Bill Text: NJ A5285 | 2016-2017 | Regular Session | Introduced
Bill Title: Establishes certain best practices for maternal care, and establishes Maternal Mortality Review Commission to annually review maternal death rates and causes and recommend further improvements in maternal care.
Spectrum: Partisan Bill (Republican 2-0)
Status: (Introduced - Dead) 2017-12-07 - Introduced, Referred to Assembly Women and Children Committee [A5285 Detail]
Download: New_Jersey-2016-A5285-Introduced.html
Sponsored by:
Assemblyman DAVID W. WOLFE
District 10 (Ocean)
Assemblyman GREGORY P. MCGUCKIN
District 10 (Ocean)
SYNOPSIS
Establishes certain best practices for maternal care, and establishes Maternal Mortality Review Commission to annually review maternal death rates and causes and recommend further improvements in maternal care.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning maternal care and mortality, supplementing Title 26 of the Revised Statutes, and amending R.S.26:8-24.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. (New section) The Legislature finds and declares that:
a. While most nations across the globe have successfully reduced their maternal mortality rates over the past two and a half decades, in response to a United Nations' call to action, the United States is one of only a handful of countries where maternal mortality rates have continued to rise, increasing by 27 percent between 2000 and 2014.
b. More women die in labor or after childbirth in the United States than in any other high-income nation, and more than half of all maternal deaths in the United States are preventable.
c. Hypertensive disorders, including preeclampsia, severe preeclampsia, eclampsia, HELLP syndrome, and associated conditions, are some of the most common disorders of pregnancy, and are a leading cause of maternal morbidity and mortality. The incidence of preeclampsia, alone, has increased by 25 percent in the United States over the past two decades.
d. Preeclampsia is often accompanied by proteinuria, thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, or cerebral or visual symptoms; can worsen or initially present after delivery; increases the future risk of cardiovascular and metabolic disease in the mother; and, in many cases, remains undiagnosed and untreated by practitioners until after the mother has already suffered a seizure or stroke.
e. For every preeclampsia-related death that occurs in the United States, there are approximately 50 to 100 "near miss" situations involving preeclampsia, which do not result in death, but which still result in significant health risks and health care costs.
f. Obstetric hemorrhage is another leading cause of maternal morbidity and mortality in the United States, and the overall rate of postpartum hemorrhage rose by 26 percent between 1994 and 2006.
g. Rapid recognition and treatment of obstetric hemorrhage is necessary to prevent progressive blood loss in pregnant women, who can lose large volumes of blood very quickly due to physiologic changes that occur during pregnancy; however, because obstetric hemorrhage is a low-volume, high-risk event for any birthing facility, such facilities often do not often have standardized response protocols for hemorrhage control, and do not plan for hemorrhage events, thereby reducing the ability of practitioners to mount a rapid and coordinated response when hemorrhage situations do arise.
h. The failure of practitioners to timely recognize and communicate about a patient's risk factors for maternal hemorrhage and hypertensive disorders such as preeclampsia, and the failure of practitioners to adequately identify warning signs of patient deterioration in association with these conditions, often leads to delays in diagnosis and treatment while allowing for the development of more severe complications, and thereby increases the likelihood of maternal death stemming from these conditions.
i. Birthing facilities in other states, which have implemented systematic protocols for recognizing and responding to maternal complications, have demonstrated improved maternal outcomes, and have reduced the use of more severe obstetric interventions such as uterine artery embolization and hysterectomy.
j. Non-medically indicated elective deliveries, including induced deliveries and cesarean deliveries occurring before 39 weeks of gestation, carry significant risks for the baby with no known benefit to the mother, and non-medically indicated cesarean deliveries can also cause significant problems for the mother, both in the short and long term.
k. The rate of cesarean deliveries among American women rose 53 percent from 1996 to 2007, and cesarean deliveries now account for 32 percent of all births in the United States and 37 percent of all births in New Jersey.
l. A cesarean section constitutes major abdominal surgery, which is associated with immediate risks such as hemorrhage, longer hospital stays, longer and more painful recovery times, delayed and difficult breastfeeding, and psychological stress, anxiety, and post-traumatic stress disorder. In addition, each subsequent cesarean section significantly increases the risk of major maternal complications, including uterine rupture, uterine atony, placenta previa, placenta accreta, and surgical adhesions.
m. Women often request the early induction of labor, or the early use of a cesarean section, without knowing the negative clinical implications of these procedures.
n. Non-pharmacological interventions and approaches to labor can be used to improve any woman's coping abilities and levels of comfort during childbirth, and can also facilitate proper fetal rotation and positioning, thereby making a successful vaginal delivery more likely. In addition, the availability of labor and birthing support from a doula has been associated with lower cesarean section rates, fewer obstetric interventions, fewer complications, decreased use of pain medication, shorter labor hours, and higher scores on the APGAR test, which indicates how well a baby is doing outside the womb.
o. In order to reduce the rate of maternal death in New Jersey and ensure that maternal patients are provided with attentive, respectful, responsive, and high quality care, it is reasonable and necessary for the State to adopt certain best practices for maternal care, and to establish a commission that will review the rates and causes of maternal death in the State, and develop additional recommendations and best practices to improve care in this area.
2. (New section) As used in this act:
"Birthing center" means a licensed ambulatory care facility or a distinct part of a facility that is separately licensed as an ambulatory care facility, which provides routine prenatal and intrapartal care to low-risk patients who are expected to deliver newborns that weigh more than 2,499 grams and are at least 37 weeks of gestational age, and who are expected to require less than 24 hours of postpartum observation after delivery.
"Commissioner" means the Commissioner of Health.
"Department" means the Department of Health.
"Doula" means a trained professional who provides physical, emotional, and educational support, but not medical care, to maternal patients during labor and delivery.
"Maternal death" means a pregnancy-associated death, or a pregnancy-related death.
"Maternal Mortality Review Commission" or "commission" means the Maternal Mortality Review Commission, established pursuant to section 13 of this act, which is responsible for annually reviewing and reporting on maternal death rates and the causes of maternal death in the State, and which is further responsible for providing recommendations to improve maternal care and reduce adverse maternal outcomes.
"Maternal patient" or "patient" shall mean a pregnant woman or new mother who is receiving medical care during pregnancy, during labor and delivery, or within six weeks after delivery.
"Obstetric hemorrhage" means intrapartum or postpartum blood loss of at least 1,000 mL, or intrapartum or postpartum blood loss that is accompanied by signs or symptoms of hypovolemia within 24 hours following the birth process.
"Practitioner" means a physician, nurse, certified midwife, certified nurse midwife, or other health care practitioner who is licensed or certified pursuant to Title 45 of the Revised Statutes, and who attends to, or is on the care team of, a maternal patient.
"Pregnancy-associated death" means the death of a woman, which occurs while the woman is pregnant, or during the one-year period following the date of the end of the pregnancy, irrespective of the cause of death.
"Pregnancy-related death" means the death of a woman, which occurs while the woman is pregnant, or during the one-year period following the date of the end of the pregnancy, regardless of the duration of the pregnancy, and which results from any cause related to, or aggravated by, the pregnancy or its management, but excluding any accidental or incidental cause.
"Report of maternal death" means a report of actual or perceived maternal death, which is filed with the department, pursuant to the processes established under subsection a. of section 16 of this act, and which is to be forwarded to the commission for the purposes of investigation, as provided by subsection b. of section 16 of this act.
"Severe maternal morbidity" means the physical and psychological conditions that result from, or are aggravated by, pregnancy, and which have an adverse effect on the health of a woman.
"State registrar" means the State registrar of vital statistics, who is responsible for supervising the registration of, and maintaining, death records in the State, in accordance with the provisions of R.S.26:8-1 et seq.
"Supportive care techniques" or "supportive care" means non-pharmacological methods and techniques that are used to provide continuous support to, and improve the comfort of, laboring patients, in order to help them to cope with the mental and physical strains associated with labor. "Supportive care techniques" include, but are not limited to, breathing and relaxation techniques, touch therapy and massage, heat and cold therapy, hydrotherapy, sterile water injections, and transcutaneous electrical nerve stimulation (TENS).
3. (New section) a. Every birthing center, and every hospital that provides care to maternal patients, shall:
(1) implement regularly scheduled simulation drills to allow practitioners to practice their response to obstetric hemorrhage, hypertensive disorders such as preeclampsia, and other critical obstetric events such as emergency cesarean sections; and
(2) consider establishing a rapid response obstetric team, which will be required to regularly train under simulated conditions and develop and implement skilled and coordinated responses to critical obstetric events occurring in the facility, and which will act as the primary response team when critical obstetric events occur.
b. Simulation drills conducted pursuant to this section shall provide for practitioners to diagnose and treat a wide array of critical obstetric conditions in patients with varying degrees of symptomatic presentation and varying levels of treatment response, and shall attempt to prepare practitioners to deal appropriately with any unforeseen circumstances in treatment, and to identify subtle or unusual indicators of patient deterioration.
4. (New section) a. Every birthing center, and every hospital that provides care to maternal patients, shall maintain a preeclampsia response tool kit in a central and easily accessible location, both in the labor and delivery unit and in the postpartum unit.
b. Each preeclampsia response tool kit shall contain the following medications and supplies needed for the treatment of hypertensive disorders, preeclampsia, severe preeclampsia, eclampsia, HELLP syndrome, and associated conditions:
(1) Magnesium sulfate;
(2) Labetalol, in both tablet and liquid form;
(3) Hydralazine;
(4) Calcium gluconate;
(5) Propofol or another similar anesthetic;
(6) an IV start kit, or tubing, needles, and syringes in various sizes, as necessary to provide intravenous administration of the medications described in this subsection;
(7) intubation equipment, including endotracheal tubing, tube holders, and a carbon dioxide detector; and
(8) any other appropriate equipment or medications, such as second-line anti-hypertensives, as may be determined by the facility or the Maternal Mortality Review Commission to be necessary.
5. (New section) Practitioners providing care to maternal patients shall adhere to the following best practices when assessing and treating patients for hypertensive disorders, including, but not limited to, preeclampsia, severe preeclampsia, eclampsia, HELLP syndrome, and associated conditions:
a. A patient who presents with a new onset of hypertension or proteinuria shall be determined to be at a high risk of hypertensive disorders, preeclampsia, and associated conditions, shall be closely monitored in relation to the development of such disorders, and, if the onset of hypertension or proteinuria occurs prior to delivery, shall be evaluated to determine whether a diagnosis of early-onset preeclampsia is warranted.
b. A patient who presents with vague symptoms, such as headache, abdominal pain, shortness of breath, generalized swelling, or other non-descript indications of distress, shall be evaluated for atypical presentations or severe features of preeclampsia.
c. A patient who presents with a blood pressure of at least 160 systolic or 105 to 110 diastolic shall be treated with antihypertensive medications as soon as possible, and no later than one hour after presentation.
d. A patient who presents with preeclampsia, severe preeclampsia, eclampsia, HELLP syndrome, or another associated condition at a facility that has limited resources to care for either the infant or mother shall be stabilized and transferred to another facility that has the capacity to provide appropriate care for expected and unexpected complications arising in both the infant and mother.
e. Magnesium sulfate therapy for seizure prophylaxis shall be administered to any patient who presents with severe preeclampsia with subjective neurological symptoms, such as headache, blurry vision, or right upper quadrant or epigastric abdominal pain, and shall be considered for use in any patient who presents with preeclampsia without such severe features.
f. Magnesium sulfate therapy shall be administered immediately to any patient who is suffering from an eclamptic seizure, and the patient's airway shall be opened, protected, and adequately maintained during any such seizure event, preferably by an anesthesiologist who is accustomed to treating unconscious patients, in order to prevent hypertensive brain hemorrhage and encephalopathy, and fetal and maternal hypoxic brain damage.
g. Magnesium sulfate therapy shall be administered to any patient who is diagnosed with HELLP syndrome or severe preeclampsia, and to any unstable patient whose hypertensive disorder is evolving.
h. A patient who is diagnosed with severe preeclampsia at 34 or more weeks of gestation, and a patient who is diagnosed with preeclampsia without severe features at 37 or more weeks of gestation, shall undergo appropriate delivery procedures.
i. A patient who is diagnosed with gestational hypertension, preeclampsia, or superimposed preeclampsia shall have their blood pressure regularly monitored, either in the hospital or on an outpatient basis, for at least 72 hours postpartum, and shall have their blood pressure measured again seven to 10 days after delivery, or at an earlier date if the patient presents with symptoms.
j. A patient who is diagnosed with preeclampsia, severe preeclampsia, eclampsia, HELLP syndrome, or an associated condition shall be given regular status updates, shall be closely monitored in the facility by a nurse who is experienced in caring for high-risk patients, and shall be subject to an early post-discharge follow-up evaluation conducted within three to seven days after delivery if blood pressure medication was administered during the labor and delivery or postpartum, or within seven to 14 days after delivery if no such medication was administered.
k. Upon a patient's discharge from the facility, the patient shall be provided with a clear and simply written list of patient symptoms that may indicate the development of preeclampsia and associated conditions, as well as a pictogram that shows these symptoms in a visual format. The patient shall also be verbally informed of these symptoms, and instructed to go immediately to the hospital if any such symptoms arise during the six week period immediately following delivery.
l. A patient in the postpartum period who presents with hypertension, preeclampsia, severe preeclampsia, eclampsia, HELLP syndrome, or an associated condition at the emergency department of a hospital shall be assessed by, or admitted to, an obstetrical service. If the patient is treated in the emergency department and is discharged, the emergency department shall arrange for adequate follow-up care to be provided by an obstetrical provider.
m. A patient in the postpartum period who presents with a headache shall be evaluated for the onset of delayed postpartum preeclampsia.
n. Practitioners shall take care in treating hypertensive disorders in a patient who has a history of chronic cocaine or amphetamine use, since treatment for hypertension may cause an exaggerated decrease in blood pressure in such a patient.
6. (New section) a. Every birthing center, and every hospital that provides care to maternal patients, shall maintain a mobile hemorrhage response cart in a central and easily accessible location in both the labor and delivery unit and the postpartum unit, to be used in cases of obstetric hemorrhage. The cart shall contain the following sterile supplies, which may be necessary to properly treat an obstetric hemorrhage:
(1) vaginal retractors and a long weighted speculum;
(2) at least two sponge forceps;
(3) B-Lynch sutures and sutures for cervical laceration repair;
(4) vaginal packs;
(5) at least one intrauterine balloon;
(6) assorted sizes of banjo curettes;
(7) a long needle holder;
(8) uterine forceps;
(9) a bright task light on wheels;
(10) an ultrasound machine;
(11) diagrams depicting various hemorrhage control procedures, such as B-Lynch suturing, uterine artery ligation, and intrauterine balloon placement;
(12) an IV start kit, or tubing, needles, and syringes in various sizes, as necessary to provide intravenous administration of the medications described in subsection b. of this section; and
(13) any other equipment or tools that the facility or Maternal Mortality Review Commission deems to be necessary.
b. (1) In addition to the supplies described in subsection a. of this section, a hemorrhage response cart shall be stocked with a supply of the following medications:
(a) one IV bag of oxytocin;
(b) one ampule of Hemabate;
(c) five tablets of Cytotec;
(d) one ampule of Methergine;
(e) a one liter bag of Ringer's lactate solution; and
(f) any other appropriate medications, including, but not limited to, second-line uterotonic drugs, as may be determined by the facility or the Maternal Mortality Review Commission to be necessary.
(2) A hemorrhage response cart shall ideally be equipped with a refrigeration unit in which to store the medications identified in this subsection; however, if a hemorrhage response cart does not have refrigeration capacity, the facility may elect to maintain any medications requiring refrigeration in an unlocked refrigerated space that is separate from the hemorrhage response cart. In any such case, the facility shall ensure that a separate stock of such medications is maintained in both the labor and delivery unit and the postpartum unit, and remains readily accessible to all practitioners.
7. (New section) Practitioners providing care to maternal patients shall adhere to the following best practices when preparing for and responding to an obstetric hemorrhage:
a. Blood products shall be available on-site at the time of delivery, and their availability shall be clearly communicated to all members of the clinical team caring for the patient in the labor and delivery unit, and in the postpartum unit.
b. The patient shall be regularly evaluated during the prenatal, intrapartum, and postpartum periods, in order to determine whether the patient has developed any risk factors for obstetric hemorrhage. Such evaluation shall occur: (1) at least once during the prenatal period; (2) immediately upon the patient's admission to the labor and delivery unit; (3) after admission, at least once per shift until the time of delivery; (4) at the time of delivery; and (5) at least once per shift during the first 24 hours of the postpartum period. The birthing plan shall be modified, as appropriate, to respond to and mitigate any identified hemorrhage risk factors, and all members of the clinical team caring for the patient in the labor and delivery unit, and in the postpartum unit, shall be made aware of any identified risk factors.
c. The patient's medical, surgical, and pregnancy history shall be reviewed, prior to delivery, in order to determine whether the patient has any coagulation or bleeding disorders, has had any prior clinical symptoms of excessive bleeding after surgery, or has a history of noticeable bruising, joint hemorrhage, or heavy menstrual bleeding. A patient with any such history shall be encouraged to undergo laboratory screening tests for hemophilia and von Willebrand Disorder, prior to delivery. If the patient is determined to have a coagulation or bleeding disorder, intrapartum and postpartum management plans shall be developed well in advance of, and the patient shall undergo a consultation with a hematologist prior to, the date of delivery, and any necessary medications and blood components shall be available on-site during labor and delivery.
d. A patient who has had a prior cesarean birth shall be given an ultrasound screening, prior to delivery, in order to determine whether the patient has developed placenta previa. A patient who is determined to have placenta previa shall be given a follow-up screening with ultrasound, or with MRI if the ultrasound is inconclusive or suspicious, to determine whether placenta accreta has occurred.
e. A patient who is determined to have placenta accreta shall receive counseling about delivery risks, potential complications, and the possibility of future infertility if a hysterectomy is performed. Prior to delivery, the blood bank shall be notified of the potential for massive hemorrhage, and a multi-disciplinary approach for delivery, which includes a plan for emergency surgery, shall be developed by all relevant practitioners, in consultation with each other. Planning shall include the primary obstetric surgeon, the blood bank, the perinatologist, the anesthesiologist, the gynecologic oncologist or experienced pelvic surgeon, the labor and delivery nurses, any operating room personnel, the nursery and pediatric teams, and any other relevant practitioners. During labor and delivery of a patient with placenta accreta, four to six units of PRBC, FFP, and platelets, and a surgeon with advanced skills in controlling heavy pelvic bleeding and repairing injuries to the bladder and urethra, shall be immediately available in the delivery room.
f. In the case of significant obstetric hemorrhage, a resuscitation transfusion shall be administered based on the patient's vital signs and blood loss, and shall not be delayed while awaiting laboratory results.
g. During a massive resuscitation transfusion, the patient's arterial blood gas, electrolytes, and core temperature shall be monitored to guide clinical management. In addition, all transfused fluids shall be warmed, and the direct warming of the patient shall be initiated as needed to maintain euthermia and avoid added coagulopathy.
h. Whenever a balloon is inserted to control intrauterine bleeding, practitioners shall remain aware of the potential for concealed intra-abdominal bleeding. The patient shall be carefully inspected for unrepaired lacerations prior to intrauterine balloon insertion, and practitioners shall closely monitor the patient's vital signs after the balloon is inserted, even when visible bleeding has been reduced or eliminated.
i. A tailored and specific
discharge plan shall be prepared for any patient who has experienced an
obstetric hemorrhage. Such plan shall provide for at least one follow-up
assessment of the patient's physical and emotional recovery, and shall include
referrals for counseling and community supports.
8. (New section) a. Practitioners providing care to maternal patients shall adhere to the following best practices when assessing obstetric blood loss:
(1) Cumulative blood loss of 500mL for a vaginal birth or 1000mL for a cesarean birth shall alert the attending practitioners to the need for increased surveillance of the patient's blood loss and vital signs;
(2) Rapid interventions shall be initiated following a cumulative blood loss of 500mL or more in a vaginal birth, or 1000mL or more in a cesarean birth, if the bleeding continues or if the practitioner detects any changes in the patient's vital signs;
(3) The amount of blood that has been lost by a patient shall be determined through quantitative measurement, as provided by subsection b. of this section, and shall not be determined solely on the basis of visual observation; however, unusual visual or auditory cues to excessive bleeding, such as blood on the walls, floor, or ceiling, or the continuous vibration of suction tubing, shall be urgently investigated.
b. Quantitative measurement of blood loss shall be accomplished in the following manner:
(1) for vaginal births: (a) under-buttock drapes with graduated markers, or another type of graduated collection container, shall be used to collect any blood lost during labor and delivery; (b) immediately after the birth, practitioners shall assess the amount of fluid in the under-buttock drape or other collection container, and mark this as the baseline value, with all subsequent fluid representing blood loss; (c) at the completion of the delivery, and throughout the recovery period, practitioners shall weigh all blood clots, and all absorbing materials that have been laid on the table or bed, as provided in subsection d. of this section, in order to determine the cumulative volume of blood loss; and
(2) for cesarean births: (a) immediately after the birth, and before delivery of the placenta, all amniotic fluid shall be suctioned and measured to form a baseline value, with all subsequent fluid, except for measured irrigation fluid, representing blood loss; (b) after delivery of the placenta, practitioners shall weigh all lap sponges and other absorbing materials that have been laid on the table or bed, as provided in subsection d. of this section, in order to determine the cumulative volume of blood loss.
c. To facilitate the quantitative measurements required by this subsection, dry lap sponges, under-buttock drapes, and other dry absorbent materials, as appropriate, shall be placed on the operating table or patient's bed immediately after a baseline value has been established, as provided by paragraphs (1) and (2) of subsection b. of this section. Whenever bloodied materials are removed from the table or bed for weighing purposes, they shall be immediately replaced with other absorbing materials.
d. In weighing bloodied absorbent materials pursuant to this section, saturation levels shall be determined by comparing the weight of the bloodied item to the weight of the item when dry, and one gram of increased weight shall equal one mL of fluid loss. To the extent practicable, practitioners shall use electronic tools, such as the Triton OR, to assist in weighing bloodied materials pursuant to this section. The weighing of bloodied materials, and the replacement of bloodied materials with dry absorbent materials, shall continue at regular and frequent intervals until the patient's bleeding is stopped.
e. Every birthing center, and every hospital that provides care to maternal patients, shall establish a standardized in-house training program to train practitioners in quantitative blood loss measurement, as provided in this section. All practitioners employed at the facility shall be required to successfully complete this standardized training on at least an annual basis.
9. (New section) a. Every birthing center, and every hospital that provides care to maternal patients, shall maintain a log that shows the number of blood products that were used for obstetric hemorrhage during each month, and the number of patients during each month who required large transfusions of at least four units of packed red blood cells. This data shall be used as an internal measure of the quality of maternal care provided by the facility, and as a means to evaluate the success of any obstetric quality improvement initiatives that are instituted by the facility.
b. In any case where a patient has experienced a cumulative blood loss of more than 1000mL, or has received four or more units of blood products, the facility where care was provided shall complete an intensive case review to determine the root causes of both the hemorrhage and any delays in treatment. Based on the case review, the facility shall identify opportunities for improvement in the quality of care provided, and shall implement strategies and protocols to address identified issues and make improvements in care.
10. (New section) a. Every birthing center, and every hospital providing care to maternal patients, shall perform a comprehensive review of existing policies used in the labor and delivery unit, and revise those policies appropriately, so as to: (1) support and encourage vaginal births; (2) encourage patients to carry their pregnancies to full term, and discourage patients and practitioners from engaging in non-medically indicated labor inductions and cesarean section procedures; and (3) safely reduce the use of routine interventions for low-risk patients. Each facility shall additionally implement an ongoing quality improvement program that is designed to reduce unnecessary cesarean section and labor induction procedures.
b. The revised policies implemented pursuant to subsection a. of this section shall:
(1) discourage the admission of low-risk patients during early, non-active labor, and provide written, standardized criteria for admitting patients in active labor, and for determining when patients in early labor should be provided with continued on-site observation of their labor status, or discharged to their homes;
(2) require informational material to be provided to any patient in early labor who is discharged to her home, explaining the rationale for delayed admission and the safety of completing early labor at home, describing the expectations for early labor, and providing guidance on when to return to the labor and delivery unit;
(3) establish protocols for the safe, patient-centered transfer of a patient from an off-site birthing environment to the birthing center or hospital, and provide for the development of relationships with local off-site providers, as may be necessary to increase collaborative communication and facilitate safe and respectful transfers of care;
(4) provide for the better integration of doulas into the maternal care team; establish guidelines that foster two-way teaching between nurses and doulas, and that facilitate the delineation and mutual understanding of the specific roles and expectations of nurses and doulas on the care team; and encourage teamwork, open communication, and collegial rapport between nurses and doulas to promote safe, patient-centered care and continuous labor support. The integration of doulas into the maternal care team may be accomplished by working with a local doula organization, by connecting with community-based doula programs, or by implementing a facility-based doula program, as deemed by the hospital or birthing center to be appropriate;
(5) promote the use of early labor supportive care techniques and other non-pharmacologic methods that support the physiologic onset of active labor, reduce stress and anxiety for the patient and family, and improve coping and pain management; eliminate any staffing or documentation requirements or protocols that act as a barrier to the application of supportive care techniques within the facility; and require informational materials and specific guidance to be provided to each patient's spouse, partner, and family members to encourage and empower those actors to provide supportive care to the patient during labor;
(6) ensure that unit nurses possess the training, knowledge, and competency necessary to engage in supportive care techniques, and to support labor progress and prevent dysfunctional labor through the use of non-pharmacologic methods, such as by facilitating the patient's freedom of movement and upright and ambulatory positioning, and engaging in the use of techniques and tools that facilitate fetal rotation, flexion, and descent for patients both with and without epidural anesthesia; and encourage nurses to make liberal use of these supportive care techniques and non-pharmacologic methods of care;
(7) require unit nurses to help reposition the patient at least once every 20 minutes during labor, in order to better ensure appropriate fetal positioning;
(8) provide for the adequate availability, within the unit, of non-pharmacologic coping tools, such as tubs or showers, rocking chairs, birthing balls, squat bars, and peanut balls; require practitioners to encourage patients without an epidural to move, stand, walk, make frequent position changes, and make use of available non-pharmacologic coping tools, in the patient's discretion; and require practitioners to support the upright positioning and regular repositioning of patients with epidurals;
(9) require unit practitioners to regularly assess each patient's pain levels and ongoing coping abilities;
(10) require unit practitioners to evaluate the position of the fetus in laboring patients, where feasible, during the early second stage of labor, and to utilize appropriate pre-delivery interventions, such as the rotation of the baby by hand or instrument, in the event that the fetus is malpositioned;
(11) allow for patients with regional anesthesia to experience longer durations of the second stage of labor, as long as maternal and fetal statuses remain reassuring;
(12) allow for passive descent of the fetus when the patient is not experiencing an urge to push, and allow for a delay in pushing until the patient has a stronger urge to do so, which generally occurs one to two hours after complete dilation;
(13) require practitioners to preserve as much motor function in the patient as is possible by administering the lowest concentration of epidural anesthetic necessary to provide adequate maternal pain relief, or by utilizing patient-controlled epidural anesthesia with a background maintenance infusion that is intermittent or continuous; but ensure that practitioners do not delay or avoid the administration of epidural anesthesia, where warranted;
(14) promote the default use of intermittent fetal auscultation or intermittent electronic fetal monitoring during labor in low-risk patients, as opposed to the use of continuous fetal monitoring; ensure that relevant practitioners are trained and competent in intermittent auscultation and monitoring procedures; ensure adequate staffing to accommodate intermittent auscultation and monitoring; provide a checklist with exclusion criteria, which can be used by practitioners to identify low-risk patients for which intermittent auscultation or monitoring is appropriate; modify standing admission protocols to reflect the fact that intermittent auscultation or electronic fetal monitoring is the default mode of monitoring low-risk patients who do not meet identified exclusion criteria; require practitioners to engage in shared decision-making with each patient, after providing education thereto about the various types of intermittent and continuous monitoring, in order to determine the most appropriate method of monitoring in each case; provide for practitioners to engage in on-going patient assessments to determine whether it is appropriate to continue intermittent monitoring or necessary to convert to continuous monitoring; and encourage the use of telemetry for patients who require continuous monitoring, so as to enable the patient to remain mobile;
(15) provide that vaginal birth shall remain the preferred method of birth for patients with a history of genital herpes who do not have active lesions at the time of delivery;
(16) establish standardized diagnostic criteria and response mechanisms to help practitioners engage in the safe use of oxytocin, appropriately respond to abnormal fetal heart rate patterns and uterine activity, and identify and appropriately respond to maternal, fetal, and placental dystocia;
(17) encourage unit physicians to engage in operative vaginal delivery, as opposed to cesarean delivery, in eligible cases, and ensure that unit physicians are trained and competent in forceps and vacuum extraction techniques; and
(18) ensure that unit practitioners are educated about the potential maternal and neonatal complications that may be associated with non-medically indicated pre-term labor inductions; require practitioners to educate patients about these potential complications; discourage practitioners from engaging in the induction of labor, except when medically indicated as provided by subsection d. of this section; require practitioners to recommend the induction of labor at or after 41 weeks of gestation, in order to reduce the risk of cesarean delivery and perinatal morbidity and mortality, and require patients undergoing induction without a favorable cervix to receive cervical ripening.
c. The policies adopted pursuant to this section shall reflect and be consistent with any available national quality standards or criteria, and any relevant standards adopted by the American Congress of Gynecologists (ACOG).
d. Acceptable medical
indications supporting the induction of labor shall include the following: (1)
placental abruption; (2) fetal demise in either the current pregnancy or a
previous pregnancy; (3) premature rupture of membranes; (4) a gestational
period that has lasted at least 41 weeks without the advent of spontaneous
labor; (5) maternal medical conditions, including pre-existing or gestational
diabetes, renal disease, chronic pulmonary disease, cholestasis of pregnancy, cardiovascular
diseases, HIV infection, or maternal coagulation defects such as
antiphospholipid syndrome; or (6) fetal medical conditions, including, but not
limited to, IUGR, oligohydramnios, polyhydramnios, fetal distress,
isoimmunization, fetal-maternal hemorrhage, fetal malformation, chromosomal
abnormality, or suspected fetal injury.
11. (New section) Practitioners providing care to maternal patients shall adhere to the following best practices when engaging in prenatal care:
a. Patients in the prenatal period, and their families, shall be provided with educational information about the expectations of early labor, the safety of completing early labor at home, the supportive care techniques that can be used to facilitate the completion of early labor, and the potential maternal and neonatal complications that may be associated with non-medically indicated labor inductions and cesarean section procedures;
b. Fetal presentation shall be assessed no later than the 36th week of gestation;
c. Patients who are determined to have a singleton breech fetus shall be afforded the opportunity to undergo external cephalic version (ECV) prior to delivery; and
d. Oral suppressive therapy shall be offered at 35 weeks of gestation, or within three to four weeks before expected delivery, to any patient with a history of genital herpes, including those without active lesions.
12. (New section) a. Every birthing center, and every hospital providing care to maternal patients, shall annually report the following information to the department:
(1) the number and percentage of maternal patients who were treated for hypertensive disorders, including preeclampsia and associated conditions, during the reporting period;
(2) the number and percentage of maternal patients who experienced an obstetric hemorrhage during the reporting period, and the number and percentage of such patients who experienced an obstetric hemorrhage necessitating an intensive case review under subsection b. of section 9 of this act;
(3) the number of intensive case reviews necessitated under subsection b. of section 9 of this act that were successfully completed during the reporting period, and the number of intensive case reviews from the current and prior reporting periods that are still outstanding;
(4) the number and percentage of maternal patients who underwent non-medically indicated labor induction procedures, and the number and percentage of maternal patients who underwent medically indicated induction procedures, during the reporting period;
(5) the number and percentage of maternal patients who underwent non-medically indicated cesarean section procedures, and the number and percentage of maternal patients who underwent medically indicated cesarean section procedures, during the reporting period;
(6) the number and percentage of maternal patients who delivered after the onset of spontaneous labor;
(7) the number and percentage of maternal patients who delivered at 41 or more weeks of gestation;
(8) the number and percentage of maternal patients who delivered at 39 or more weeks of gestation;
(9) the number and percentage of maternal patients who delivered after 37 weeks of gestation, but before 39 weeks of gestation;
(10) the number and percentage of maternal patients who delivered after 34 weeks of gestation, but before 37 weeks of gestation; and
(11) any other information that the department deems to be necessary.
b. The department shall compile the information received pursuant to this section into an online database, which shall be searchable by facility. The database shall be accessible to the public, and a hyperlink to the database shall appear at a publicly-accessible location on the department's Internet website. Wherever possible, the facility-specific data included in the database shall be depicted in a graph or other pictorial form, so that practitioners, facilities, members of the public, and members of the Maternal Mortality Review Commission can quickly and easily identify upward or downward trends in facility-specific data and compare variances among facilities.
13. (New section) a. There is hereby established, in the Department of Health, the Maternal Mortality Review Commission, which shall be tasked with annually reviewing and reporting on maternal death rates and the causes of maternal death in the State, and providing recommendations to improve maternal care and reduce adverse outcomes related to, or associated with, pregnancy. The commission shall be composed of 31 members, including 18 ex officio members or their designees, as provided in subsection b. of this section, and 13 public members, as provided in subsection c. of this section.
b. The ex officio members of the commission shall include the following persons, or their designees: the State registrar; the State Medical Examiner; the Director of the Division of Family Health Services in the Department of Health; the Director of the Office of Emergency Medical Services in the Department of Health; the Director of the Office of Minority and Multicultural Health in the Department of Health; the Director of the Division of Medical Assistance and Health Services in the Department of Health; the President of the New Jersey Hospital Association; the President of the New Jersey Health Care Quality Institute; the Chief Executive Officer of the Medical Society of New Jersey; the Executive Director of the New Jersey Chapter of the National Association of Social Workers; the Chair of the New Jersey section of the American Congress of Obstetricians and Gynecologists; the President of the New Jersey Affiliate of the American College of Nurse Midwives; the Executive Director of the Partnership for Maternal and Child Health of Northern New Jersey; the Chief Executive Officer of the Central Jersey Family Health Consortium; the Executive Director of the Southern New Jersey Perinatal Cooperative; the Director of the City of Newark's Department of Health and Community Wellness; the Director of the City of Trenton's Health and Human Services Department; and the Director of the Camden County Department of Health and Human Services.
c. The public members of the commission shall be appointed by the Governor, and shall include: five licensed and practicing health care practitioners, one of whom specializes in obstetrics or gynecology, one of whom specializes in maternal and fetal medicine, one of whom specializes in family planning, one of whom specializes in critical care medicine, and one of whom specializes in perinatal pathology; one licensed and practicing health care practitioner, mental health care practitioner, or substance use disorder treatment professional who specializes in perinatal addiction; one certified nurse midwife; one registered professional nurse or advanced practice nurse who specializes in hospital-based obstetric nursing; one licensed practical nurse, registered professional nurse, or advanced practice nurse who participates in, and represents, the Nurse-Family Partnership operating in New Jersey; one health care administrator who has experience in overseeing the operations of maternity wards or birthing centers; one private citizen who is engaged in maternal health advocacy; one private citizen who is engaged in minority health advocacy; and one private citizen who is engaged in patient advocacy.
d. Of the public members appointed to the commission, not more than seven shall be of the same political party.
e. Each public member of the commission shall serve for a term of four years; however, of the public members first appointed, four shall serve an initial term of two years, four shall serve an initial term of three years, and five shall serve an initial term of four years. Each public member shall serve for the term of their appointment, and until a successor is appointed and qualified, except that a public member may be reappointed to the commission upon the expiration of their term. Any vacancy in the membership shall be filled, for the unexpired term, in the same manner as the original appointment.
f. All initial appointments to the commission shall be made within 60 days after the effective date of this act.
g. Any member of the commission may be removed by the Governor, for cause, after a public hearing.
14. (New section) a. The commission shall organize as soon as practicable following the appointment of a majority of its members, and shall annually elect a chairperson and vice-chairperson from among its members. The chairperson may appoint a secretary, who need not be a member of the commission.
b. The commission shall meet pursuant to a schedule to be established at its first meeting, and it shall additionally meet at the call of its chairperson or the Commissioner of Health; however, in no case shall the commission meet less than four times a year.
c. A majority of the total number of members appointed to the commission shall constitute a quorum for the conducting of official commission business. A vacancy in the membership of the commission shall not impair the right of the commission to exercise its powers and duties, provided that a majority of the currently appointed members are available to conduct business. Any recommendations of the commission shall be approved by a majority of the members present.
d. The members of the commission shall serve without compensation, but shall be reimbursed for travel and other necessary expenses incurred in the discharge of their official duties, within the limits of funds appropriated or otherwise made available for such purposes.
e. The Department of Health shall provide such administrative staff support to the commission as shall be necessary for the commission to carry out its duties.
15. (New section) a. The Maternal Mortality Review Commission shall have the power to:
(1) carry out any power, duty, or responsibility expressly granted by this act;
(2) adopt, amend, or repeal suitable bylaws for the management of its affairs;
(3) maintain an office at such place or places as it may designate;
(4) apply for, receive, and accept, from any federal, State, or other public or private source, grants, loans, or other moneys that are made available for, or in aid of, the commission's authorized purposes, or that are made available to assist the commission in carrying out its powers, duties, and responsibilities under this act;
(5) enter into any and all agreements or contracts, execute any and all instruments, and do and perform any and all acts or things necessary, convenient, or desirable to further the purposes of the commission;
(6) call to its assistance, and avail itself of the services of, such employees of any State entity or local government unit as may be required and available for the commission's purposes;
(7) review and investigate reports of maternal death; conduct witness interviews, and hear testimony provided under oath at public or private hearings, on any material matter; and request, or compel through the issuance of a subpoena, the attendance of relevant witnesses and the production of relevant documents, records, and papers;
(8) solicit and consider public input and comment on the commission's activities by periodically holding public hearings or conferences, and by providing other opportunities for such input and comment by interested parties; and
(9) identify, and promote the use of, best practices in maternal care, and encourage and facilitate cooperation and collaboration among health care facilities, practitioners, administrative agencies, and local government units for the purposes of ensuring the provision of the highest quality maternal care throughout the State.
b. The Maternal Mortality Review Commission shall have the duty and responsibility to:
(1) develop mandatory and voluntary maternal death reporting processes, in accordance with the provisions of section 16 of this act;
(2) conduct an investigation of each reported case of maternal death, and prepare a de-identified case summary for each such case, in accordance with the provisions of section 17 of this act;
(3) review the statistical data on maternal deaths that is forwarded by the State registrar, pursuant to section 21 of this act, and the reports of maternal death that are forwarded by the department, pursuant to subsection b. of section 16 of this act, in order to identify Statewide and regional maternal death rates; trends, patterns, and disparities in adverse maternal outcomes; and medical, non-medical, and system-related factors that may have contributed to maternal deaths and treatment disparities; and
(4) annually report its findings and recommendations on maternal mortality to the department, the Governor, and the Legislature, in accordance with section 18 of this act.
16. (New section) a. Within 90 days after the commission's organizational meeting, the commission shall:
(1) develop a mandatory maternal death reporting process, pursuant to which practitioners, medical examiners, hospitals, birthing centers, and other relevant professional actors and health care facilities will be required to confidentially report to the Department of Health on individual cases of maternal death; and
(2) develop a voluntary maternal death reporting process, pursuant to which the family members of a deceased woman, and any other interested members of the public, will be permitted, but not required, to confidentially report to the Department of Health on individual cases of perceived maternal death. At a minimum, the process developed pursuant to this paragraph shall require the department to: (a) post on its Internet website a hyperlink, a toll-free telephone number, and an email address, which may each be used for the voluntary submission of public reports of maternal death; and (b) publicize the availability of these resources to professional organizations, community organizations, social service agencies, and members of the public.
b. The department shall keep a record of all reports of maternal death that are submitted thereto through the reporting processes that are established by the commission pursuant to paragraphs (1) and (2) of subsection a. of this section. The department shall also ensure that a copy of each such report of maternal death is promptly forwarded to the commission, so that the commission may properly execute its investigatory functions and other duties and responsibilities under this act.
17. (New section) a. Upon receipt of a report of maternal death, which has been forwarded to the commission pursuant to subsection b. of section 16 of this act, the commission shall investigate the reported case in accordance with the provisions of this section. In conducting the investigation, the commission shall consider:
(1) the information contained in the forwarded report of maternal death;
(2) any relevant information contained in the deceased woman's autopsy report or death record, or in a certificate of live birth or fetal death for the woman's child, or in any other vital records pertaining to the woman;
(3) any relevant information contained in the deceased woman's medical records, including: (a) records related to the health care that was provided to the woman prior to her pregnancy; (b) records related to the woman's prenatal and postnatal care, labor and delivery care, emergency room care, and any other care delivered up until the time of the woman's death; and (c) the woman's hospital discharge records;
(4) information obtained through the oral and written interviews of individuals who were directly involved in the care of the woman either during, or immediately following, her pregnancy, including interviews with relevant health care practitioners, mental health care practitioners, and social service providers, and, as deemed to be appropriate and necessary, interviews with the woman's family members;
(5) background information about the deceased woman, including, but not limited to, information regarding the woman's age, race, and socioeconomic status; and
(6) any other information that may shed light on the maternal death, including, but not limited to, reports from social service or child welfare agencies.
b. At the conclusion of an investigation conducted pursuant to this section, the commission shall prepare a case summary, which shall include the commission's findings with regard to the cause of, or the factors that contributed to, the maternal death, and recommendations for actions that should be undertaken, or policies that should be implemented, to mitigate or eliminate those factors and causes in the future. Any case summary prepared pursuant to this subsection shall omit the personally identifying information of the deceased woman and her family members.
c. The commission may present its findings and recommendations on each individual case, or on groups of individual cases, as deemed appropriate, to the health care facility or facilities where relevant care was provided in the case or group of cases, and to the individual practitioners who provided such care, or to any relevant professional organization, for the purposes of instituting or facilitating policy changes, educational activities, or improvements in the quality of care provided; or for the purposes of exploring, facilitating, or establishing regional projects or other collaborative projects that are designed to reduce instances of maternal death.
d. In addition to investigating reports of maternal death, as provided by this section, the Maternal Mortality Review Commission may additionally elect to investigate alleged cases of severe maternal morbidity, using data and information obtained through patient registries, or the oral or written interviews of pregnant women and their families.
18. (New section) a. Within one year after its organization, and annually thereafter, the commission shall prepare, and submit to the Department of Health, to the Governor, and, pursuant to section 2 of P.L.1991, c.164 (C.52:14-19.1), to the Legislature, a report containing the commission's findings on the rates and causes of maternal deaths occurring in the State during the preceding year, and providing recommendations for legislative or other action that can be undertaken to: (1) improve the quality of maternal care and reduce adverse maternal outcomes in the State; (2) increase the availability of, and improve access to, social and health care services for pregnant women; and (3) reduce or eliminate disparities in maternal care and treatment, both during, and in the year after, pregnancy. Each annual report, with the exception of the first report prepared under this section, shall additionally identify the extent to which the commission's prior recommendations have been successfully implemented in practice, and the apparent impact that the implementation of such recommended changes has had on maternal care in the preceding year.
b. The report that is annually prepared pursuant to this section shall be based on:
(1) the case summaries that were prepared by the commission over the preceding year, pursuant to subsection b. of section 17 of this act;
(2) the statistical data that was forwarded to the commission, during the preceding year, by the State registrar, pursuant to section 21 of this act; and
(3) any other relevant information, including information on any collaborative maternal health arrangements that have been established by health care providers, professional organizations, local government units, or other relevant actors or entities in the preceding year, in response to the commission outreach authorized by subsection c. of section 17, or by paragraph (9) of subsection a. of section 15, of this act.
c. Upon receipt of the commission's annual report pursuant to this section, the department shall post a copy of the report at a publicly accessible location on its Internet website, and shall take appropriate steps to otherwise broadly publicize the commission's findings and recommendations. The Commissioner of Health shall also adopt rules and regulations, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), to implement the recommendations contained in the report, to the extent that such recommendations can be implemented through administrative rule-making action.
19. (New section) a. Upon receipt of the commission's first annual report, issued pursuant to section 18 of this act, the department, working in consultation with the commission, as well as with relevant professional organizations and patient advocacy groups, shall develop an ongoing maternal health educational program for practitioners, as may be necessary to improve the quality of maternal care and reduce adverse outcomes related to, or associated with, pregnancy. The educational program established pursuant to this section shall initially be based on, and shall reflect, the findings and recommendations identified in the commission's first report. However, once the educational program is established, the department shall, on at least a biennial basis thereafter, review the program and make necessary changes to ensure that the ongoing education provided thereunder accurately reflects, and is consistent with, the latest data, findings, and recommendations of the commission, as reflected in the commission's most recent annual report.
b. Each of the State's professional licensing boards, as appropriate, shall adopt rules and regulations, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), which require practitioners under each board's respective jurisdiction to satisfactorily complete the educational program established pursuant to this section. Each licensing board shall require the practitioners under its jurisdiction to complete this educational program as a condition of initial licensure, or, in the case of practitioners who are already licensed as of the effective date of this act, within 180 days after the program is established under this section; and shall additionally require practitioners to complete the program on at least a biennial basis thereafter, as a condition of license renewal.
20. (New section) a. (1) Except as otherwise provided by subsection b. of this section, all proceedings and activities of the Maternal Mortality Review Commission; all opinions of the members of the commission, which are formed as a result of the commission's proceedings and activities; and all records obtained, created, or maintained by the commission, including written reports and records of interviews or oral statements, shall be confidential, and shall not be subject to public inspection, discovery, subpoena, or introduction into evidence in any civil, criminal, legislative, or other proceeding.
(2) In no case shall the commission disclose any personally identifiable information to the public, or include any personally identifiable information in a case summary that is prepared pursuant to subsection b. of section 17 of this act, or in an annual report that is prepared pursuant to section 18 of this act.
(3) Members of the commission shall not be questioned in any civil, criminal, legislative, or other proceeding regarding information that has been presented in, or opinions that have been formed as a result of, a meeting or communication of the commission; however, nothing in this paragraph shall prohibit a commission member from being questioned, or from testifying, in relation to publicly available information or information that was obtained independent of the member's participation on the commission.
b. Nothing in this section shall be deemed to prohibit the commission from publishing, or from otherwise making available for public inspection, case summaries, statistical compilations, or reports that are based on confidential information, provided that those summaries, compilations, and reports do not contain personally identifying information or other information that could be used to ultimately identify the individuals concerned.
21. (New section) a. (1) On an annual basis, and using the death records that have been filed during the preceding year, the State registrar shall identify: (a) the total number of maternal deaths that have occurred in the State during the year, and during each quarter of the year; (b) the average Statewide rate of maternal death occurring during the year; (c) the number and percentage of maternal deaths that occurred during the year in each of the Northern, Central, and Southern regions of the State; (d) the number and percentage of maternal deaths, on a Statewide and regional basis, that constituted pregnancy-associated deaths, and the number and percentage of maternal deaths, on a Statewide and regional basis, that constituted pregnancy-related deaths; and (e) the areas of the State where the rates of maternal death are significantly higher than the Statewide average.
(2) The results of the annual analysis that is conducted pursuant to this subsection shall be posted at a publicly accessible location on the Internet website of the Office of Vital Statistics and Registry, in the Department of Health, and shall also be promptly forwarded to the commission.
b. In order to accomplish its duties under this section, the State registrar shall:
(1) for the purposes of determining the total number of pregnancy-associated deaths, review each woman's death record, and match the death record with a certificate of live birth, or with a fetal or infant death record, for the woman's child, in order to confirm whether the woman died during pregnancy, or within one year after the end of pregnancy; and
(2) for the purposes of determining the total number of pregnancy-related deaths, review each woman's death record, and identify each such death record in which the death is reported to have resulted from an underlying or contributing cause related to pregnancy, regardless of the amount of time that has passed between the end of the pregnancy and the death.
The State registrar may also use any other appropriate means or methods to identify maternal deaths, including, but not limited to, reviewing a random sample of reported deaths to ascertain cases of pregnancy-related death and pregnancy-associated death that are not discernable from a review of death records alone.
22. R.S.26:8-24 is amended to read as follows:
26:8-24. The State registrar shall:
a. Have general supervision throughout the State of the registration of vital records;
b. Have supervisory power over local registrars, deputy local registrars, alternate deputy local registrars, and subregistrars, in the enforcement of the law relative to the disposal of dead bodies and the registration of vital records;
c. Prepare, print, and supply to all registrars, upon request therefor, all blanks and forms used in registering the records required by said law, and provide for and prescribe the use of the NJ-EDRS. The blanks and forms supplied under this subsection, and any electronic blanks and forms that are used in the NJ-EDRS, shall require the person registering a birth or death record, at a minimum, to provide the same information as is required by the National Center for Vital Health Statistics in its standardized U.S. certificates of live birth, death, and fetal death. No [other] blanks , forms, or methods of registration shall be used , other than those that satisfy the requirements of this subsection, and which are supplied or approved by the State registrar;
d. Carefully examine the certificates or electronic files received periodically from the local registrars or originating from their jurisdiction; and, if any are incomplete or unsatisfactory, require such further information to be supplied as may be necessary to make the record complete and satisfactory;
e. Arrange or bind, and permanently preserve the certificates of vital records, or the information comprising those records, in a systematic manner and in a form that is deemed most consistent with contemporary and developing standards of vital statistical archival record keeping;
f. Prepare and maintain a comprehensive and continuous index of all vital records registered, the index to be arranged alphabetically:
1. In the case of deaths, by the name of the decedent;
2. In the case of births, by the name of child, if given, and if not, then by the name of father or mother;
3. In the case of marriages, by the surname of the husband and also by the maiden name of the wife;
4. In the case of civil unions, by the surname of each of the parties to the civil union;
5. In the case of domestic partnerships, by the surname of each of the partners;
g. Mark the birth certificate of a missing child when notified by the Missing Persons Unit in the Department of Law and Public Safety pursuant to section 3 of P.L.1995, c.395 (C.52:17B-9.8c);
h. Develop and provide to local registrars an education and training program, which the State registrar may require each local registrar to complete as a condition of retaining that position, and which may be offered to deputy local registrars, alternate deputy local registrars and subregistrars at the discretion of the State registrar, that includes material designed to implement the NJ-EDRS and to familiarize local registrars with the statutory requirements applicable to their duties and any rules and regulations adopted pursuant thereto, as deemed appropriate by the State registrar; [and]
i. Facilitate the electronic notification, upon completion of the death record and issuance of a burial permit, of the decedent's name, Social Security number and last known address to the Department of Labor and Workforce Development and the Department of Human Services to safeguard public benefit programs and diminish the criminal use of a decedent's name and other identifying information; and
j. Facilitate the provision of relevant statistical data on maternal deaths to the Maternal Mortality Review Commission, in accordance with the provisions of section 21 of P.L. , c. (C. ) (pending before the Legislature as this act).
(cf: P.L.2013, c.274, s.1)
23. The Commissioner of
Health shall adopt rules and regulations, pursuant to the "Administrative
Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), as may be necessary to
implement the provisions of this act.
24. This act shall take effect immediately.
STATEMENT
This bill would attempt to reduce the maternal mortality rate in New Jersey by establishing certain best practices for maternal care, and by establishing a permanent Maternal Mortality Review Commission to review maternal death rates and causes in the State, conduct investigations of individual reports of maternal death, and provide recommendations for further action in this area. The bill does not attempt to govern the day-to-day activities of maternal health practitioners, but it does require such practitioners and birthing facilities to adopt a more responsive and less hurried approach to maternal care, and to implement a more deliberate and practiced approach to critical maternal events.
The bill would require birthing centers and hospitals that provide care to maternal patients to: 1) implement regularly scheduled simulation drills to allow practitioners to practice their response to critical obstetric events; and additionally consider establishing a rapid response obstetric team; 2) maintain a preeclampsia response tool kit in both the labor and delivery unit and the postpartum unit, which contains easily accessible hypertensive medications, IV equipment, and airway maintenance tools; 3) maintain a hemorrhage response cart in both the labor and delivery unit and the postpartum unit, which contains easily accessible hemorrhage medications, examination tools, laceration repair tools, IV equipment, and hemorrhage control diagrams; and 4) revise existing policies used in the labor and delivery unit to better support and facilitate vaginal births, to encourage patients to carry their pregnancies to full term and discourage non-medically indicated labor inductions and cesarean section procedures, and to safely reduce the use of routine interventions for low-risk patients.
Any revised labor and delivery policies are to (among other things) require practitioners to: 1) discourage the admission of low-risk patients during early, non-active labor, and provide information to patients about completing early labor at home, and about when to return to the labor and delivery unit; 2) allow for the passive descent of the fetus when the patient is not experiencing an urge to push; 2) allow anesthetized patients to experience longer durations of the second stage of labor, so long as fetal and maternal status remain reassuring; 3) assess fetal positioning by the second stage of labor, take appropriate action to reposition the fetus prior to delivery, and use operative vaginal delivery options, as opposed to cesarean sections, where appropriate; 4) allow patients to retain as much freedom of movement during labor as is possible, and encourage patients to utilize non-pharmacologic tools to facilitate labor and vaginal delivery; 5) promote the use of supportive care techniques, such as water therapy, heat and cold therapy, and massage, which can be used to facilitate labor and successful vaginal delivery; 6) use intermittent fetal monitoring as a default monitoring practice for low-risk patients, and telemetry for patients who require continuous fetal monitoring, in order to enable the patient to remain mobile; and 7) better incorporate doulas into the maternal care team.
The bill would also provide certain best practice standards that are specifically designed to improve practitioner response to obstetric hemorrhage and hypertensive disorders such as preeclampsia. For example, in order to reduce maternal deaths from preeclampsia and similar disorders, the bill requires practitioners (among other things) to closely monitor patients who are determined to be at high risk of developing such disorders, and to examine any patient who presents with so-called "normal" childbirth-related symptoms, such as abdominal pain, headache, or other nondescript indicators of distress, in order to determine whether such symptoms constitute atypical presentations or severe features of preeclampsia, or represent the onset of delayed postpartum preeclampsia. The bill further requires patients who are diagnosed with preeclampsia or similar disorders to receive regular status updates from attending practitioners, close monitoring by a nurse who is experienced in caring for high-risk patients, and early post-discharge follow-up care. Finally, the bill requires practitioners to give new mothers a list and visual pictogram of the symptoms of preeclampsia, and a warning to return to the hospital if any such symptoms present.
In order to reduce maternal deaths from obstetric hemorrhage, the bill requires practitioners (among other things) to thoroughly evaluate patients for hemorrhage risk factors; to take special hemorrhage precautions in certain cases (such as when a patient has placenta accreta); to measure blood loss through the standardized quantification practices specified in the bill, rather than through visual estimation alone; to communicate about and ensure the availability of blood products; and to develop tailored and specific discharge plans for patients who have experienced a hemorrhage. The bill further requires a hospital or birthing center to conduct an intensive case review in any case of obstetric hemorrhage wherein the patient has experienced a cumulative blood loss of more than 1000mL, or has received four or more units of blood products, and to implement internal quality improvement strategies in response to the findings of each such case review.
In addition to establishing basic best practices for maternal care, this bill would also establish a Maternal Mortality Review Commission in the Department of Health (DOH), which would be tasked with annually reviewing and reporting on maternal death rates and the causes of maternal death in New Jersey, and providing recommendations to improve maternal care and reduce adverse maternal outcomes in the State. "Maternal death" is defined to include both pregnancy-associated deaths and pregnancy-related deaths. A "pregnancy-associated death" is one that occurs while the woman is pregnant, or during the one-year period following the date of the end of the pregnancy, irrespective of cause; while a "pregnancy-related death" is one that occurs while the woman is pregnant, or during the one-year period following the date of the end of the pregnancy, as a result of a non-accidental or non-incidental cause that is related to, or aggravated by, the pregnancy or its management.
Among its formal duties, the commission would be required to:
1) develop a mandatory maternal death reporting process, pursuant to which health care practitioners, medical examiners, hospitals, birthing centers, and other relevant professional actors and health care facilities will be required to confidentially report to the DOH on individual cases of maternal death; and
2) develop a voluntary maternal death reporting process, pursuant to which the family members of a deceased woman, and any other interested members of the public, will be permitted, but not required, to confidentially report to the DOH on individual cases of perceived maternal death.
The commission would be required to conduct an investigation in association with each report of maternal death that is filed pursuant to the bill's provisions. Upon the conclusion of each investigation, the commission would be required to prepare a de-identified case summary, which is to include the commission's findings with regard to the factors that contributed to the maternal death, and recommendations for actions that should be undertaken or policies that should be implemented to mitigate or eliminate those factors in the future. The commission would also be authorized to investigate cases of "severe maternal morbidity," which is defined to mean the physical and psychological conditions that result from, or are aggravated by, pregnancy, and which have an adverse effect on the health of a woman.
The bill would authorize the commission to identify, and promote the use of, best practices in maternal care, and to encourage and facilitate cooperation and collaboration among health care facilities, health care professionals, administrative agencies, and local government units for the purposes of ensuring the provision of the highest quality maternal care throughout the State. The bill would further authorize the commission to present its findings and recommendations on each individual de-identified case, or on groups of de-identified cases, to the health care facility or facilities where care was provided, and to the individual health care practitioners who provided such care, or to any relevant professional organization, for the purposes of instituting or facilitating policy changes, educational activities, or improvements in the quality of care provided; or for the purposes of exploring, facilitating, or establishing regional projects or other collaborative projects that are designed to reduce instances of maternal death.
In addition to investigating individual cases of maternal death, the commission would also be required to identify system-wide trends, patterns, and disparities in adverse maternal outcomes. To facilitate trend identification, the bill would require the State registrar to annually provide statistical maternal death data to the commission. The data would also be posted on the website of the Office of Vital Statistics and Registry, in the DOH. In order to ensure that the State's death records contain the information that is necessary to allow the State registrar to make the requisite statistical determinations, the bill would amend the State's existing vital records law to clarify that the blanks and forms used for vital record registration are to include, at a minimum, the same information (including pregnancy-related information) that is included in standardized U.S. certificates of live birth, death, and fetal death.
The commission would be required to annually report its findings on maternal mortality to the DOH, the Governor, and the Legislature. Each annual report is to additionally provide recommendations for legislative or other action that can be undertaken to: 1) improve the quality of maternal care and reduce adverse maternal outcomes in the State; 2) increase the availability of, and improve access to, social and health care services for pregnant women; and 3) reduce or eliminate disparities in maternal care and treatment, both during, and in the year after, pregnancy. Each annual report, with the exception of the first, would also identify the extent to which the commission's prior recommendations have been successfully implemented, and the apparent impact that the implementation of such recommended changes has had on maternal care in the preceding year.
Each commission report is to be posted on the DOH website, and the Commissioner of Health is to adopt rules and regulations to implement the recommendations contained in each such report, to the extent that such recommendations can be implemented through administrative rule-making action.
The DOH, working in consultation with the commission, as well as with relevant professional organizations and patient advocacy groups, would also be required by the bill to develop an ongoing maternal health educational program for health care practitioners. Although the program will initially be designed to reflect the findings and recommendations contained in the commission's first report, the DOH will be required to biennially review the program and make any necessary changes to ensure that the ongoing education accurately reflects, and is consistent with, the latest data, findings, and recommendations of the commission, as reflected in the commission's most recent report. Each of the State's professional licensing boards, as appropriate, would be required to adopt rules requiring the maternal health care practitioners under each board's jurisdiction to complete the DOH maternal care educational program as a condition of licensure.
