Researcher: ND Page 1 6/2/23
OLR Bill Analysis
sSB 986 (File 425, as amended by Senate "A")*
AN ACT PROTECTING MATERNAL HEALTH.
SUMMARY
This bill makes various unrelated changes affecting maternal and
infant health. Principally, it:
1. creates a new license category for freestanding birth centers
administered by the Department of Public Health (DPH), and
starting January 1, 2024, prohibits anyone from establishing or
operating a birth center unless it gets this license (§§ 1-9);
2. prohibits DPH from issuing or renewing a maternity hospital
license starting January 1, 2024, and repeals this licensure
program on July 1, 2025 (§§ 7 & 17);
3. establishes an Infant Mortality Relief Program within DPH to
review medical records and other data on infant deaths (i.e.,
those occurring between birth and one year of age) and sets
related requirements on record access, information sharing, and
confidentiality (§§ 10 & 12);
4. establishes an Infant Mortality Review Committee within DPH
to conduct a comprehensive, multidisciplinary review of infant
deaths to reduce health care disparities, identify associated
factors, and make recommendations to reduce the deaths (§§ 11
& 12);
5. requires DPH, within available resources, to establish an 18-
member Doula Advisory Committee to develop
recommendations on doula certification requirements and
standards for recognizing training programs that meet the
certification requirements (§ 13); 2023SB-00986-R01-BA.DOCX
Researcher: ND Page 2 6/2/23
6. establishes a voluntary doula certification program administered
by DPH and, starting October 1, 2023, prohibits someone from
using the title “certified doula” unless they are certified (§ 14);
7. requires the DPH commissioner to create a midwifery working
group to study and make recommendations on advancing
choices for community birth care (i.e., planned home birth or
birth at a birth center) and the role of community midwives in
addressing maternal and infant health disparities (§ 15); and
8. requires the Office of Early Childhood (OEC) commissioner,
within available appropriations, to develop and implement a
statewide universal nurse home visiting services program for all
families with newborns living in the state (§ 16).
The bill also makes technical and conforming changes.
*Senate Amendment “A” replaces the underlying bill (File 425) and
adds the provisions (1) requiring DPH, before issuing a birth center
license, to review and approve the information the birth center gave the
Commission for Accreditation of Birth Centers, (2) establishing
requirements for certain patient transfers from birth centers, (3)
requiring OHS to study whether to extend the CON exemption for birth
centers, and (4) establishing a Doula Advisory Committee and Doula
Training Program Review Committee.
It also (1) requires, rather than allows, DPH to adopt birth center
licensure regulations; (2) limits birth centers’ exemption from CON
requirements until June 30, 2028; (3) specifies that doulas who are not
certified by DPH may still provide doula services, so long as they do not
use the title “certified doula”; (4) modifies doula certification
requirements; and (5) allows, rather than requires, Universal Nurse
Home Visiting Program services to be offered in every community in
the state and to all families with newborns based on provider capacity.
EFFECTIVE DATE: October 1, 2023, except the provisions on (1) birth
center licensure fees, CON exemption, statutory definitions, and nurse-
midwives practice take effect January 1, 2024; (2) the doula advisory 2023SB-00986-R01-BA.DOCX
Researcher: ND Page 3 6/2/23
committee, doula certification, the midwifery working group, and the
universal nurse home visiting services program take effect July 1, 2023;
and (3) repealing the maternity hospital licensure program take effect
July 1, 2025.
§§ 1-9 & 17 — BIRTH CENTER LICENSURE
The bill creates a new license category for freestanding birth centers
administered by the Department of Public Health (DPH). Starting
January 1, 2024, it prohibits a person, entity, firm, partnership,
corporation, limited liability company, or association from establishing,
conducting, operating, or maintaining a birth center unless it gets this
license. The bill also expressly prohibits an outpatient clinic, except in
the case of an emergency, from providing birth center services as part of
its ambulatory medical services without a birth center license.
Also starting on this date, the bill prohibits the DPH commissioner
from granting or renewing a maternity hospital license. It then repeals
the maternity hospital licensure program on July 1, 2025. (The one
facility that currently holds this license will, presumably, transfer to the
new birth center license.)
The bill also makes various conforming changes, such as authorizing
the Office of Health Strategy’s Health Planning Unit to collect patient-
level outpatient data from birth centers (§ 5) and requiring birth centers
to report adverse events to DPH (§ 6).
Definitions
Under the bill, a “birth center” is a freestanding DPH-licensed facility
that provides perinatal, labor, delivery, and postpartum care during and
immediately after delivery to those presenting with a low-risk
pregnancy and healthy newborns for generally less than 24 hours. It is
not a licensed hospital or attached to or located in a licensed hospital.
A “low-risk pregnancy” is an uncomplicated, single-fetus pregnancy
with vertex presentation (i.e., positioned head-first) that is at low risk of
developing complications during labor and delivery, as a licensed
provider, acting within his or her scope of practice, determines through 2023SB-00986-R01-BA.DOCX
Researcher: ND Page 4 6/2/23
an evaluation and examination.
The bill also makes a conforming change by adding “birth center” to
the statutory definition of health care “institution.” In doing so, the bill
extends to these centers statutory requirements for health care
institutions on things like workplace safety committees, patient record
access, HIV-related information disclosure, and smoking prohibitions.
Licensure Application
Under the bill, birth centers must be accredited by the Commission
for the Accreditation of Birth Centers (1) on or before the effective date
of their licensure and (2) maintain accreditation when they are licensed.
If a birth center loses accreditation, it must immediately notify the DPH
commissioner and stop providing birth center services to patients until
the commissioner authorizes it to reinstate services.
Before issuing a license, the DPH commissioner must review and
approve the information the birth center submitted to the Commission
for Accreditation of Birth Centers, including information relating to the
birth center’s (1) plan for ongoing risk assessment and adherence to
patient eligibility criteria, as determined by the commission, during the
delivery of birth center services to a patient and (2) policies and
procedures for a patient’s prenatal, intrapartum, or postpartum transfer
if the patient no longer meets the eligibility criteria.
Licensure Fees
Under the bill, DPH must license and inspect birth centers every two
years. Birth centers must pay an initial and renewal license fee of $940
per site and $7.50 per bed.
Emergency Plan
The bill requires birth centers to have a written plan to get services
for their patients from a licensed hospital if there is an emergency or
other conditions that pose a risk to the patient’s health and require the
patient’s transfer to a hospital.
Patient Transfers 2023SB-00986-R01-BA.DOCX
Researcher: ND Page 5 6/2/23
If a patient receiving birth center services no longer presents with a
low-risk pregnancy, or otherwise fails to meet the Commission for
Accreditation of Birth Centers’ patient eligibility criteria, the bill
requires the birth center to ensure the patient’s care is transferred to a
licensed health care provider capable of providing the patient with the
appropriate level of obstetrical care.
The bill also requires licensed hospitals that have an emergency
department, other than a children’s hospital, to work cooperatively with
birth centers to coordinate care for patients who require services in the
event of an emergency or other condition that poses a risk to the
patient’s health and requires their transfer to a hospital.
Under the bill, children’s hospitals that have an emergency
department must work cooperatively with birth centers to coordinate
the care of neonatal patients that require the patient’s transfer to a
children’s hospital.
Nurse Midwife Practice
Under current law, nurse midwives must practice within a health
care system and have a clinical relationship with obstetrician-
gynecologists that provide for consultation, collaborative management,
or referral as indicated by the patient’s health status. The bill requires
nurse midwives to instead practice either within a health care system or
a birth center in the same manner.
Under existing law, unchanged by the bill, nurse midwives must
provide (1) care consistent with standards the Accreditation
Commission for Midwifery Education establishes and (2) information
about, or referral to, other providers or services, if the patient asks or
requires care that is not in the nurse-midwife’s scope of practice.
Certificate of Need
The bill exempts birth centers enrolled as a Connecticut Medical
Assistance Program (i.e., Medicaid and the State Children’s Health
Insurance Program) provider from the state’s certificate of need (CON)
requirements until June 30, 2028. By law, health care facilities must 2023SB-00986-R01-BA.DOCX
Researcher: ND Page 6 6/2/23
generally apply for and receive a CON from the Office of Health
Strategy’s Health Systems Planning Unit when proposing to (1)
establish a new facility or provide new services, (2) change ownership,
(3) purchase or acquire certain equipment, or (4) terminate certain
services.
The bill also requires the OHS executive director, in consultation with
the DPH commissioner and within available appropriations, to study
whether this CON exemption for birth centers should be extended. In
conducting the study, the executive director must collect data from birth
centers on the following:
1. the number of deliveries performed at each birth center and the
number of patient transfers or referrals to other care settings, and
the reasons for them;
2. the number and percentages of patients who are self-pay or are
covered by private or public insurance (e.g., Medicaid);
3. patient demographic information, include patients’ race,
ethnicity, and preferred language;
4. geographic locations of birth centers and catchment areas;
5. financial assistance and uncompensated care provided by each
birth center; and
6. any other information the executive director deems necessary.
Under the bill, the executive director must report on the study by July
2, 2027, to the Public Health Committee.
Regulations
The bill requires the DPH commissioner to adopt regulations to
implement the licensure, including provisions on facility
administration, staffing requirements, infection control protocols,
physical plant requirements, accommodating participation of support
people the patient chooses, limitations on providing anesthesia and
surgical procedures, operating procedures for determining patients’ 2023SB-00986-R01-BA.DOCX
Researcher: ND Page 7 6/2/23
risk status at admission and during labor, reportable events, medical
records, pharmaceutical services, laundry services, emergency
planning, and requirements for professional and medical liability
insurance for facilities and health care providers.
Under the bill, the commissioner may implement policies and
procedures to administer the license while adopting them into
regulations. However, she may only do this if she notifies her intent to
adopt regulations in the eRegulations System within 20 days after the
implementation date. These policies and procedures remain in effect
until the final regulations are adopted.
§§ 10 & 12 — DPH INFANT MORTALITY REVIEW PROGRAM
The bill establishes an Infant Mortality Relief Program within DPH to
review medical records and other relevant data on infant deaths.
Under the bill, this review must include information from birth and
death records and medical records from health care providers and
facilities to make recommendations on reducing health care disparities
and identify gaps in, or problems with, health care or service delivery
to reduce infant deaths.
Record Access and Information Sharing
Under the bill, pharmacies, health care providers, and facilities must
give the DPH commissioner, or her designee, upon the commissioner’s
request, access to all medical and other records, including prenatal
records, associated with infant death cases under the program’s review.
The bill allows the commissioner or her designee, to give the Infant
Mortality Review Committee (see § 8, below) information she
determines it needs to make recommendations on infant death
prevention.
Death Certificates
The bill requires the Office of the Chief Medical Examiner and funeral
directors and licensed embalmers who complete a death certificate for
an infant death to report the death to DPH in a way the commissioner
sets. 2023SB-00986-R01-BA.DOCX
Researcher: ND Page 8 6/2/23
Child Fatality Review Panel
The bill requires the DPH commissioner to notify the existing child
fatality review panel about an infant death if the program reviews an
infant death and determines that it occurred in out-of-home care or due
to unexpected or unexplained causes.
The bill expressly provides that it does not limit or alter the authority
of the Office of the Child Advocate or the child fatality review panel to
investigate or make recommendations about a child’s death.
By law, the child fatality review panel reviews the death of a child
who was placed in out-of-home care or whose death was unexpected or
unexplained to (1) develop prevention strategies to address identified
trends and risk patterns and (2) improve service coordination for
children and families (CGS § 46a-13l).
Confidentiality
Under the bill, the information the commissioner or her designee
obtains for the program and all information DPH gives to the Infant
Mortality Review Committee (see § 8, below) (1) is confidential and not
subject to disclosure, (2) is not admissible as evidence in a court or
agency proceeding, and (3) must be used solely for medical or scientific
research purposes (CGS § 19a-25).
§§ 11 & 12 — INFANT MORTALITY REVIEW COM MITTEE
The bill creates an Infant Mortality Review Committee within DPH
to conduct a comprehensive, multidisciplinary review of infant deaths
to reduce health care disparities, identify factors associated with infant
deaths, and make recommendations to reduce these deaths.
Members
The bill allows the committee’s membership to vary, as needed,
depending on the infant death under review, but it may include the
following members:
1. a licensed physician specializing in obstetrics and gynecology,
designated by the American College of Obstetrics and 2023SB-00986-R01-BA.DOCX
Researcher: ND Page 9 6/2/23
Gynecology’s Connecticut chapter;
2. a community health worker, designated by the Commission on
Women, Children, Seniors, Equity, and Opportunity;
3. a licensed pediatric nurse, designated by the Connecticut Nurses
Association;
4. a licensed clinical social worker designated by the National
Association of Social Workers Connecticut chapter;
5. the chief medical examiner, or his designee;
6. a Connecticut Hospital Association member representing a
pediatric facility;
7. a representative of the UConn-sponsored Health Disparities
Institute;
8. a licensed physician practicing neonatology, designated by the
Connecticut Medical Society;
9. a licensed physician assistant (PA) or advanced practice
registered nurse (APRN) designated by an association
representing PAs or APRNs in Connecticut;
10. the child advocate, or her designee;
11. the commissioners of children and families, early childhood,
mental health and addiction services, and social services, or their
designees; and
12. any additional members the committee co-chairs determine
would be beneficial.
Leadership and Meetings
Under the bill, the DPH commissioner, or her designee, and a
representative designated by the American Academy of Pediatrics’
Connecticut chapter, co-chair the committee. The co-chairs must
convene a committee meeting when the commissioner requests it. 2023SB-00986-R01-BA.DOCX
Researcher: ND Page 10 6/2/23
Infant Mortality Reviews
The bill allows the committee, when conducting an infant mortality
review, to consult with relevant experts to evaluate information and
findings it obtains from the Infant Mortality Review Program (see
above) and make recommendations on preventing infant deaths.
In its review, the committee must include available infant death
reports and recommendations from the existing child fatality review
panel to recommend ways to reduce health care disparities and identify
gaps in, or problems with, delivering health care and services to reduce
infant deaths.
Confidentiality
Under the bill, all information DPH gives the committee or an expert
with whom the committee consults (1) is confidential and not subject to
disclosure, (2) is not admissible as evidence in a court or agency
proceeding, and (3) must be used solely for medical or scientific research
purposes (CGS § 19a-25).
Report
Within 90 days after completing an infant mortality review, the bill
requires the committee, in consultation with the Office of the Child
Advocate, to report its findings and recommendations to the DPH
commissioner in a way that meets the confidentiality requirements.
§§ 13 & 18 — DOULA ADVISORY COMMITTEE
Duties
The bill requires the DPH commissioner, within available resources,
to establish a Doula Advisory Committee within DPH. The committee
must develop recommendations on (1) requirements for initial and
renewal doula certification, including training, experience, and
continuing education requirements and (2) standards for recognizing
doula training program curricula that satisfy the doula certification
requirements.
The advisory committee must also establish a Doula Training
Program Review Committee to (1) continuously review of doula 2023SB-00986-R01-BA.DOCX
Researcher: ND Page 11 6/2/23
training programs and (2) provide DPH a list of doula training
programs in the state that meet the advisory committee’s requirements.
Membership
Under the bill, the DPH commissioner or her designee is the advisory
committee’s chairperson. Additional members include (1) the
commissioners of early childhood, mental health and addiction services,
and social services, or their designees and (2) 14 members appointed by
the DPH commissioner or her designee, as follows:
1. seven actively practicing doulas in the state;
2. one licensed nurse-midwife who has experience working with a
doula;
3. one representative of an acute care hospital, appointed in
consultation with the Connecticut Hospital Association;
4. one representative of an association representing hospitals and
health-related organizations in the state;
5. one licensed health care provider specializing in obstetrics and
has experience working with a doula;
6. one representative of a community-based doula training
organization;
7. one representative of a community-based maternal and child
health organization; and
8. one member with expertise in health equity.
Under the bill, the DPH commissioner or her designee serves as the
advisory committee’s chairperson.
Repealer
The bill repeals a provision in PA 22-58 that required DPH, within
available resources, to establish an 18-member Doula Advisory
Committee in a similar manner as under the bill. 2023SB-00986-R01-BA.DOCX
Researcher: ND Page 12 6/2/23
§ 14 — DOULA CERTIFICATION
The bill establishes a DPH-administered voluntary doula certification
program and related requirements. Starting October 1, 2023, it prohibits
someone from using the title “certified doula” unless they obtain the
certification. But it does not prohibit a doula who is not certified from
providing doula services, so long as they do not use the title “certified
doula.”
Under the bill, a “doula” is a trained, nonmedical professional who
provides physical, emotional, and informational support, virtually or in
person, to a pregnant person and any family or friends supporting them,
before, during, and after birth.
Doula Advisory Committee and Training Program Review
Committee
The bill requires DPH’s Doula Advisory Committee established
under the bill (see § 13 above) to advise the DPH commissioner or her
designee on doula services matters, including (1) access and promotion
of education and resources for pregnant persons, and family and friends
supporting them; (2) recommendations to improve access to doula care;
and (3) furthering interagency efforts to address maternal health
disparities.
It also requires the advisory committee’s Doula Training Program
Review Committee the bill establishes (see § 13 above) to (1) conduct an
ongoing review of doula education and training programs and (2) give
the commissioner or her designee a list of approved doula education
and training programs that meet the advisory committee’s certification
requirements. The bill also requires this committee to (1) ensure that its
list of approved programs includes training in core doula competencies
and (2) make recommendations on certified doula continuing education
requirements to the commissioner.
The bill requires the advisory committee to annually decide whether
to renew or disband in a manner the commissioner or her designee
determines.
Certification Application 2023SB-00986-R01-BA.DOCX
Researcher: ND Page 13 6/2/23
Under the bill, a doula must apply to DPH for certification on forms
the commissioner sets and pay an application fee of $100.
The application must include the following information:
1. proof that the applicant is at least 18 years old,
2. two reference letters from families or professionals with direct
knowledge of the applicant’s experience as a doula that verify the
applicant’s training or experience, and
3. evidence that the applicant (a) completed a doula training
program or a combination of programs approved by the Doula
Advisory Committee or (b) attests that, in the five years
preceding the application date, he or she provided doula services
to at least three families and trained in at least four core
competencies the Doula Training Program Review Committee
identified.
The bill prohibits the commissioner from issuing a certificate to an
applicant with pending professional disciplinary action or unresolved
complaints against them.
Certification Renewal and Continuing Education
The bill requires doulas to renew their certification every three years
and pay a $100 renewal fee.
Under the bill, DPH must adopt continuing education requirements
for certified doulas, which the Doula Training Program Review
Committee must provide. Certification renewal applicants must give
DPH evidence of meeting the continuing education requirements.
Certification by Endorsement
The bill allows the DPH commissioner to grant certification by
endorsement to a doula who presents satisfactory evidence that he or
she is certified as a doula in another state or jurisdiction with
certification requirements substantially similar to Connecticut’s
requirements for at least two years before the certification application 2023SB-00986-R01-BA.DOCX
Researcher: ND Page 14 6/2/23
date.
Disciplinary Action
The bill authorizes the DPH commissioner to take several
disciplinary actions against a certified doula, such as suspending or
revoking the doula’s certification, limiting his or her practice, and
imposing a civil penalty of up to $25,000 (see CGS § 19a-17). The
commissioner may take these actions for a certified doula’s failure to
conform to accepted professional standards, including the following:
1. fraud or deceit in obtaining or seeking reinstatement of
certification;
2. engaging in fraud or material deception in his or her professional
services or activities;
3. negligent, incompetent, or wrongful conduct in professional
activities;
4. aiding or abetting the use of the title “certified doula” by an
uncertified person;
5. physical, mental, or emotional illness or disorder resulting in an
inability to conform to accepted professional standards; or
6. drug abuse or excessive drug use, including alcohol, narcotics, or
chemicals.
Under the bill, the commissioner may also order a certified doula to
have a reasonable physical or mental examination if the doula’s physical
or mental capacity to safely practice is the subject of an investigation.
The commissioner may also petition the Superior Court in Hartford to
enforce an order or action she takes. The bill requires the commissioner
to give the doula notice and an opportunity to be heard on any
contemplated disciplinary action.
§ 15 — MIDWIFERY WORKING GROUP
The bill requires the DPH commissioner to create a midwifery
working group to study and make recommendations on (1) advancing 2023SB-00986-R01-BA.DOCX
Researcher: ND Page 15 6/2/23
choices in care for community birth (i.e., planned home birth or birth at
a birth center) and (2) direct entry midwives’ role in addressing
maternal and infant health disparities.
Under the bill, the study must include the following:
1. improvements in birthing care quality and safety, including
those addressing racial disparities in maternal and infant health
outcomes;
2. regulation, licensure, or certification of direct entry midwives
and certified midwives not otherwise licensed to practice
midwifery in Connecticut; and
3. advancements of interprofessional coordination of birthing care,
including community birth.
The working group must annually decide whether to renew or
disband in a manner the DPH commissioner or her designee
determines.
Members
The bill requires the DPH commissioner to appoint the working
group members. It must at least include the following members:
1. a DPH commissioner designee and one Department of Social
Services (DSS) representative,
2. at least six direct entry midwives practicing in Connecticut,
3. one certified nurse-midwife with experience working with direct
entry midwives,
4. one certified midwife representing an entity that certifies
midwives,
5. one doula serving communities of color,
6. one representative of families or a community -based
organization with an interest in maternity care, 2023SB-00986-R01-BA.DOCX
Researcher: ND Page 16 6/2/23
7. one representative of a community organization furthering
health equity,
8. representatives of associated maternity care professions, and
9. one representative of the Connecticut Hospital Association.
Under the bill, a “direct entry midwife” is a person trained in planned
out-of-hospital births other than a nurse-midwife, including certified
midwives, certified professional midwives, community midwives, and
traditional midwives.
A “certified midwife” is someone with a graduate degree in
midwifery who passed a national certification examination
administered by the American Midwifery Certification Board.
Report
The bill requires the working group, starting by February 1, 2024, to
annually report its findings and recommendations to the DPH
commissioner and the Public Health Committee.
§ 16 — UNIVERSAL NURSE HOME VISITING PROGRAM
The bill requires the Office of Early Childhood (OEC) commissioner
to develop a statewide program offering universal nurse home visiting
services to all families with newborns living in the state to support
parental health, healthy child development, and strengthen families.
She must do this within available appropriations, and in collaboration
with the DSS and DPH commissioners and the Office of Health Strategy
(OHS) executive director.
When developing the program, the commissioners and executive
director must do the following:
1. consult with insurers that offer health benefit plans in the state,
hospitals, local public health authorities, existing early childhood
home visiting programs, community-based organizations, and
social service providers and
2. maximize available federal funding. 2023SB-00986-R01-BA.DOCX
Researcher: ND Page 17 6/2/23
Under the bill, “universal nurse home visiting” is an evidence-based
nurse home visiting model in which a licensed registered nurse with
specialized training provides in-home services to families with
newborns.
Program Services
The program must provide universal nurse home visiting services
that are evidenced-based and designed to improve outcomes in one or
more of the following areas:
1. child safety, health, and development;
2. family economic self-sufficiency;
3. maternal and parental health;
4. positive parenting and parent-infant bonding;
5. reducing child mistreatment and family violence; and
6. any other appropriate area the commissioners and executive
director establish in writing.
Under the bill, the program’s services must be voluntary and have no
negative consequences for a family that does not participate. Services
may be offered in every community in the state and to all families with
newborns based on the full extent of available provider capacity.
The services must also allow families to choose up to a certain
number of additional visits, consistent with an evidence-based model;
provide information and referrals to address each family’s identified
needs; and include the following:
1. an evidence-based assessment of the physical, social, and
emotional factors affecting a family receiving these services;
2. at least one visit during a newborn’s first three months or other
timeframe the commissioners and executive director deem
appropriate and that is consistent with an evidence-based model; 2023SB-00986-R01-BA.DOCX
Researcher: ND Page 18 6/2/23
and
3. a follow-up visit within three months or another time frame
established by the model after the last visit.
Medicaid Waiver or State Plan Amendment
The bill authorizes the DSS commissioner to seek federal Centers for
Medicare and Medicaid Services approval for a Medicaid state plan
amendment or waiver for universal nurse home visiting services
coverage. The commissioner must do this in a time frame and manner
to ensure that this coverage does not duplicate any other applicable
federal funding.
Program Data
The bill requires the OEC commissioner, in collaboration with the
DSS and DPH commissioners and OHS executive director, to collect and
analyze program data to do the following:
1. assess the program’s effectiveness in meeting its goals and
2. collaborate with other state agencies to develop protocols for
sharing the data, including doing so in a timely manner with
primary care providers that provide care to families with
newborns receiving program services.
COMMITTEE ACTION
Public Health Committee
Joint Favorable Substitute
Yea 26 Nay 11 (03/20/2023)
Appropriations Committee
Joint Favorable
Yea 45 Nay 8 (05/01/2023)