Creates provisions relating to maternal care

SECOND REGULAR SESSION
HOUSE BILL NO. 1950
103RD GENERAL ASSEMBL Y
INTRODUCED BY REPRESENT A TIVE BOSLEY .
4878H.01I JOSEPH ENGLER, Chief Clerk
AN ACT
T o repeal section 192.990, RSMo, and to enact in lieu thereof three new sections relating to
maternal care.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Section 192.990, RSMo, is repealed and three new sections enacted in lieu
2 thereof, to be known as sections 192.258, 192.990, and 192.1030, to read as follows:
192.258. 1. For purposes of this section, the following terms mean:
2 (1) "Local public health agency", a county health center board established
3 under chapter 205, a county health department, a city health department or agency , a
4 combined city and county health department or agency , a multicounty health
5 department or agency , or any other county or city health authority;
6 (2) "T erm infants", infants who ar e at thirty-six weeks or mor e of gestation.
7 2. (1) Each county shall annually r eport infant deaths to the local public health
8 agency or agencies with jurisdiction over the county or any part of the county .
9 (2) The data shall be aggr egated to ensur e data ref lects how region alized car e
10 systems ar e, or should be, collaborating to impr ove fetal and infant health outcomes
11 based on standard statistical methods for accurate dissemination of public health data
12 without risking a confidentiality or other disclosure brea ch.
13 (3) The data shall be disaggreg ated by racial and ethnic identity .
14 3. Subject to appr opriation, a local public health agency shall establish a fetal
15 and infant mortality r eview committee to investigate infant deaths to pr event fetal and
16 infant death if both of the following apply with res pect to the local public health
17 agency's jurisdiction:
EXPLANA TION — Matter enclosed in bold-faced brackets [thus] in the above bill is not enacted and is
intended to be omitted from the law . Matter in bold-face type in the above bill is proposed language.
18 (1) The jurisdiction has five or mor e infant deaths in a single year; and
19 (2) The jurisdiction has an infant death rate that is higher than the state's infant
20 death rate for two consecutive years.
21 4. The department of health and senior services shall establish a fetal and infant
22 mortality review pr ocess in which all local public health agencies may voluntarily
23 participate. A local public health agency that participates in the fetal and infant
24 mortality r eview pr ocess established by the department of health and senior services
25 shall do all of the following:
26 (1) Annually investigate, track, and review a minimum amount of twenty
27 per cent of the jurisdiction's cases of term infants who wer e born following labor with
28 the outcome of intrapartum stillbirth, early neonatal death, or postneonatal death,
29 focusing on demographic gro ups that ar e dispr oportionately impacted by infant death.
30 A jurisdiction that has fewer than five infant deaths in a year shall investigate at least
31 one infant death;
32 (2) Establish a committee for fetal and infant mortality revi ews led by local
33 public health agencies. The committee shall include members of the community but
34 shall not include anyone employed by a law enforcem ent agency . In jurisdictions in
35 which the corone r , medical examiner , or other medical pr ofessional is employed by law
36 enfor cement, these individuals can shar e information with the committee in their
37 medical pr ofessional capacity only . The committee shall be subject to the following
38 pr ovisions:
39 (a) All data and r ecords obtained, pr epare d, creat ed, and maintained in
40 anticipation of a revi ew meeting shall be confidential. Data and record s pr epar ed,
41 cr eated, and maintained in anticipation of a re view meeting shall not be subject to
42 public reco rds requ ests, subpoena, or civil pr ocesses and shall not be admissible in
43 evidence in connection with any administrative, judicial, executive, legislative, or other
44 pr oceeding;
45 (b) All participants engaged in and associated with the review pr ocess shall sign
46 a confidentiality agr eement that states such participants will not discuss or share
47 information about individual cases and the procee dings of the review meeting outside
48 the meeting. This shall not preclu de the committee fr om publishing, or fr om otherwise
49 making available for public inspection, statistical compilations or repo rts that ar e based
50 on confidential information, pr ovided that those compilations or r eports shall not
51 contain personally identifying information or other information that could be used to
52 ultimately identify the individuals concerned and shall utilize standard public health
53 r eporting practices for accurate dissemination of these data elements, especially with
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54 r egard to the reporting of small numbers so as not to inadvertently risk a br each of
55 confidentiality or other disclosur e; and
56 (c) T o the extent prescrib ed by section 537.035, members of the committee,
57 persons attending a committee meeting, and persons who present information to a
58 committee shall not be questioned in any administrative, civil, or criminal pr oceeding
59 r egarding information present ed in, or opinions formed as a res ult of, a meeting. This
60 paragraph shall not pr ohibit a person fr om testifying to information obtained
61 independently of the committee or that is public information. A health care pro vider ,
62 health car e facility , or pharmacy pr oviding access to medical record s under this section
63 shall not be held liable for civil damages or be subject to any criminal or disciplinary
64 action for good faith efforts in prov iding the r ecords;
65 (3) Conduct voluntary interviews with individuals who have experienced child
66 loss or surviving family members of maternal or infant death who have knowledge of
67 the event. The interview shall include questions to determine if the pregn ant person had
68 concerns about perinatal car e during any point in the person's pr egnancy or
69 postpartum car e, whether ther e wer e disagr eements about care offered and receiv ed,
70 and whether the pr egnant person had asked for certain car e that was denied or not
71 r eceived;
72 (4) Conduct a repo rt or investigation, to the degr ee practicable, with all medical
73 staff involved with a maternal or infant death; and
74 (5) Offer grief counseling to surviving family members.
75 5. Counties, hospitals, birthing centers, and state entities shall provi de to local
76 public health agencies death r ecords, medical records, autopsy r eports, toxicology
77 r eports, hospital discharge records, birth reco rds, and any other information that will
78 help the local public health agency conduct the fetal and infant mortality r eview within
79 thirty days of a re quest made in writing by a local public health agency . The local public
80 health agency shall not re quest, and health car e pr oviders shall not pr ovide, rep orts,
81 testimony , or other information pr oduced as a res ult of activities undertaken by a peer
82 r eview committee, as defined in section 537.035, that has the res ponsibility to evaluate or
83 impr ove the quality of car e r ender ed in a hospital.
84 6. (1) Ther e is hereb y cr eated in the state tr easury the "Fetal and Infant
85 Mortality Review Fund", which shall consist of moneys appr opriated to it by the general
86 assembly and any gifts, contributions, grants, or bequests receiv ed fr om federal, private,
87 or other sources . The state tr easurer shall be custodian of the fund. In accordance with
88 sections 30.170 and 30.180, the state tr easurer may appr ove disbursements. The fund
89 shall be a dedicated fund and, upon appro priation, moneys in this fund shall be used
90 solely as provi ded in this section.
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91 (2) Notwithstanding the pro visions of section 33.080 to the contrary , any moneys
92 r emaining in the fund at the end of the biennium shall not r evert to the credit of the
93 general reven ue fund.
94 (3) The state tre asurer shall invest moneys in the fund in the same manner as
95 other funds ar e invested. Any interes t and moneys earned on such investments shall be
96 cr edited to the fund.
192.990. 1. There is hereby established within the department of health and senior
2 services the "Pregnancy-Associated Mortality Review Board" to improve data collection and
3 reporting with respect to maternal deaths. The department may collaborate with localities and
4 with other states to meet the goals of the initiative.
5 2. For purposes of this section, the following terms shall mean:
6 (1) "Department", the Missouri department of health and senior services;
7 (2) "Maternal death" or "maternal mortality" , the death of a woman while pregnant
8 or during the one-year period following the date of the end of pregnancy , regardless of the
9 cause of death and regardless of whether a delivery , miscarriage, or death occurs inside or
10 outside of a hospital ;
11 (3) "Sever e maternal morbidity", unexpected outcomes of preg nancy , labor , or
12 delivery that result in significant short-term or long-term consequences to the pr egnant
13 person's mental or physical health .
14 3. The board shall be composed of no more than eighteen members, with a chair
15 elected from among its membership. The board shall meet at least twice per year and shall
16 approve the strategic priorities, funding allocations, work processes, and products of the
17 board. Members of the board shall be appointed by the director of the department. Members
18 shall serve four -year terms, except that the initial terms shall be staggered so that
19 approximately one-third serve three-, four- , and five-year terms.
20 4. The board shall have a multidisciplinary and diverse membership that represents a
21 variety of medical and nursing specialties, including, but not limited to, obstetrics and
22 maternal-fetal care, as well as state or local public health of ficials, epidemiologists,
23 statisticians, community org anizations, geographic regions, and other individuals or
24 or ganizations that are most affected by maternal deaths and lack of access to maternal
25 health care services.
26 5. The duties of the board shall include, but not be limited to:
27 (1) Conducting ongoing comprehensive, multidisciplinary reviews of all maternal
28 deaths;
29 (2) Identifying factors associated with maternal deaths;
30 (3) Reviewing medical records and other relevant data, which shall include, to the
31 extent available:
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32 (a) A description of the maternal deaths determined by matching each death record of
33 a maternal death to a birth certificate of an infant or fetal death record, as applicable, and an
34 indication of whether the delivery , miscarriage, or death occurred inside or outside of a
35 hospital;
36 (b) Data collected from medical examiner and coroner reports, as appropriate; and
37 (c) Using other appropriate methods or information to identify maternal deaths,
38 including deaths from pregnancy outcomes not identified under paragraph (a) of this
39 subdivision;
40 (4) Consulting with relevant experts, as needed;
41 (5) Analyzing cases to produce recommendations for reducing maternal mortality;
42 (6) Analyzing common indicators of sever e maternal morbidity to identify
43 pr evention opportunities and r educe near -miss experiences;
44 (7) Disseminating recommendations to policy makers, health care providers and
45 facilities, and the general public on best practices to preven t maternal mortality and
46 morbidity including, but not limited to, addr essing socioeconomic and envir onmental
47 impacts, including global warming, on pregn ancy outcomes ;
48 [ (7) ] (8) Recommending and promoting preventative strategies and making
49 recommendations for systems changes , including changes in data collection and
5 0 investigatory pr ocesses ;
51 [ (8) ] (9) Protecting the confidentiality of the hospitals and individuals involved in any
52 maternal deaths;
53 [ (9) ] (10) Examining racial and social disparities in maternal deaths and making
54 r ecommendations on the preven tion of racial and social disparities ;
55 [ (10) ] (1 1) T racking and examining disparities experienced by lesbian, bisexual,
56 transgender , intersex, and gender -nonconforming individuals and r eporting findings, to
57 the extent practicable;
58 (12) Subject to appropriation, providing for voluntary and confidential case reporting
59 of maternal deaths to the appropriate state health agency by family members of the deceased,
60 and other appropriate individuals, for purposes of review by the board;
61 [ (1 1) ] (13) Making publicly available the contact information of the board for use in
62 such reporting;
63 [ (12) ] (14) Conducting outreach to local professional or ganizations, community
64 or ganizations, and social services agencies regarding the availability of the review board; and
65 [ (13) ] (15) Ensuring that data collected under this section is made available, as
66 appropriate and practicable, for research purposes, in a manner that protects individually
67 identifiable or potentially identifiable information and that is consistent with state and federal
68 privacy laws.
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69 6. (1) The board's r eview of cases of maternal mortality and morbidity shall
70 include, to the degr ee practicable, for populations experiencing disparity , voluntary
71 interviews with the following individuals:
72 (a) Pertinent surviving family members or support people present with direc t
73 knowledge of, or involvement in, the event, including the patient in cases of sever e
74 maternal morbidity . The board shall transcribe or summarize in writing any oral
75 statements recei ved in accordance with this paragraph; and
76 (b) Members of the medical team who wer e pr esent or involved in the deceased
77 individual's dir ect care.
78 (2) In determining the practicability of the interviews under subdivision (1) of
79 this subsection, the board may prioritize interviews with populations that have a
80 documented higher rate of maternal death.
81 7. The board may contract with other entities consistent with the duties of the board.
82 [ 7. ] 8. (1) Before June 30, 2020, and annually thereafter , the board shall submit to the
83 Director of the Centers for Disease Control and Prevention, the director of the department, the
84 governor , and the general assembly a report on maternal mortality in the state based on data
85 collected through ongoing comprehensive, multidisciplinary reviews of all maternal deaths,
86 and any other projects or ef forts funded by the board. The data shall be collected using best
87 practices to reliably determine and include all maternal deaths, regardless of the outcome of
88 the pregnancy and shall include data, findings, and recommendations of the committee, and,
89 as applicable, information on the implementation during such year of any recommendations
90 submitted by the board in a previous year .
91 (2) The report shall be made available to the public on the department's website and
92 the director shall disseminate the report to all health care providers and facilities that provide
93 women's health services in the state.
94 [ 8. ] 9. The director of the department, or his or her designee, shall provide the board
95 with the copy of the death certificate and any linked birth or fetal death certificate for any
96 maternal death occurring within the state.
97 [ 9. ] 10. Upon request by the department, health care providers, health care facilities,
98 clinics, laboratories, medical examiners, coroners, law enforcement agencies, driver's license
99 bureaus, other state agencies, and facilities licensed by the department shall provide to the
100 department data related to maternal deaths from sources such as medical records, autopsy
101 reports, medical examiner's reports, coroner's reports, law enforcement reports, motor vehicle
102 records, social services records, and other sources as appropriate. Such data requests shall be
103 limited to maternal deaths which have occurred within the previous twenty-four months. No
104 entity shall be held liable for civil damages or be subject to any criminal or disciplinary action
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105 when complying in good faith with a request from the department for information under the
106 provisions of this subsection.
107 [ 10. ] 1 1. (1) The board shall protect the privacy and confidentiality of all patients,
108 decedents, providers, hospitals, or any other participants involved in any maternal deaths or
109 any cases of sever e maternal morbidity . In no case shall any individually identifiable
110 health information be provided to the public or submitted to an information clearinghouse.
111 (2) Nothing in this subsection shall prohibit the board or department from publishing
112 statistical compilations and research reports that:
113 (a) Are based on confidential information relating to mortality reviews under this
114 section; and
115 (b) Do not contain identifying information or any other information that could be
116 used to ultimately identify the individuals concerned.
117 (3) Information, records, reports, statements, notes, memoranda, or other data
118 collected under this section shall not be admissible as evidence in any action of any kind in
119 any court or before any other tribunal, board, agency , or person. Such information, records,
120 reports, notes, memoranda, data obtained by the department or any other person, statements,
121 notes, memoranda, or other data shall not be exhibited nor their contents disclosed in any
122 way , in whole or in part, by any of ficer or representative of the department or any other
123 person. No person participating in such review shall disclose, in any manner , the information
124 so obtained except in strict conformity with such review project. Such information shall not
125 be subject to disclosure under chapter 610.
126 (4) All information, records of interviews, written reports, statements, notes,
127 memoranda, or other data obtained by the department, the board, and other persons, agencies,
128 or or ganizations so authorized by the department under this section shall be confidential.
129 (5) All proceedings and activities of the board, opinions of members of such board
130 formed as a result of such proceedings and activities, and records obtained, created, or
131 maintained under this section, including records of interviews, written reports, statements,
132 notes, memoranda, or other data obtained by the department or any other person, agency , or
133 or ganization acting jointly or under contract with the department in connection with the
134 requirements of this section, shall be confidential and shall not be subject to subpoena,
135 discovery , or introduction into evidence in any civil or criminal proceeding; provided,
136 however , that nothing in this section shall be construed to limit or restrict the right to discover
137 or use in any civil or criminal proceeding anything that is available from another source and
138 entirely independent of the board's proceedings.
139 (6) Members of the board shall not be questioned in any civil or criminal proceeding
140 regarding the information presented in or opinions formed as a result of a meeting or
141 communication of the board; provided, however , that nothing in this section shall be
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142 construed to prevent a member of the board from testifying to information obtained
143 independently of the board or which is public information.
144 [ 1 1. ] 12. The department may use grant program funds to support the ef forts of the
145 board and may apply for additional federal government and private foundation grants as
146 needed. The department may also accept private, foundation, city , county , or federal moneys
147 to implement the provisions of this section.
192.1030. 1. For purposes of this section, the following terms mean:
2 (1) "Certified nurse midwife", the same meaning given to the term in section
3 335.016;
4 (2) "Department", the department of health and senior services;
5 (3) "Pr ofessional midwife", any midwife allowed to practice in this state in
6 accordance with the pr ovisions of section 376.1753;
7 (4) "Pr ograms that train certified nurse midwives", a nurse-midwifery
8 education pr ogram that is recogn ized by the state board of nursing as pr oviding
9 education necessary to become a certified nurse midwife;
10 (5) "Progr ams that train pr ofessional midwives", a midwifery education
11 pr ogram that pr ovides the education necessary to practice as a midwife in this state in
12 accordance with the pr ovisions of section 376.1753.
13 2. Subject to appr opriation, the department shall establish a pro gram to
14 contract with pr ograms that train certified nurse midwives and pr ograms that train
15 pr ofessional midwives in accordance with the global standards for midwifery education
16 and the international definition of the term "midwife" as established by the
1 7 International Confederation of Midwives in order to incr ease the number of students
18 r eceiving quality education and training as a certified nurse midwife or as a pr ofessional
19 midwife.
20 3. The department shall contract only with pr ograms that train certified nurse
21 midwives and pro grams that train pr ofessional midwives that, at minimum, include, or
22 that intend to creat e, a component of training designed for medically underserved
23 multicultural communities, lower socioeconomic neighborhoods, or rural communities,
24 and that ar e organized to pr epare pr ogram graduates for service in those
2 5 neighborhoods and communities, or that seek to recru it and ret ain racially and
26 ethnically diverse students, underre present ed gr oups, or people fr om underserved or
27 historically marginalized communities.
28 4. (1) The department may adopt standards and regul ations necessary to carry
29 out the pro visions of this section. In adopting eligibility standards for pro grams that
30 train certified nurse midwives and pr ograms that train profession al midwives in
31 accordance with the standards set forth in subsections 2 and 3 of this section, the
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32 department may accept those educational standards and competencies established by
33 the state board of nursing or by the pro visions of section 376.1753. The department
34 shall take care not to implement education or competency standards beyond what is
35 r equir ed by the state board of nursing or the pr ovisions of section 376.1753 that could
36 inadvertently creat e an unnecessary barrier for training pr ograms to obtain funding for
37 the training of midwives in this state.
38 (2) Any rule or portion of a rule, as that term is defined in section 536.010, that is
39 cr eated under the authority delegated in this section shall become effective only if it
40 complies with and is subject to all of the pr ovisions of chapter 536 and, if applicable,
41 section 536.028. This section and chapter 536 are nonseverable and if any of the powers
42 vested with the general assembly pursuant to chapter 536 to revi ew , to delay the
43 effective date, or to disappr ove and annul a rule are subsequently held unconstitutional,
44 then the grant of rulemaking authority and any rule pro posed or adopted after August
45 28, 2026, shall be invalid and void.
46 5. The department shall develop alternative strategies to pr ovide long-term
47 stability for , or expansion of, the training pr ovided for under this section, such as
48 thr ough funding prov ided by private foundations and administer ed by the department
49 for the purposes of carrying out this section.
50 6. Nothing in this section prev ents the department fr om developing a protocol to
51 contract with potential pr ograms that train certified nurse midwives or potential
52 pr ograms that train pr ofessional midwives in order to support the initial startup of new
53 training pro grams as long as the eligibility requi rem ents of this section are met or can be
54 met thr ough an award of funds.
55 7. The department may pay contracted prog rams that train certified nurse
56 midwives and pro grams that train profes sional midwives in an amount calculated based
57 on a single per -student capitation formula, or thr ough another method, in order to cover
58 the costs of innovative special pr ojects or prog rams.
59 8. Funds appr opriated to the department for purposes of this section and
60 awarded by the department to eligible pr ograms that train certified nurse midwives or
61 pr ograms that train pr ofessional midwives may be used by the training pr ogram to
62 develop new initiatives, project s, or curricula, or to expand existing initiatives, pr ojects,
63 or curricula. A warded funds may also be used for general support and sustainability of
64 the overall training pr ogram, or to sustain specific components of the training pr ogram
65 including, but not limited to, tuition assistance for students, support for pr eceptor
66 r ecruitment, or support to sustain precep tor training sites for students.
67 9. (1) Ther e is her eby cr eated in the state tr easury the "Midwifery Education
68 Fund", which shall consist of moneys appr opriated to it by the general assembly and
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69 any gifts, contributions, grants, or bequests re ceived fr om federal, private, or other
70 sour ces. The state tr easure r shall be custodian of the fund. In accordance with sections
71 30.170 and 30.180, the state trea sur er may appr ove disbursements. The fund shall be a
72 dedicated fund and, upon appr opriation, moneys in this fund shall be used solely as
73 pr ovided in this section.
74 (2) Notwithstanding the pro visions of section 33.080 to the contrary , any moneys
75 r emaining in the fund at the end of the biennium shall not r evert to the credit of the
76 general reven ue fund.
77 (3) The state tre asurer shall invest moneys in the fund in the same manner as
78 other funds ar e invested. Any interes t and moneys earned on such investments shall be
79 cr edited to the fund.
✔
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