BILL ANALYSIS Ó
AB 508
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Date of Hearing: January 12, 2016
ASSEMBLY COMMITTEE ON HEALTH
Rob Bonta, Chair
AB 508
(Cristina Garcia) - As Amended 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:
a) Patient demographics;
b) Underlying causes;
c) Contributing factors; and,
d) Suggestions for improvements in care.
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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:
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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
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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
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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
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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:
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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