Existing law finds and declares that postpartum care, among other things, is an essential service necessary to ensure maternal health. Existing law establishes the State Department of Health Care Services, and requires the department to, among other things, maintain programs relating to maternal health.

This bill would, commencing January 1, 2026, until January 1, 2029, authorize San Diego County to establish a pilot program for pelvic floor and core conditioning group classes that would be provided to people twice a week between their 6 to 12 week postpartum window to help people rebuild their pelvic floor after pregnancy. The bill would require the program to record specified information to directly assess pelvic floor changes.

This bill would make legislative findings and declarations as to the necessity of a special statute for San Diego County.

Existing law finds and declares that postpartum care, among other things, is an essential service necessary to ensure maternal health. Existing law establishes the State Department of Health Care Services, and requires the department to, among other things, maintain programs relating to maternal health.

This bill would, commencing January 1, 2026, until January 1, 2029, authorize San Diego County to establish a pilot program for pelvic floor and core conditioning group classes that would be provided to people twice a week between their 6 to 12 week postpartum window to help people rebuild their pelvic floor after pregnancy. The bill would require the program to record specified information to directly assess pelvic floor changes.

This bill would make legislative findings and declarations as to the necessity of a special statute for San Diego County.

Existing law finds and declares that postpartum care, among other things, is an essential service necessary to ensure maternal health. Existing law establishes the State Department of Health Care Services, and requires the department to, among other things, maintain programs relating to maternal health.

This bill would, commencing January 1, 2026, until January 1, 2029, authorize the County of San Diego San Diego County to establish a pilot program for pelvic floor and core conditioning group classes that would be provided to people twice a week between their 6 to 12 week postpartum window to help people rebuild their pelvic floor after pregnancy. The bill would require the program to record specified information to directly assess pelvic floor changes.

This bill would make legislative findings and declarations as to the necessity of a special statute for the County of San Diego. San Diego County.

Existing law finds and declares that postpartum care, among other things, is an essential service necessary to ensure maternal health. Existing law establishes the State Department of Health Care Services, and requires the department to, among other things, maintain programs relating to maternal health.

This bill would, commencing January 1, 2026, until January 1, 2029, authorize the County of San Diego to establish a pilot program for pelvic floor and core conditioning group classes that would be provided to people twice a week between their 6 to 12 week postpartum window to help people rebuild their pelvic floor after pregnancy. The bill would require the program to record specified information to directly assess pelvic floor changes, and would require the program to annually report all the information and outcomes to the department. The bill would require the department to provide a final report on the program to the Legislature by June 1, 2029. changes.

This bill would make legislative findings and declarations as to the necessity of a special statute for the County of San Diego.

Existing law finds and declares that postpartum care, among other things, is an essential service necessary to ensure maternal health. Existing law establishes the State Department of Health Care Services, and requires the department to, among other things, maintain programs relating to maternal health.

This bill would, commencing January 1, 2026, until January 1, 2029, authorize the County of San Diego to establish a pilot program for pelvic floor and core conditioning group classes that would be provided to people twice a week between their 6 to 12 week postpartum window to help people rebuild their pelvic floor after pregnancy. The bill would require the program to record specified information to directly assess pelvic floor changes, and would require the program to annually report all the information and outcomes to the department. The bill would require the department to provide a final report on the program to the Legislature by June 1, 2029.

Existing law finds and declares that postpartum care, among other things, is an essential service necessary to ensure maternal health. Existing law establishes the State Department of Health Care Services, and requires the department to, among other things, maintain programs relating to maternal health.

This bill would, commencing January 1, 2026, until January 1, 2029, authorize the County of San Diego to establish a pilot program for pelvic floor and core conditioning group classes that would be provided to people twice a week between their 6 to 12 week postpartum window to help people rebuild their pelvic floor after pregnancy. The bill would require the program to record specified information to directly assess pelvic floor changes, and would require the program to annually report all the information and outcomes to the department. The bill would require the department to provide a final report on the program to the Legislature by June 1, 2029.

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 2756

Author:(Boerner)

As Amended Ver:June 12, 2024

Majority vote

SUMMARY

Authorizes the County of San Diego, commencing January 1, 2026, until January 1, 2029, to establish a pilot program for pelvic floor and core conditioning group classes that would be provided to people twice a week between their six-to-12-week postpartum window.

Senate Amendments

Are technical and clarifying.

COMMENTS

According to the California Health Benefits Review Program, pelvic floor physical therapy, also referred to as pelvic floor muscle training, refers to a set of modalities that are used to prevent and treat pelvic floor dysfunction (PFD). Symptoms of PFD include urinary incontinence, fecal incontinence, pelvic organ prolapse, and pelvic pain. Primary risk factors for PFD include childbirth, which increases with number of births, and aging (menopause).

Pelvic Floor Physical Therapy Provider Certifications. Pelvic floor physical therapy (used to treat symptoms of incontinence, pelvic organ prolapse, and sexual dysfunction) teaches correct contractions, muscle and body awareness, coordination and motor control, muscle strength and endurance, and relaxation. This bill does not define which providers would be authorized to provide pelvic floor physical therapy. Although licensed health providers (physical therapists, medical doctors, doctors of osteopathic medicine, nurse practitioners, etc.) are not required to have particular training to offer these types of therapies, those without specific training do not regularly offer pelvic floor physical therapy; pelvic floor physical therapy is usually provided by physical therapists with specialized pelvic floor physical therapy training. The Academy of Pelvic Health Physical Therapy (APTA Pelvic Health) offers a Certificate of Achievement in Pelvic Health or Obstetric Physical Therapy. Licensed physical therapists who complete required coursework through APTA Pelvic Health and a case reflection within a year of completing coursework are eligible to apply for these certifications. The American Board of Physical Therapy Services offers a Specialist Certification in Women's Health, which requires licensed physical therapists to complete an exam, along with patient care requirements, to receive certification. The Herman & Wallace Pelvic Rehabilitation Institute also offers specialized training for physical therapists.

Disparities and Social Determinants of Health in Pelvic Floor Disorders. Disparities exist in prevalence of pelvic floor disorders. For example, one study demonstrated an increasing prevalence of pelvic floor disorders as cohorts aged, with about 50% of women over age 80 years experiencing at least one disorder. Other studies presented evidence of racial/ethnic disparities in stress urinary incontinence and urge urinary incontinence. Asian American women appear to have the lowest risk of urinary incontinence overall as compared with white and Hispanic women. Several studies showed that black women had highest rates of urge urinary incontinence while white women had three times the risk of stress urinary incontinence as black women and two times the risk of Asian American women. Finally, Hispanic women appear to have significantly elevated risk of pelvic organ prolapse as compared with white women.

According to the Author

One in three people who have given birth will experience a pelvic floor disorder in their lifetime. In the media, we have heard of Brittany Mahomes, wife of Kansas City Chiefs Quarterback Patrick Mahomes, who most recently fractured her back because of her weak pelvic floor. This is just one story being highlighted in the media when there are women every day dealing with functional problems that could have been avoided with preventative postpartum pelvic floor care. If we support new parents before they give birth, we should support them through their healing journey. The author concludes that this bill creates a pilot program in the County of San Diego for preventative postpartum pelvic floor and core conditioning group classes to avoid long-term issues with pelvic floor disorders.

Arguments in Support

Maternal and Child Health Access (MCHA) writes in support this bill which would, subject to state funding, authorize a three-year pilot program for group class exercises to help people rebuild their pelvic floor after pregnancy. MCHA notes that the Department of Health Care Services would report on the data from the pilot by June 1, 2029. Ideally, data from the pilot would be used to: 1) establish protocols for addressing postpartum pelvic floor issues without the need for surgical intervention; and 2) expand insurance coverage to include pelvic floor and core conditioning exercises as needed postpartum. MCHA notes that according to research published in January 2024 in the Journal of Obstetrics & Gynecology, pelvic floor disorders after childbirth have distressing lifelong consequences for women, requiring more than 300,000 women to have surgery annually. This represents approximately 10% of the 3 million women who give birth vaginally each year. Vaginal birth is the largest modifiable risk factor for prolapse, the pelvic floor disorder most strongly associated with birth, and is an important contributor to stress.

Arguments in Opposition

There is no known opposition to this bill.

FISCAL COMMENTS

None.

VOTES:

ASM HEALTH: 16-0-0

YES: Bonta, Waldron, Aguiar-Curry, Arambula, Wendy Carrillo, Flora, Haney, Jones-Sawyer, Maienschein, McCarty, Joe Patterson, Rodriguez, Sanchez, Santiago, Schiavo, Weber

ASM APPROPRIATIONS: 11-0-4

YES: Wicks, Arambula, Bryan, Calderon, Wendy Carrillo, Mike Fong, Grayson, Haney, Hart, Pellerin, Villapudua

ABS, ABST OR NV: Sanchez, Dixon, Jim Patterson, Ta

ASSEMBLY FLOOR: 73-0-7

YES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Chen, Connolly, Davies, Dixon, Flora, Mike Fong, Vince Fong, Friedman, Gabriel, Gallagher, Garcia, Gipson, Grayson, Haney, Hart, Hoover, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Papan, Jim Patterson, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Rendon, Reyes, Rodriguez, Sanchez, Santiago, Schiavo, Soria, Ta, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Robert Rivas

ABS, ABST OR NV: Cervantes, Megan Dahle, Essayli, Holden, Mathis, Luz Rivas, Blanca Rubio

SENATE FLOOR: 39-0-1

YES: Allen, Alvarado-Gil, Archuleta, Ashby, Atkins, Becker, Blakespear, Bradford, Caballero, Cortese, Dahle, Dodd, Durazo, Eggman, Glazer, Gonzalez, Grove, Hurtado, Jones, Laird, Limón, McGuire, Menjivar, Min, Newman, Nguyen, Niello, Ochoa Bogh, Padilla, Portantino, Roth, Rubio, Seyarto, Skinner, Smallwood-Cuevas, Stern, Umberg, Wahab, Wiener

ABS, ABST OR NV: Wilk

UPDATED

VERSION: June 12, 2024

CONSULTANT: Lara Flynn / HEALTH / (916) 319-2097 FN: 0003685

 CONSENT  

Bill No: AB 2756

Author: Boerner (D)

Amended: 6/12/24 in Senate

Vote: 21

SENATE HEALTH COMMITTEE: 11-0, 6/26/24

AYES: Roth, Nguyen, Glazer, Gonzalez, Grove, Hurtado, Limón, Menjivar, Rubio, Smallwood-Cuevas, Wiener

ASSEMBLY FLOOR: 73-0, 5/23/24 - See last page for vote

SUBJECT: Pelvic Floor and Core Conditioning Pilot Program

SOURCE: Author

DIGEST:

This bill permits the County of San Diego to establish a pilot program for pelvic floor and core conditioning group classes between January 1, 2026 and January 1, 2029.

ANALYSIS:

Existing law requires the California Department of Public Health to maintain a program of maternal and child health; establishes the Medi-Cal program to provide health care coverage to certain low-income persons, including coverage for maternal health (including any necessary maternal physical assessments); and, requires commercial health insurance coverage for “basic health care services,” including preventive health services. [Health and Safety Code (HSC) §123225, Welfare and Institutions Code (WIC) §14132, HSC §1367.005, and Insurance Code (INS) §10112.27]

This bill:

1. Permits the County of San Diego to establish a pilot program for pelvic floor and core conditioning group classes between January 1, 2026 and January 1, 2029.
2. Requires the classes to be a combination of yoga and pilates exercises that strengthen the pelvic floor muscles, and to be provided to people twice a week between their six-to-12-week postpartum window to help people rebuild their pelvic floor after pregnancy. Requires the pilot program to require all postpartum providers who teach the classes to be certified.
3. Requires the pilot program to record the following information to directly assess pelvic floor changes, including, but not limited to: the number of incontinent episodes per week before and after the exercises; and, any changes with varied increases or decreases in intraabdominal pressure, including leaking with a jump, cough, or sneeze.

Comments

1. Author’s statement. According to the author, one in three people who have given birth will experience a pelvic floor disorder in their lifetime. In the media, we have heard of Brittany Mahomes, wife of Kansas City Chief’s Quarterback Patrick Mahomes, who most recently fractured her back because of her weak pelvic floor. This is just one story being highlighted in the media when there are people every day dealing with functional problems that could have been avoided with preventative postpartum pelvic floor care. If we support new parents before they give birth, we should support them through their healing journey. This bill creates a pilot program in the County of San Diego for preventative postpartum pelvic floor and core conditioning group classes to avoid long-term issues with pelvic floor disorders.
2. Background. According to the California Health Benefits Review Program (CHBRP) pelvic floor physical therapy, also referred to as pelvic floor muscle training (PFMT) refers to a set of modalities that are used to prevent and treat pelvic floor dysfunction (PFD). Symptoms of PFD include urinary incontinence, fecal incontinence, pelvic organ prolapse, and pelvic pain. Primary risk factors for PFD include childbirth, which increases with number of births, and aging (menopause). This bill would authorize the County of San Diego to implement a Pelvic Floor and Core Conditioning Pilot Program, similar to an existing program at Scripps Health, which offers pelvic floor and core conditioning group exercise classes as a voluntary option for patients experiencing issues with their pelvic floor muscles. As part of its analysis of a previous bill [AB 1904 (Boerner of 2020), which would have required all state-regulated health insurance to cover pelvic floor physical therapy after pregnancy], CHBRP found:
   1. There is inconclusive evidence that PFMT is effective at treating urinary incontinence in postpartum women (0–12 months after delivery);
   2. There is a preponderance of evidence that PFMT is effective at treating urinary incontinence in non-postpartum women;
   3. There is limited evidence that PFMT is not effective at treating fecal incontinence in women;
   4. There is limited evidence that PFMT is effective at treating pelvic organ prolapse; and,
   5. There is insufficient evidence as to whether PFMT is effective at treating pelvic pain in postpartum women.
3. Knowledge around pelvic floor disorders. According to CHBRP, most women do not seek medical treatment despite high rates of pelvic floor disorders, although this pattern is more frequent among women of color than white women. Reasons for not seeking treatment include: embarrassment; urinary incontinence assumed to be a normal part of postpartum status or aging; and, poor understanding of pelvic floor dysfunction/disorders and treatment options. According to a 2015 study, women of color were significantly less likely than white women to know that childbirth was a cause of urinary incontinence and that exercises can help control leakage. Women of color were also less likely than white women to know that pelvic organ prolapse can occur at any age, and to know that treatment options are available, including exercises that can be done to prevent progression. There is conflicting evidence in identifying potential socioeconomic barriers for accessing PFMT.
4. Pelvic floor physical therapy provider certifications. Pelvic floor physical therapy (used to treat symptoms of incontinence, pelvic organ prolapse, and sexual dysfunction) teaches correct contractions, muscle and body awareness, coordination and motor control, muscle strength and endurance, and relaxation. This bill does not define which providers would be authorized to provide pelvic floor physical therapy. Although licensed health providers are not required to have particular training to offer these types of therapies, those without specific training do not regularly offer pelvic floor physical therapy; pelvic floor physical therapy is usually provided by physical therapists with specialized pelvic floor physical therapy training. The Academy of Pelvic Health Physical Therapy (APTA Pelvic Health) offers a Certificate of Achievement in Pelvic Health or Obstetric Physical Therapy. Licensed physical therapists who complete required coursework through APTA Pelvic Health and a case reflection within a year of completing coursework are eligible to apply for these certifications. The American Board of Physical Therapy Services offers a Specialist Certification in Women’s Health, which requires licensed physical therapists to complete an exam, along with patient care requirements, to receive certification. The Herman & Wallace Pelvic Rehabilitation Institute also offers specialized training for physical therapists.
5. Related legislation. AB 47 (Boerner of 2023) and AB 1904 (Boerner of 2020) would have mandated health insurance coverage for pelvic floor physical therapy after pregnancy. Both bills were not heard in the Assembly Health Committee.

FISCAL EFFECT: Appropriation: No Fiscal Com.: No Local: No

SUPPORT: (Verified 6/27/24)

Maternal and Child Health Access

Reproductive Freedom for All California

OPPOSITION: (Verified 6/27/24)

None received

ARGUMENTS IN SUPPORT: Maternal and Child Health Access (MCHA) writes in support of this bill which would, subject to state funding, authorize a three-year pilot program for group class exercises to help people rebuild their pelvic floor after pregnancy. Ideally, data from the pilot would be used to: 1) establish protocols for addressing postpartum pelvic floor issues without the need for surgical intervention; and 2) expand insurance coverage to include pelvic floor and core conditioning exercises as needed postpartum. MCHA notes that according to research published in January 2024 in the Journal of Obstetrics & Gynecology, pelvic floor disorders after childbirth have distressing lifelong consequences for women, requiring more than 300,000 women to have surgery annually. This represents approximately 10% of the three million women who give birth vaginally each year. Vaginal birth is the largest modifiable risk factor for prolapse, the pelvic floor disorder most strongly associated with birth, and is an important contributor to stress incontinence. MCHA points to their work with low-income families throughout Los Angeles County, and states that they know there is an urgent need for this bill’s services particularly in Medi-Cal, which covers 40% of all California births. Funding for the pilot for other insurance types might be available from the recent needs assessment grant on perinatal health equity awarded to DHCS and three other partner agencies by the federal Health Resources and Services Agency.

ASSEMBLY FLOOR: 73-0, 5/23/24

AYES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Chen, Connolly, Davies, Dixon, Flora, Mike Fong, Vince Fong, Friedman, Gabriel, Gallagher, Garcia, Gipson, Grayson, Haney, Hart, Hoover, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Papan, Jim Patterson, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Rendon, Reyes, Rodriguez, Sanchez, Santiago, Schiavo, Soria, Ta, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Robert Rivas

NO VOTE RECORDED: Cervantes, Megan Dahle, Essayli, Holden, Mathis, Luz Rivas, Blanca Rubio

Prepared by: Melanie Moreno / HEALTH / (916) 651-4111

6/27/24 15:38:55

**** END ****

SENATE COMMITTEE ON HEALTH

Senator Richard Roth, Chair

BILL NO: AB 2756

SUBJECT: Pelvic Floor and Core Conditioning Pilot Program

SUMMARY:

1. Permits the County of San Diego to establish a pilot program for pelvic floor and core conditioning group classes between January 1, 2026 and January 1, 2029.

Existing law: Requires the California Department of Public Health to maintain a program of maternal and child health; establishes the Medi-Cal program to provide health care coverage to certain low-income persons, including coverage for maternal health (including any necessary maternal physical assessments); and, requires commercial health insurance coverage for “basic health care services,” including preventive health services. [HSC §123225, WIC §14132, HSC §1367.005, and INS §10112.27]

This bill:

1. Permits the County of San Diego to establish a pilot program for pelvic floor and core conditioning group classes between January 1, 2026 and January 1, 2029.
2. Requires the classes to be a combination of yoga and pilates exercises that strengthen the pelvic floor muscles, and to be provided to people twice a week between their 6-to-12-week postpartum window to help people rebuild their pelvic floor after pregnancy. Requires the pilot program to require all postpartum providers who teach the classes to be certified.
3. Requires the pilot program to record the following information to directly assess pelvic floor changes, including, but not limited to: the number of incontinent episodes per week before and after the exercises; and, any changes with varied increases or decreases in intraabdominal pressure, including leaking with a jump, cough, or sneeze.

FISCAL EFFECT:

According to the Assembly Appropriations Committee, there are no state costs associated with this bill.

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, one in three people who have given birth will experience a pelvic floor disorder in their lifetime. In the media, we have heard of Brittany Mahomes, wife of Kansas City Chief’s Quarterback Patrick Mahomes, who most recently fractured her back because of her weak pelvic floor. This is just one story being highlighted in the media when there are people every day dealing with functional problems that could have been avoided with preventative postpartum pelvic floor care. If we support new parents before they give birth, we should support them through their healing journey. This bill creates a pilot program in the County of San Diego for preventative postpartum pelvic floor and core conditioning group classes to avoid long-term issues with pelvic floor disorders.
2. Background. According to the California Health Benefits Review Program (CHBRP) pelvic floor physical therapy, also referred to as pelvic floor muscle training (PFMT) refers to a set of modalities that are used to prevent and treat pelvic floor dysfunction (PFD). Symptoms of PFD include urinary incontinence, fecal incontinence, pelvic organ prolapse, and pelvic pain. Primary risk factors for PFD include childbirth, which increases with number of births, and aging (menopause). This bill would authorize the County of San Diego to implement a Pelvic Floor and Core Conditioning Pilot Program, similar to an existing program at Scripps Health, which offers pelvic floor and core conditioning group exercise classes as a voluntary option for patients experiencing issues with their pelvic floor muscles. As part of its analysis of a previous bill [AB 1904 (Boerner of 2020), which would have required all state-regulated health insurance to cover pelvic floor physical therapy after pregnancy], CHBRP found:
   1. There is inconclusive evidence that PFMT is effective at treating urinary incontinence in postpartum women (0–12 months after delivery);
   2. There is a preponderance of evidence that PFMT is effective at treating urinary incontinence in non-postpartum women;
   3. There is limited evidence that PFMT is not effective at treating fecal incontinence in women;
   4. There is limited evidence that PFMT is effective at treating pelvic organ prolapse; and,
   5. There is insufficient evidence as to whether PFMT is effective at treating pelvic pain in postpartum women.
3. Knowledge around pelvic floor disorders. According to CHBRP, most women do not seek medical treatment despite high rates of pelvic floor disorders, although this pattern is more frequent among women of color than white women. Reasons for not seeking treatment include: embarrassment; urinary incontinence assumed to be a normal part of postpartum status or aging; and, poor understanding of pelvic floor dysfunction/disorders and treatment options. According to a 2015 study, women of color were significantly less likely than white women to know that childbirth was a cause of urinary incontinence and that exercises can help control leakage. Women of color were also less likely than white women to know that pelvic organ prolapse can occur at any age, and to know that treatment options are available, including exercises that can be done to prevent progression. There is conflicting evidence in identifying potential socioeconomic barriers for accessing PFMT.
4. Pelvic floor physical therapy provider certifications. Pelvic floor physical therapy (used to treat symptoms of incontinence, pelvic organ prolapse, and sexual dysfunction) teaches correct contractions, muscle and body awareness, coordination and motor control, muscle strength and endurance, and relaxation. This bill does not define which providers would be authorized to provide pelvic floor physical therapy. Although licensed health providers are not required to have particular training to offer these types of therapies, those without specific training do not regularly offer pelvic floor physical therapy; pelvic floor physical therapy is usually provided by physical therapists with specialized pelvic floor physical therapy training. The Academy of Pelvic Health Physical Therapy (APTA Pelvic Health) offers a Certificate of Achievement in Pelvic Health or Obstetric Physical Therapy. Licensed physical therapists who complete required coursework through APTA Pelvic Health and a case reflection within a year of completing coursework are eligible to apply for these certifications. The American Board of Physical Therapy Services offers a Specialist Certification in Women’s Health, which requires licensed physical therapists to complete an exam, along with patient care requirements, to receive certification. The Herman & Wallace Pelvic Rehabilitation Institute also offers specialized training for physical therapists.
5. Prior legislation. AB 47 (Boerner of 2023) and AB 1904 (Boerner of 2020) would have mandated health insurance coverage for pelvic floor physical therapy after pregnancy. AB 47 and AB 1904 were not heard in the Assembly Health Committee.
6. Support. Maternal and Child Health Access (MCHA) writes in support of this bill which would, subject to state funding, authorize a three-year pilot program for group class exercises to help people rebuild their pelvic floor after pregnancy. Ideally, data from the pilot would be used to: 1) establish protocols for addressing postpartum pelvic floor issues without the need for surgical intervention; and 2) expand insurance coverage to include pelvic floor and core conditioning exercises as needed postpartum. MCHA notes that according to research published in January 2024 in the Journal of Obstetrics & Gynecology, pelvic floor disorders after childbirth have distressing lifelong consequences for women, requiring more than 300,000 women to have surgery annually. This represents approximately 10% of the three million women who give birth vaginally each year. Vaginal birth is the largest modifiable risk factor for prolapse, the pelvic floor disorder most strongly associated with birth, and is an important contributor to stress incontinence. MCHA points to their work with low-income families throughout Los Angeles County, and states that they know there is an urgent need for this bill’s services particularly in Medi-Cal, which covers 40% of all California births. Funding for the pilot for other insurance types might be available from the recent needs assessment grant on perinatal health equity awarded to DHCS and three other partner agencies by the federal Health Resources and Services Agency.

SUPPORT AND OPPOSITION:

Support: Maternal and Child Health Access

Reproductive Freedom for All California

Oppose: None received

-- END --

ASSEMBLY THIRD READING

ATR Bill Id:AB 2756

Author:(Boerner)

As Amended Ver:May 16, 2024

Majority vote

SUMMARY

Authorizes the County of San Diego, commencing January 1, 2026, until January 1, 2029, to establish a pilot program for pelvic floor and core conditioning group classes that would be provided to people twice a week between their six-to-12-week postpartum window.

Major Provisions

COMMENTS

According to the California Health Benefits Review Program, pelvic floor physical therapy, also referred to as pelvic floor muscle training, refers to a set of modalities that are used to prevent and treat pelvic floor dysfunction (PFD). Symptoms of PFD include urinary incontinence, fecal incontinence, pelvic organ prolapse, and pelvic pain. Primary risk factors for PFD include childbirth, which increases with number of births, and aging (menopause).

Pelvic Floor Physical Therapy Provider Certifications. Pelvic floor physical therapy (used to treat symptoms of incontinence, pelvic organ prolapse, and sexual dysfunction) teaches correct contractions, muscle and body awareness, coordination and motor control, muscle strength and endurance, and relaxation. This bill does not define which providers would be authorized to provide pelvic floor physical therapy. Although licensed health providers (physical therapists, medical doctors, doctors of osteopathic medicine, nurse practitioners, etc.) are not required to have particular training to offer these types of therapies, those without specific training do not regularly offer pelvic floor physical therapy; pelvic floor physical therapy is usually provided by physical therapists with specialized pelvic floor physical therapy training. The Academy of Pelvic Health Physical Therapy (APTA Pelvic Health) offers a Certificate of Achievement in Pelvic Health or Obstetric Physical Therapy. Licensed physical therapists who complete required coursework through APTA Pelvic Health and a case reflection within a year of completing coursework are eligible to apply for these certifications. The American Board of Physical Therapy Services offers a Specialist Certification in Women's Health, which requires licensed physical therapists to complete an exam, along with patient care requirements, to receive certification. The Herman & Wallace Pelvic Rehabilitation Institute also offers specialized training for physical therapists.

Disparities and Social Determinants of Health in Pelvic Floor Disorders. Disparities exist in prevalence of pelvic floor disorders. For example, one study demonstrated an increasing prevalence of pelvic floor disorders as cohorts aged, with about 50% of women over age 80 years experiencing at least one disorder. Other studies presented evidence of racial/ethnic disparities in stress urinary incontinence and urge urinary incontinence. Asian American women appear to have the lowest risk of urinary incontinence overall as compared with white and Hispanic women. Several studies showed that black women had highest rates of urge urinary incontinence while white women had three times the risk of stress urinary incontinence as black women and two times the risk of Asian American women. Finally, Hispanic women appear to have significantly elevated risk of pelvic organ prolapse as compared with white women.

According to the Author

One in three people who have given birth will experience a pelvic floor disorder in their lifetime. In the media, we have heard of Brittany Mahomes, wife of Kansas City Chiefs Quarterback Patrick Mahomes, who most recently fractured her back because of her weak pelvic floor. This is just one story being highlighted in the media when there are women every day dealing with functional problems that could have been avoided with preventative postpartum pelvic floor care. If we support new parents before they give birth, we should support them through their healing journey. The author concludes that this bill creates a pilot program in the County of San Diego for preventative postpartum pelvic floor and core conditioning group classes to avoid long-term issues with pelvic floor disorders.

Arguments in Support

Maternal and Child Health Access (MCHA) writes in support this bill which would, subject to state funding, authorize a three-year pilot program for group class exercises to help people rebuild their pelvic floor after pregnancy. MCHA notes that the Department of Health Care Services would report on the data from the pilot by June 1, 2029. Ideally, data from the pilot would be used to: 1) establish protocols for addressing postpartum pelvic floor issues without the need for surgical intervention; and 2) expand insurance coverage to include pelvic floor and core conditioning exercises as needed postpartum. MCHA notes that according to research published in January 2024 in the Journal of Obstetrics & Gynecology, pelvic floor disorders after childbirth have distressing lifelong consequences for women, requiring more than 300,000 women to have surgery annually. This represents approximately 10% of the 3 million women who give birth vaginally each year. Vaginal birth is the largest modifiable risk factor for prolapse, the pelvic floor disorder most strongly associated with birth, and is an important contributor to stress incontinence.

Arguments in Opposition

There is no known opposition to this bill.

FISCAL COMMENTS

According to the Assembly Appropriations Committee, there are no state costs associated with this bill.

VOTES

ASM HEALTH: 16-0-0

YES: Bonta, Waldron, Aguiar-Curry, Arambula, Wendy Carrillo, Flora, Haney, Jones-Sawyer, Maienschein, McCarty, Joe Patterson, Rodriguez, Sanchez, Santiago, Schiavo, Weber

ASM APPROPRIATIONS: 11-0-4

YES: Wicks, Arambula, Bryan, Calderon, Wendy Carrillo, Mike Fong, Grayson, Haney, Hart, Pellerin, Villapudua

ABS, ABST OR NV: Sanchez, Dixon, Jim Patterson, Ta

UPDATED

VERSION: May 16, 2024

CONSULTANT: Lara Flynn / HEALTH / (916) 319-2097 FN: 0003339

Date of Hearing: May 15, 2024

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Buffy Wicks, Chair

ABPCA Bill Id:AB 2756

Author:(Boerner) – As Amended Ver:April 3, 2024

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

SUMMARY:

This bill authorizes the County of San Diego to establish a pilot program to provide pelvic floor and core conditioning group classes to help people rebuild their pelvic floor after pregnancy. The bill requires the program to record specified information to directly assess pelvic floor changes of program participants, and requires the program to annually report all the information and outcomes to the Department of Health Care Services (DHCS). The bill would require DHCS to provide a final report on the program to the Legislature by June 1, 2029.

FISCAL EFFECT:

DHCS anticipates no costs associated with the pilot program. For the report, DHCS will require one limited-term, full-time staff position to work with the pilot program, analyze data, and prepare the final report, at costs of $159,000 in fiscal year (FY) 2027-28 and $150,000 in FY 2028-29 (50% General Fund, 50% federal funds).

COMMENTS:

1. Purpose. According to the author:

One in three people who have given birth will experience a pelvic floor disorder in their lifetime. In the media, we have heard of Brittany Mahomes, wife of Kansas City Chiefs Quarterback Patrick Mahomes, who most recently fractured her back because of her weak pelvic floor. This is just one story being highlighted in the media when there are women every day dealing with functional problems that could have been avoided with preventative postpartum pelvic floor care. If we support new parents before they give birth, we should support them through their healing journey. This bill creates a pilot program in the County of San Diego for preventative postpartum pelvic floor and core conditioning group classes to avoid long-term issues with pelvic floor disorders.

1. Pelvic Floor Dysfunction (PFD). Symptoms of PFD include urinary incontinence, fecal incontinence, pelvic organ prolapse, and pelvic pain. Risk for PFD is associated with childbirth, with risk of PFD increasing with number of births and aging (menopause). Pelvic floor physical therapy, also referred to as pelvic floor muscle training, refers to a set of modalities used to prevent and treat PFD.

Analysis Prepared by: Allegra Kim / APPR. / (916) 319-2081

Date of Hearing: April 23, 2024

ASSEMBLY COMMITTEE ON HEALTH

Mia Bonta, Chair

ABPCA Bill Id:AB 2756

Author:(Boerner) – As Amended Ver:April 3, 2024

SUBJECT: Pelvic Floor and Core Conditioning Pilot Program.

SUMMARY: Authorizes the County of San Diego, commencing January 1, 2026, to establish a pilot program for pelvic floor and core conditioning group classes that would be provided to people twice a week between their six-to-12-week postpartum window. Specifically, this bill:

1. Authorizes the County of San Diego, commencing January 1, 2026, until January 1, 2029, to establish a pilot program for pelvic floor and core conditioning group classes.
   
2. Requires the classes to be a combination of yoga and Pilates exercises that strengthen the pelvic floor muscles provided to people twice a week between their six-to-12-week postpartum window to help people rebuild their pelvic floor after pregnancy.
   
3. Requires the program to require all postpartum providers who teach the classes to be certified.
   
4. Requires the program to record the following information to directly assess pelvic floor changes, including, but not limited to, both of the following:
   1. The number of incontinent episodes per week before and after the exercises; and,
   2. Any changes with varied increases or decreases in intra-abdominal pressure, including leaking with a jump, cough, or sneeze.
      
5. Requires the program to annually report all the information and outcomes recorded pursuant to 4) above to the State Department of Health Care Services (DHCS).
   
6. Requires DHCS to provide a final report on the program established pursuant to this bill to the Legislature by June 1, 2029.
   
7. Makes finding and declarations as to the necessity of a special statute for the County of San Diego.

EXISTING LAW:

1. Establishes the Department of Managed Health Care to regulate health plans under the Knox-Keene Health Care Service Plan Act of 1975 and the California Department of Insurance to regulate health insurers. [Health and Safety Code (HSC) §1340, et seq., and Insurance Code (INS) §106, et seq.]
2. Establishes as California's essential health benefits (EHBs) benchmark under the Patient Protection and Affordable Care Act (ACA), the Kaiser Small Group Health Maintenance Organization contract, existing California health insurance mandates, and the 10 ACA mandated benefits. [HSC §1367.005 and INS §10112.27]
3. Defines “basic health care services” as all of the following:
   1. Physician services, including consultation and referral;
   2. Hospital inpatient services and ambulatory care services;
   3. Diagnostic laboratory and therapeutic radiologic services;
   4. Home health services;
   5. Preventive health services;
   6. Emergency health care services; and,
   7. Hospice care. [HSC §1345]
4. Requires the criteria or guidelines used by health plans and insurers, or any entities with which plans or insurers contract for utilization review or utilization management functions, to determine whether to authorize, modify, or deny health care services to:
   1. Be developed with involvement from actively practicing health care providers;
   2. Be consistent with sound clinical principles and processes;
   3. Be evaluated, and updated if necessary, at least annually;
   4. If used as the basis of a decision to modify, delay, or deny services in a specified case under review, be disclosed to the provider and the enrollee or insured in that specified case; and,
   5. Be available to the public upon request. [HSC §1363.5 and INS §10123.135]
      
5. Requires reviews, for purposes of Independent Medical Review (IMR), to determine whether the disputed health care service was medically necessary based on the specific medical needs of the enrollee or insured and any of the following:
6. Peer-reviewed scientific and medical evidence regarding the effectiveness of the disputed service;
7. Nationally recognized professional standards;
8. Expert opinion;
9. Generally accepted standards of medical practice; or,
10. Treatments that are likely to provide a benefit to a patient for conditions for which other treatments are not clinically efficacious. [HSC §1374.33 and INS §10169.3]
11. Requires every health plan or insurer to provide an external, IMR to examine the plan or insurer’s coverage decisions regarding experimental or investigational therapies for an individual with a life-threatening or seriously debilitating condition, as specified. [HSC §1370.4 and INS §10145.3]

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

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, one in three people who have given birth will experience a pelvic floor disorder in their lifetime. In the media, we have heard of Brittany Mahomes, wife of Kansas City Chiefs Quarterback Patrick Mahomes, who most recently fractured her back because of her weak pelvic floor. This is just one story being highlighted in the media when there are women every day dealing with functional problems that could have been avoided with preventative postpartum pelvic floor care. If we support new parents before they give birth, we should support them through their healing journey. The author concludes that this bill creates a pilot program in the County of San Diego for preventative postpartum pelvic floor and core conditioning group classes to avoid long-term issues with pelvic floor disorders.
2. BACKGROUND. According to the California Health Benefits Review Program (CHBRP) pelvic floor physical therapy, also referred to as pelvic floor muscle training (PFMT), refers to a set of modalities that are used to prevent and treat pelvic floor dysfunction (PFD). Symptoms of PFD include urinary incontinence, fecal incontinence, pelvic organ prolapse, and pelvic pain. Primary risk factors for PFD include childbirth, which increases with number of births, and aging (menopause).
   1. CHBRP analysis. AB 1996 (Thomson), Chapter 795, Statutes of 2002, requests the University of California to assess legislation proposing a mandated benefit or service and prepare a written analysis with relevant data on the medical, economic, and public health impacts of proposed health plan and health insurance benefit mandate legislation. CHBRP was created in response to AB 1996. SB 125 (Hernandez), Chapter 9, Statutes of 2015, added an impact assessment on EHBs, and legislation that impacts health insurance benefit designs, cost sharing, premiums, and other health insurance topics. CHBRP reviewed AB 1904 (Boerner) of 2020, which would have required all state-regulated health insurance, including Medi-Cal managed care, to cover pelvic floor physical therapy after pregnancy, and stated the following in its analysis:
      1. Benefit coverage. CHBRP estimated that 99.9% of enrollees with insurance that would have been subject to AB 1904 already had coverage for pelvic floor physical therapy. The 0.1% of the population subject to AB 1904 who did not have benefit coverage for pelvic floor physical therapy were a segment of those enrolled in CDI-regulated grandfathered individual market policies.
      2. Medical effectiveness. CHBRP found:
         1. There is inconclusive evidence that PFMT is effective at treating urinary incontinence in postpartum women (0–12 months after delivery);
         2. There is a preponderance of evidence that PFMT is effective at treating urinary
         3. incontinence in non-postpartum women;
         4. There is limited evidence that PFMT is not effective at treating fecal incontinence in women;
         5. There is limited evidence that PFMT is effective at treating pelvic organ prolapse in postpartum or nonpostpartum women; and,
         6. There is insufficient evidence as to whether PFMT is effective at treating pelvic pain in postpartum women (0–12 months after delivery).

This bill would authorize the County of San Diego to implement a Pelvic Floor and Core Conditioning Pilot Program, similar to an existing program at Scripps Health system in San Diego which currently offers pelvic floor and core conditioning group exercise classes as a voluntary option for patients experiencing issues with their pelvic floor muscles.

• 1. Pelvic Floor Physical Therapy Provider Certifications. Pelvic floor physical therapy (used to treat symptoms of incontinence, pelvic organ prolapse, and sexual dysfunction) teaches correct contractions, muscle and body awareness, coordination and motor control, muscle strength and endurance, and relaxation. This bill does not define which providers would be authorized to provide pelvic floor physical therapy. Although licensed health providers (physical therapists, medical doctors, doctors of osteopathic medicine, nurse practitioners, etc.) are not required to have particular training to offer these types of therapies, those without specific training do not regularly offer pelvic floor physical therapy; pelvic floor physical therapy is usually provided by physical therapists with specialized pelvic floor physical therapy training. The Academy of Pelvic Health Physical Therapy (APTA Pelvic Health) offers a Certificate of Achievement in Pelvic Health or Obstetric Physical Therapy. Licensed physical therapists who complete required coursework through APTA Pelvic Health and a case reflection within a year of completing coursework are eligible to apply for these certifications. The American Board of Physical Therapy Services offers a Specialist Certification in Women’s Health, which requires licensed physical therapists to complete an exam, along with patient care requirements, to receive certification. The Herman & Wallace Pelvic Rehabilitation Institute also offers specialized training for physical therapists.
  2. Disparities and Social Determinants of Health in Pelvic Floor Disorders. Disparities exist in prevalence of pelvic floor disorders. For example, one study demonstrated an increasing prevalence of pelvic floor disorders as cohorts aged, with about 50% of women over age 80 years experiencing at least one disorder. Other studies presented evidence of racial/ethnic disparities in stress urinary incontinence and urge urinary incontinence. Asian American women appear to have the lowest risk of urinary incontinence overall as compared with white and Hispanic women. Several studies showed that black women had highest rates of urge urinary incontinence while white women had three times the risk of stress urinary incontinence as black women and two times the risk of Asian American women. Finally, Hispanic women appear to have significantly elevated risk of pelvic organ prolapse as compared with white women.
     
  3. Knowledge and Treatment Seeking. According to CHBRP, most women do not seek medical treatment despite high rates of pelvic floor disorders, although this pattern is more frequent among women of color than white women. Reasons for not seeking treatment include: Embarrassment; Urinary incontinence assumed to be a normal part of postpartum status or aging; and, Poor understanding of pelvic floor dysfunction/disorders and treatment options. According to one study, women of color were significantly less likely than white women to know that childbirth was a cause of urinary incontinence and that exercises can help control leakage. Women of color were also less likely than white women to know that pelvic organ prolapse can occur at any age, and to know that treatment options are available, including exercises that can be done to prevent progression. There is conflicting evidence in identifying potential socioeconomic barriers for accessing PFMT.

1. SUPPORT. Maternal and Child Health Access (MCHA) writes in support this bill which would, subject to state funding, authorize a three-year pilot program for group class exercises to help people rebuild their pelvic floor after pregnancy. MCHA notes that DHCS would report on the data from the pilot by June 1, 2029. Ideally, data from the pilot would be used to: 1) establish protocols for addressing postpartum pelvic floor issues without the need for surgical intervention; and 2) expand insurance coverage to include pelvic floor and core conditioning exercises as needed postpartum. MCHA notes that according to research published in January 2024 in the Journal of Obstetrics & Gynecology, pelvic floor disorders after childbirth have distressing lifelong consequences for women, requiring more than 300,000 women to have surgery annually. This represents approximately 10% of the 3 million women who give birth vaginally each year. Vaginal birth is the largest modifiable risk factor for prolapse, the pelvic floor disorder most strongly associated with birth, and is an important contributor to stress incontinence. MCHA points to their work with low-income families throughout Los Angeles County, and states that they know there is an urgent need for this bill’s services particularly in Medi-Cal, which covers 40% of all California births. Most Medi-Cal-funded deliveries are to Latinas. Postpartum pelvic floor and core conditioning exercises should be included in DHCS’s draft Medi-Cal Birthing Pathways initiative, scheduled for release in June 2024. In addition, funding for the pilot for other insurance types might be available from the recent needs assessment grant on perinatal health equity awarded to DHCS and three other partner agencies by the federal Health Resources and Services Agency.
   
2. PREVIOUS LEGISLATION.
   1. AB 47 (Boerner) of 2023 would have required a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2024, to provide coverage for pelvic floor physical therapy after pregnancy. AB 47 was not heard in the Assembly Health Committee.
      
   2. AB 1904 (Boerner) of 2020 would have required all state-regulated health insurance, including Medi-Cal managed care, to cover pelvic floor physical therapy after pregnancy. AB 1904 was not heard in the Assembly Health Committee.

REGISTERED SUPPORT / OPPOSITION:

Support

Maternal and Child Health Access
Reproductive Freedom for All California (formerly NARAL Pro-Choice California),

Opposition

None on file.

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