause of pregnancy-related death;
  3. Racial and ethnic disparities persist, with African-American women continuing to experience higher risk of a pregnancy-related death;
  4. Multiple patient, facility, and health care provider factors contributed to pregnancy-related deaths; and,
  5. Case reviews informed public health prevention programs and led to the development of maternity care quality improvement strategies, known as California Toolkits to Transform Maternity Care.

1. CA-EDRS. In 2015, the California State Registrar (SR), with DPH convened a workgroup to review the contents of the California’s Birth, Death, and Fetal Death certificates and consider proposed changes to data elements collected on those certificates. The Certificate Review Workgroup (CRW) was tasked with comparing California’s Birth, Death, and Fetal Death certificates with the U.S. Standard certificates.

CRW members had extensive experience using vital events data for public health surveillance, health outcomes research, demographic analysis, and program evaluation. Recommendations from the CRW were presented to the Vital Statistics Advisory Committee (VSAC) for consideration and those proposed changes were then referred to the SR for a decision. Both the CRW and VSAC concurred that the death certificate should capture pregnancy status consistent with the U.S. Standard Death Certificate.

Currently, the U.S. Standard Death Certificate collects additional data fields, not included in the current CA-EDRS, regarding pregnancy status that includes the following data:

- 1. Not pregnant within past year;
  2. Pregnant at time of death;
  3. Not pregnant, but pregnant within 42 days of death;
  4. Not pregnant, but pregnant within 43 days and 1 year before death; and,
  5. Unknown if pregnant within the last year.

The current California Death Certificate form only collects data if the decedent was pregnant in the last year with check boxes for yes, no, or unknown. DPH is in the process of modifying CA-EDRS to electronically capture the needed data elements. This additional data capture within CA-EDRS regarding pregnancy status will be consistent with the data elements on the U.S. Standard Death Certificate, and will require no change in the face of the California Death Certificate. This system change is already in development and is expected to be deployed in early 2020.

1. California Perinatal Equity Initiative (PEI). AB 1810, Committee on Budget, Chapter 34, Statutes of 2018, established the PEI at DPH, and appropriated $8 million from the GF, to expand the scope of interventions provided under the Black Infant Health Program (BIH). The PEI is intended to foster Community Centers of Excellence in perinatal health and promote the use of interventions designed to fill gaps in current programming offered through BIH. Under the PEI, DPH is required to allocate funds to up to 15 county health departments, to work collaboratively with state and local BIH programs, for the purposes of improving Black infant birth outcomes and reducing infant mortality. The county health departments are required to use the funds to develop local Community Centers of Excellence at hospitals, federal qualified health centers, clinics, or community-based organizations that have demonstrated capacity to work with public health and health care systems as well as within the Black community.
2. DFEH. DFEH is the state agency that enforces California’s civil rights laws protections from unlawful discrimination in employment, housing and public accommodations, and from hate violence and human trafficking. DFEH receives, investigates, conciliates, mediates, and prosecutes complaints of alleged violations of the Fair Employment and Housing Act (FEHA), Unruh Civil Rights Act, Disabled Persons Act, Ralph Civil Rights Act, Trafficking Victims Protection Act, and statutes prohibiting discrimination in state-funded activities and programs. The Unruh Civil Rights Act prohibits business establishments, including hospitals, in California from discriminating in the provision of services, accommodations, advantages, facilities and privileges to clients, patrons and customers because of their sex, race, color, religion, ancestry, national origin, disability, medical condition, genetic information, marital status, sexual orientation, primary language, citizenship or immigration status.
3. Implicit bias training. According to the University of San Francisco’s (UCSF) Office of Outreach and Diversity, bias is a prejudice in favor of or against one thing, person, or group compared with another usually in a way that is considered to be unfair. Biases may be held by an individual, group, or institution and can have negative or positive consequences. There are types of biases: Conscious bias (also known as explicit bias) and

Unconscious bias (also known as implicit bias). Biases, conscious or unconscious, are not limited to ethnicity and race. Though racial bias and discrimination are well documented, biases may exist toward any social group. Age, gender, gender identity, physical abilities, religion, sexual orientation, weight, and many other characteristics are subject to bias. Unconscious, or implicit biases are social stereotypes about certain groups of people that individuals form outside their own conscious awareness. Unconscious bias is far more prevalent than conscious prejudice and often incompatible with one’s conscious values.

UCSF currently provides implicit bias training for faculty, staff, and students. UCSF notes that implicit bias training must be done in person, is best done in a group setting, and be interactive. UCSF contracts with People of Color, mostly Black, led organizations to design and run the trainings. The chart below shows pre- and post-training session data collected from participants in the racism and equity training sessions, in response to the following question: Do you feel confident in identifying issues of racism and equity for your patients?

Since 1997, more than 30 studies have been published relevant to unconscious bias and clinical decision-making. Racial bias is prevalent among healthcare providers and it appears that race influences medical decision making of healthcare providers.

SUPPORT. ACT for Women and Girls, Black Women for Wellness, the California Nurse Midwives Association, NARAL Pro Choice California, and the Western Center on Law & Poverty are the cosponsors of this bill. The cosponsors state that this bill, the Dignity in Pregnancy and Childbirth Act, addresses the alarming disparities in maternal health by requiring all medical providers involved in perinatal services at hospitals and alternative birth centers to undergo evidence-based implicit bias training. The cosponsors note that in the U.S., 700 women die each year from childbirth, and another 50,000 suffer from severe complications, making the U.S. the nation with the highest maternal mortality rate in the developed world. In California, while the rate of maternal mortality has decreased 55% since 2006, women of color, and particularly Black women, continue to suffer a maternal mortality rate three to four times higher than white women. Although Black women make up only 5% of the birth cohort in California, they comprise 21% of the pregnancy-related deaths. Socioeconomic status, access to prenatal care, education level, and general physical health do not explain the disparity seen in Black women’s maternal mortality and morbidity rate. Rather, evidence points to implicit bias as one of the causes for these wide disparities. In fact, a 2016 study by University of Virginia researchers found that white medical students believed biological myths about racial differences in patients, including that Black patients have less sensitive nerve endings, are able to tolerate more pain, and have thicker skin than their white counterparts.
OPPOSE UNLESS AMENDED. The California Medical Association (CMA) is opposed to this bill unless physicians are amended out of the provisions. CMA states that the training requirement established in the bill would not be an appropriate or enforceable mechanism for training physicians. CMA notes that they worked with Assemblymember Kamlager-Dove on AB 241(see 5) below) to ensure that physicians are appropriately trained through existing evidence-based continuing medical education requirements.
RELATED LEGISLATION. AB 241 (Kamlager-Dove) requires, on and after January 1, 2022, all continuing medical education courses, all continuing education for registered nurses, and all continuing education for physician assistants, to contain curriculum that includes the understanding of implicit bias and the promotion of bias-reducing strategies to address how unintended biases in decision-making may contribute to health care disparities by shaping behavior and producing differences in medical treatment along lines of race, ethnicity, gender identity, sexual orientation, socioeconomic status, or other characteristics. AB 241 is pending in the Senate Committee on Business and Professions.
AMENDMENTS. The author is proposing the following amendments to this bill:
1. In order to allow health care providers who work in more than one facility to satisfy the training requirements without duplicative training sessions, to require health care facilities to provide a certificate of training completion upon request, and to authorize a hospital to accept a certificate of completion from another facility.
2. To require facilities, when a physician is not directly employed by the facility, to offer the training to the physician.
3. In order to protect patient privacy, to aggregate the data on severe maternal morbidity by perinatal regions as defined by the Regional Perinatal Programs at DPH, and to aggregate the data on pregnancy-related deaths based upon standard statistical methods for addressing data reliability and disclosure risk.
4. Other minor and technical clarifying amendments.

REGISTERED SUPPORT / OPPOSITION:

Support

ACT for Women and Girls (cosponsor)
Black Women for Wellness (cosponsor)
California Nurse Midwives Association (cosponsor)
NARAL Pro Choice California (cosponsor)
Western Center on Law & Poverty (cosponsor)
Asian Americans Advancing Justice - Los Angeles
BreastfeedLA
California Commission on the Status of Women and Girls
California Hospital Association
California Latinas for Reproductive Justice
California Legislative Women's Caucus
California Pan-Ethnic Health Network
Child Care Law Center
Children and Families Commission of Los Angeles County
Children's Defense Fund-California
Coalition of California Welfare Rights Organizations
Consumer Watchdog
County Health Executives Association of California
County of Los Angeles Board of Supervisors
Courage Campaign
Fields Family Counseling Services
First 5 La
Friends Committee on Legislation of California
Having Our Say Coalition
Health Access California
If/When/How: Lawyering For Reproductive Justice
In Our Own Voice: National Black Women's Reproductive Justice Agenda
Legal Services For Prisoners With Children
Los Angeles Black Worker Center
Los Angeles City Council Office of Marqueece Harris-Dawson
March of Dimes
Momsrising
National Association of Social Workers, California Chapter
National Council of Jewish Women, California
National Council of Jewish Women Los Angeles
National Health Law Program
New Voices for Reproductive Justice
San Francisco Board of Supervisors
The Children's Clinic, Serving Children & Their Families
The Coalition of Orange County Community Health Centers
The Praxis Project
The Women's Foundation Of California
Therapeutic Play Foundation

Opposition

None on file

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

SB 464: California Dignity in Pregnancy and Childbirth Act.

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