O F F I C E O F L E G I S L A T I V E R E S E A R C H
P U B L I C A C T S U M M A R Y
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PA 23-147—sSB 986
Public Health Committee
Appropriations Committee
AN ACT PROTECTING MA TERNAL HEALTH
SUMMARY: This act makes various unrelated changes affecting maternal and
infant health. Principally, it:
1. creates a new license category administered by the Department of Public
Health (DPH) for freestanding birth centers, and starting January 1, 2024,
prohibits anyone from establishing or operating a birth center without 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 & 18);
6. establishes a voluntary doula certification program administered by DPH
and, starting October 1, 2023, prohibits an uncertified person from using the
title “certified doula” (§ 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 act also makes technical and conforming changes.
EFFECTIVE DATE: October 1, 2023, except the provisions on (1) birth center
licensure fees, certificate of need exemption, statutory definitions, and nurse-
midwives practice take effect January 1, 2024; (2) the doula advisory committee, O L R P U B L I C A C T S U M M A R Y
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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 act creates a new DPH-administered license category for freestanding birth
centers. 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
act also expressly prohibits an outpatient clinic, except in 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 act 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 act 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 act, 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 an evaluation and examination.
The act also makes a conforming change by adding “birth center” to the
statutory definition of health care “institution.” In doing so, the act 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 act, birth centers must (1) be accredited by the Commission for the
Accreditation of Birth Centers 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 O L R P U B L I C A C T S U M M A R Y
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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, while delivering 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 act, 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 act 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 condition that
pose a risk to the patient’s health and require the patient’s transfer to a hospital.
Patient Transfers
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 act 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 act also requires licensed hospitals with 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 act, children’s hospitals with 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
Prior law required nurse-midwives to 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 act 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 act, nurse-midwives must provide (1)
care consistent with the Accreditation Commission for Midwifery Education’s O L R P U B L I C A C T S U M M A R Y
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standards 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 act 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 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 act also requires the Office of Health Strategy (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, including 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.
The executive director must report on the study to the Public Health Committee
by July 2, 2027.
Regulations
The act 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 anesthesia and
surgical procedures, operating procedures for determining patients’ 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 act, 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.
O L R P U B L I C A C T S U M M A R Y
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§§ 10 & 12 — DPH INFANT MORTALITY REVIEW PR OGRAM
The act establishes an Infant Mortality Relief Program within DPH to review
medical records and other relevant data on infant deaths. Under the act, 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 act, pharmacies and 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 act allows the commissioner or her designee to give the Infant Mortality
Review Committee (see § 11 below) information she determines it needs to make
recommendations on infant death prevention.
Death Certificates
The act 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.
Child Fatality Review Panel
The act 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 act 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 act, the information the commissioner or her designee obtains for the
program and all information DPH gives to the Infant Mortality Review Committee
(see § 11 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). O L R P U B L I C A C T S U M M A R Y
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§§ 11 & 12 — INFANT MORTALITY REVIEW COM MITTEE
The act 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 act 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 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 act, 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.
Infant Mortality Reviews
The act allows the committee, when conducting an infant mortality review, to
consult with relevant experts to evaluate information and findings it obtains from O L R P U B L I C A C T S U M M A R Y
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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 act, 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 act 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 act 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, 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 doula training programs and (2) give DPH a
list of doula training programs in the state that meet the advisory committee’s
requirements.
Membership
Under the act, 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 doulas actively practicing in the state;
2. one licensed nurse-midwife with experience working with a doula;
3. one acute care hospital representative, appointed in consultation with the O L R P U B L I C A C T S U M M A R Y
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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 with 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.
Repealer
The act repeals a provision in PA 22-58 that required DPH, within available
resources, to establish a similar 18-member Doula Advisory Committee.
§ 14 — DOULA CERTIFICATION
The act 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
an uncertified doula from providing doula services, so long as they do not use the
title “certified doula.”
Under the act, 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 act requires DPH’s Doula Advisory Committee (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 (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. This committee must also (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 act requires the advisory committee to annually decide whether to renew
or disband in a manner the commissioner or her designee determines.
Certification Application
O L R P U B L I C A C T S U M M A R Y
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Under the act, a doula seeking certification must apply to DPH 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 an approved doula training
program or a combination of approved programs 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 act prohibits the commissioner from issuing a certificate to an applicant
with pending professional disciplinary action or an unresolved complaint.
Certification Renewal and Continuing Education
The act requires doulas to renew their certification every three years and pay a
$100 renewal fee.
Under the act, 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 act 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 date.
Disciplinary Action
The act 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 O L R P U B L I C A C T S U M M A R Y
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conform to accepted professional standards; or
6. drug abuse or excessive drug use, including alcohol, narcotics, or chemicals.
Under the act, 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 act requires the commissioner to give the doula notice and an opportunity to
be heard on any contemplated disciplinary action.
§ 15 — MIDWIFERY WORKING GROUP
The act requires the DPH commissioner to create a midwifery working group
to study and make recommendations on (1) advancing 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
act, 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.
Under the act, 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 act requires the DPH commissioner to appoint the working group members,
which must at least include the following:
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,
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. O L R P U B L I C A C T S U M M A R Y
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Report
The act 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 act requires the 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 OHS executive director.
When developing the program, the commissioners and executive director must
(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.
Under the act, “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 or child health and development,
2. family economic self-sufficiency,
3. maternal and parental health,
4. positive parenting or parent-infant bonding,
5. reducing child mistreatment or family violence, and
6. any other appropriate area the commissioners and executive director
establish in writing.
Under the act, 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 time frame
the commissioners and executive director deem appropriate that is
consistent with an evidence-based model; and O L R P U B L I C A C T S U M M A R Y
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3. a follow-up visit within three months, or another time frame the model
establishes, after the last visit.
Medicaid State Plan Amendment or Waiver
The act 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 act requires the OEC commissioner, in collaboration with the DSS and
DPH commissioners and OHS executive director, to collect and analyze program
data to (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.