Senate Bill S311B

                                 
BILL NUMBER: S311

SPONSOR: SALAZAR
 
TITLE OF BILL:

An act to amend the public health law, in relation to informing materni-
ty patients about the risks associated with cesarean section

 
PURPOSE OR GENERAL IDEA OF BILL:

To amend the public health law, in relation to informing maternity
patients about the risks associated with Cesarean section.

 
SUMMARY OF SPECIFIC PROVISIONS:

This act amends the public health law by adding a new section 2500-1 as
follows:

Section one adds a new section 2500-1, which establishes a duty on the
part of maternal health providers of primary cesarean section maternity
services to provide written communications as defined in this bill.

              

Section 2500-1(1)(a) requires such communication to be provided by
maternal health providers prior to delivery to pregnant women for whom a
cesarean section delivery is planned.

Section 2500-1(1)(b) requires such communication to be provided by
maternal health providers following delivery in the case of a cesarean
delivery that not been planned prenatally.

Section 2500-1(1) (c)defines "maternal health care provider".

Section 2500-1(2)(a) provides that the written communication required by
section one will be developed by the Commissioner based on consultations
with appropriate health care professionals, providers, consumers, educa-
tors, and patients, including the American College of Obstetricians and
Gynecologists and the NYS Association of Licensed Midwives.

Section 2500-1(2)(b) provides that such written communications shall
include, but not be limited to, potential maternal injuries, potential
injuries to the fetus, the impact of a cesarean delivery may have on
future pregnancies and deliveries, and the circumstances in which cesa-
rean delivery may be necessary to save the life of the mother or fetus.

Section 2500-1(2)(c) requires that the information provided be updated
as necessary to reflect current clinical guidance.

Section two provides the effective date.

 
JUSTIFICATION:

In New York State, nearly 20% of babies are delivered via Cesarean
section, with the rate of use of Cesarean section delivery ranging from
8% to 32%, depending on the facility.

According to the American College of Obstetricians and Gynecologists
(ACOG), Cesarean delivery is recommended for certain medical conditions
to prevent maternal and infant morbidity and mortality.  However, for

low-risk pregnancies, Cesarean delivery increases the risk of maternal
mortality and morbidity and infant morbidity.

Potential maternal injuries associated with Cesarean delivery include
but are not limited to: heavy blood loss that results in hysterectomy or
a blood transfusion, ruptured uterus, injury to other organs including
the bladder, and other complications from a major surgery.

Cesarean delivery also carries higher risk of infant injury and can
result in situations requiring the neonatal intensive care unit (NICU).

Additionally, after a Cesarean delivery, future vaginal deliveries may
be dangerous. Because of this, Cesarean delivery may be recommended in
the future. (However, vaginal birth after Cesarean (VBAC) may be possi-
ble, depending upon health characteristics).

In future pregnancies, there is risk of the Cesarean section scar break-
ing during pregnancy or labor (uterine rupture). Additionally, a preg-
nant persons' risk of developing placenta previa or accreta in future
pregnancies is higher after Cesarean deliveries than vaginal births. As
a result, it is important that all pregnant individuals who plan to have
a Cesarean delivery be informed about the risks, both immediately and in
the future. It is also important that pregnant individuals who experi-
ence unplanned Cesarean sections be informed as soon as is possible
about how having a Cesarean section may impact their maternal health in
the future.

As described in the NYS Taskforce on Maternal Mortality and Disparate
Racial Outcomes March 2019 report, and numerous peer-reviewed studies,
the high rate of maternal mortality in the U.S. is partially explained
by the high rate of Cesarean deliveries, which carry overall higher
rates of maternal mortality. The Taskforce report also documented an
almost three times higher rate of maternal mortality for Black women as
compared with white women and noted the clear linkage between poverty,
racism, and power imbalances faced by Black women and other women of
color in regard to poorer maternal outcomes.

While it is customary for informed consent to be given before a Cesarean
section, informed consent documents are not standardized and may contain
medical jargon.

Additionally, in emergency situations, lengthy discussions about the
impact of the Cesarean delivery on future pregnancies cannot be guaran-
teed to occur at the time of informed consent and may, in fact, be
detrimental as there might not be time for such discussions.

This bill requires maternal health care providers, defined as any physi-
cian, midwife, nurse practitioner, or physician assistant, or other
maternal health care practitioner acting within his or her lawful scope
of practice attending a pregnant person, to provide to each maternal
patient who a) plans to deliver via Cesarean section or b) delivered via
Cesarean section a standardized message to inform them about risks asso-
ciated with Cesarean section delivery, as well as how having a Cesarean
section may impact future pregnancies. This bill is modeled after the
law that requires patients with dense breast tissue be informed through
a written communication from their provider after a mammography exam.


The written communication required by this bill will be developed by the
CoMmissioner of Health in consultation with health care professionals,
providers, consumers, educators, patients or organizations representing
them, and, specifically including ACOG and the NYS Association of
Licensed Midwives and will provide standardized information about risks
associated with Cesarean section delivery and about the potential impact
of the Cesarean on future pregnancies.

Significantly, this bill would not require that the written communi-
cation mandated be provided in advance to a pregnant person for whom a
medical determination is made that an emergency and unplanned cesarean
section is necessary. This provision ensures that the mandate of this
bill will not interfere with or jeopardize the health or safety of the
woman or the child in such emergency situations.

 
RACIAL JUSTICE IMPACT

According to the World Health Organization (WHO), many Cesarean sections
are undertaken unnecessarily which can put the lives and well-being of
pregnant people and their babies at risk - both in the short and long-
term. African American Women in particular are significantly more likely
to have a cesarean delivery than other women.

See: https://www.marchofdimes.org/Peristats/ViewSubtopic.aspx?
reg=99&top=8&stop=35 5&lev=l&slev=l&obj=1

This bill would enhance racial justice as there are significant racial
disparities in maternal mortality and morbidity and infant and child
health. The mandate for providing full information to maternity patients
about risks associated with cesarean deliveries is consistent with WHO
recommendations and -will help to reduce maternal and infant mortality
and the racial disparities that exist.

 
GENDER JUSTICE IMPACT

To reduce unnecessary Cesarians, the World Health Organization (WHO)
recommends educational intervention for women and families to support
meaningful dialogue with providers on modes of delivery and informed
decision making. This bill would enhance gender justice by improving
informed decision-making by women and improving health outcomes overall.

 
PRIOR LEGISLATIVE HISTORY:

SENATE:

2019: S2888 (Salazar) - Reported out of the Women's Issues Committee,
amended

2020: Referred to Women's Issues Committee

2021-2022: S2736 (Salazar)- Referred to Women's Issues Committee

ASSEMBLY:

2018: A10809B (Paulin)- Died in Assembly.

2019: A318 (Paulin)- Passed Assembly, amended, repassed Assembly

2020: A318 - Passed Assembly

2021-2022: A217 (Paulin)- Passed Assembly

 
FISCAL IMPLICATION:

No negative fiscal implications to the state. On average, cesarean
births costs more than typical vaginal deliveries thus driving up the
cost of care. It is likely this bill would result in fiscal savings as
the reduction in maternal mortality and morbidity would result in
reduced health-care costs to governmental entities providing health-care
funding (such as Medicaid)as well as overall reductions in costs to
medical providers.

 
EFFECTIVE DATE:
This act shall take effect 180 days after it shall become a law.  Effec-
tive immediately, the department of health may make regulations and take
other actions reasonably necessary for the timely implementation of this
act on that date.

                                 
BILL NUMBER: S311A

SPONSOR: SALAZAR
 
TITLE OF BILL:

An act to amend the public health law, in relation to the duty to inform
maternity patients about the risks associated with cesarean section for
patients undergoing a primary cesarean section and to inform maternity
patients about the reason for performing primary cesarean section deliv-
ery

 
PURPOSE OR GENERAL IDEA OF BILL:

To amend the public health law, in relation to informing maternity
patients about the risks associated with cesarean section.

 
SUMMARY OF SPECIFIC PROVISIONS:

This act amends the public health law by adding a new section 2500-1 as
follows:

Section one adds a new section 2500-1, which establishes a duty on the
              

part of maternal health providers of primary cesarean section maternity
services to provide written communications as defined in this bill.

For primary cesarean sections planned based on medical necessity, the
basis for such recommendation must be provided prior to delivery.

For planned primary cesarean sections requested by the patient, the
provider must provide information indicating that the primary cesarean
section is not medically necessary and to explain the risks associated
prior to the delivery.

For primary cesarean sections not planned prenatally, the provider who
performed the cesarean section must provide information in writing to
the patient after the delivery explaining the reason for the unplanned
cesarean section.

In all cases, the information provided - either prior to delivery for a
planned primary cesarean section or after for an unplanned primary cesa-
rean section - the bill sets out information regarding risks associated
with cesarean sections.

Section two provides the effective date.

 
JUSTIFICATION:

In New York State, nearly 20% of babies are delivered via cesarean
section, with the rate of use of Cesarean section delivery ranging from
8% to 32%, depending on the facility.

According to the American College of Obstetricians and Gynecologists
(ACOG), cesarean delivery is recommended for certain medical conditions
to prevent maternal and infant morbidity and mortality.  However, for
low-risk pregnancies, cesarean delivery increases the risk of maternal
mortality and morbidity and infant morbidity.

Potential maternal injuries associated with cesarean delivery include
but are not limited to: heavy blood loss that results in hysterectomy or
a blood transfusion, ruptured uterus, injury to other organs including
the bladder, and other complications from a major surgery.

Cesarean delivery also carries higher risk of infant injury and can
result in situations requiring the neonatal intensive care unit (NICU).

Additionally, after a cesarean delivery, future vaginal deliveries may
be dangerous. Because of this, cesarean delivery may be recommended in
the future. (However, vaginal birth after cesarean (VBAC) may be possi-
ble, depending upon health characteristics).

In future pregnancies, there is risk of the cesarean section scar break-
ing during pregnancy or labor (uterine rupture). Additionally, a preg-
nant persons' risk of developing placenta previa or accreta in future
pregnancies is higher after cesarean deliveries than vaginal births. As
a result, it is important that all pregnant individuals who plan to have
a cesarean delivery be informed about the risks, both immediately and in
the future. It is also important that pregnant individuals who experi-
ence unplanned cesarean sections be informed as soon as is possible
about how having a cesarean section may impact their maternal health in
the future.

As described in the NYS Taskforce on Maternal Mortality and Disparate
Racial Outcomes March 2019 report, and numerous peer-reviewed studies,
the high rate of maternal mortality in the U.S. is partially explained
by the high rate of cesarean deliveries, which carry overall higher
rates of maternal mortality. The Taskforce report also documented an
almost three times higher rate of maternal mortality for Black women as
compared with white women and noted the clear linkage between poverty,
racism, and power imbalances faced by Black women and other women of
color in regard to poorer maternal outcomes.

While it is customary for informed consent to be given before a cesarean
section, informed consent documents are not standardized and may contain
medical jargon.

Additionally, in emergency situations, lengthy discussions about the
impact of the cesarean delivery on future pregnancies cannot be guaran-
teed to occur at the time of informed consent and may, in fact, be
detrimental as there might not be time for such discussions.

This bill requires maternal health care providers, defined as any physi-
cian, midwife, nurse practitioner, or physician assistant, or other
maternal health care practitioner acting within his or her lawful scope
of practice attending a pregnant person, to provide to each maternal
patient who a) plans to deliver via primary cesarean section or b)
delivered via primary cesarean section a standardized message to inform
them about risks associated with Cesarean section delivery, as well as
how having a Cesarean section may impact future pregnancies. This bill
is modeled after the law that requires patients with dense breast tissue
be informed through a written communication from their provider after a
mammography exam.

Significantly, this bill would not require that the written communi-
cation mandated be provided in advance to a pregnant person for whom a
medical determination is made that an emergency and unplanned cesarean
section is necessary. This provision ensures that the mandate of this

bill will not interfere with or jeopardize the health or safety of the
woman or the child in such emergency situations.

 
RACIAL JUSTICE IMPACT

According to the World Health Organization (WHO), many cesarean sections
are undertaken unnecessarily which can put the lives and well-being of
pregnant people and their babies at risk - both in the short and long-
term. African American Women in particular are significantly more likely
to have a cesarean delivery than other women.

See: https://www.marchofdimes.org/Peristats/Vi.ewSubtopic.as x?
reg=99&top=8&stop=35 5&lev-1&slev=1&ob3=1

This bill would enhance racial justice as there are significant racial
disparities in maternal mortality and morbidity and infant and child
health. The mandate for providing full information to maternity patients
about risks associated with cesarean deliveries is consistent with WHO
recommendations and -will help to reduce maternal and infant mortality
and the racial disparities that exist.

 
GENDER JUSTICE IMPACT

To reduce unnecessary cesarians, the World Health Organization (WHO)
recommends educational intervention for women and families to support
meaningful dialogue with providers on modes of delivery and informed
decision-making. This bill would enhance gender justice by improving
informed decision-making by women and improving health outcomes overall.

 
PRIOR LEGISLATIVE HISTORY:

SENATE:

2019: S2888 (Salazar) - Reported out of the Women's Issues Committee,
amended

2020: Referred to Women's Issues Committee

2021-2022: S2736 (Salazar)- Referred to Women's Issues Committee

ASSEMBLY:

2018: A10809B (Paulin)- Died in Assembly.

2019: A318 (Paulin)- Passed Assembly, amended, repassed Assembly

2020: A318 - Passed Assembly

2021-2022: A217 (Paulin)- Passed Assembly

 
FISCAL IMPLICATION:

No negative fiscal implications to the state. On average, cesarean
births costs more than typical vaginal deliveries thus driving up the
cost of care. It is likely this bill would result in fiscal savings as
the reduction in maternal mortality and morbidity would result in
reduced health-care costs to governmental entities providing health-care

funding (such as Medicaid)as well as overall reductions in costs to
medical providers.

 
EFFECTIVE DATE:
This act shall take effect 180 days after it shall become a law.  Effec-
tive immediately, the department of health may make regulations and take
other actions reasonably necessary for the timely implementation of this
act on that date.