A few years ago, after more than two decades as a gynecologist taking care of low-income women in Texas, Lisa Hollier began to see something unexpected and disturbing. The number of maternal deaths -- women dying in pregnancy, childbirth or the first few postpartum weeks -- was spiking. The numbers were far above those in any other state -- in fact, they were not normal for any country in the developed world.
Hollier and a handful of allies began lobbying the state legislature to form a special panel to investigate why this was happening. In 2013, a 15-member task force was put together, with Hollier heading it up. The members knew a few things going in. They knew that maternal mortality had been increasing in Texas for several years. They knew that black women were three times more likely to die from complications of childbirth than white or Hispanic women. But a bigger surprise -- just how many women were actually dying -- was about to come.
Maternal mortality rates have been edging up in much of the United States. A study published last year in the Medical Journal of Obstetrics & Gynecology found that the national rate rose 26 percent from 2000 to 2014. Systemic health problems across the country, notably unequal access to care and high rates of chronic illness, seemed to play a key role.
But Texas is in a category all by itself. For the first half-decade of the new millennium, maternal deaths were steady, hovering at around 18 deaths per 100,000 births -- not a particularly dramatic number. However, from 2011 to 2014 the number doubled. During those more recent years, more than 600 Texas women died from complications around childbirth. Those figures, the study concluded, didn’t make sense “in the absence of war, natural disaster or severe economic upheaval.”
If Texas were a country, it would have the highest maternal mortality rate in the developed world and would be on a par with Mexico or Turkey. “We’re trying to figure out how to get our rate down to a First World country,” says Tony Dunn, chair of the Texas chapter of the American Congress of Obstetricians and Gynecologists. The question is not just why Texas has this problem, but also why it’s been getting so much worse and why it’s more severe there than in other states. There are no clear answers, but there are clues.
The state task force published its first significant findings on maternal mortality last July. Cardiac events and hypertension rank as the first and third causes of death, aligning more or less with national trends. But in Texas, to the bewilderment of everyone, drug overdoses ranked second.
The entire country has been grappling with an opioid epidemic that is showing no sign of slowing down. Texas is not ground zero -- the Rust Belt and parts of New England claim that title -- but it ranks near the top. And the figures for young mothers are grim. “Were they using drugs before they got pregnant? Was it prescribed after they gave birth? We just don’t know,” says Amy Raines-Milenkov, a member of the state task force. The panel has committed itself to looking at the issue more closely this year.
Unfortunately, the data itself isn’t very good. In 2003, the Centers for Disease Control and Prevention revised death certificates to include a mortality checkbox to mark whether a woman was pregnant at the time of death, whether she had given birth in the past 42 days, or whether she had done so within the previous year. But as is usually the case with electronic health records, it was a slow-going process. Only four states adopted the new system at the onset, and it took 11 years for the rest of the states to catch up.
Even as more states started to get on board, there were discrepancies. Some states just ask if the deceased woman had been pregnant and do not collect information about the expected date of birth. So the detail on the death certificates varies enormously from state to state. Because of this, the federal government hasn’t published any significant data on maternal mortality since 2007.
Texas was a relatively early adopter of the new system, revising its death certificate in 2006 and collecting data on whether a woman gave birth within the preceding year. Consequently, there was some speculation that the state had always had a high maternal mortality rate and was simply showing the results of better reporting. But the data still raised more questions than it answered. “Death certificates don’t tell whether a woman had access to care or where she went for care,” says Marian MacDorman, lead researcher on the journal’s study.
Health-care experts know the factors that lead to maternal health: good access to care, adequate funding of services and the general health of the larger population. Texas ranks near the bottom on nearly every one of these metrics. It has the highest rate of uninsured residents of any state. Seventeen percent of Texas residents go without health insurance, a full 4 percentage points above the second highest state, Alaska. “Women in Texas have not historically had access to health care across their lifespan, so when they’re pregnant and have care, it’s really hard to treat those things in such a short amount of time,” Raines-Milenkov says.
Every state offers some Medicaid benefits for pregnant women, even if they aren’t on Medicaid otherwise. However, Texas’ program is relatively paltry -- benefits end two months after giving birth. The state also has the second-highest number of undocumented immigrants after California, and those women are not eligible for benefits.
Medicaid expansion might have helped ease this problem. Expanding Medicaid under the Affordable Care Act caused many states to see their uninsured numbers drop -- in some instances dramatically. But Texas was one of 19 states that chose not to participate in the expansion. Former Gov. Rick Perry rejected it outright when the Affordable Care Act passed, and current Gov. Greg Abbott also opposes it. Medicaid expansion didn’t kick in until 2014, so it wouldn’t have stopped the spike that began to gather momentum several years earlier. But health-care advocates insist it would have had some effect.
The same year the state saw its first dramatic jump in maternal deaths, the Texas Legislature cut public funding from Planned Parenthood and other clinics that provide abortions. More than half of the state’s family planning clinics have closed since then, primarily in rural areas. It’s likely that some women who became pregnant after the clinics closed would not have become pregnant had they remained open. A study published in the New England Journal of Medicine last year found a significant increase in the number of births in Texas in areas where a Planned Parenthood facility had shut down.
Researchers caution, however, that it’s too soon to say whether defunding Planned Parenthood played a significant role in causing the number of maternal deaths in the state to double. But residents do lose out when clinics shut down without an immediate replacement. In sparsely populated regions, where hospitals are often hours apart, the loss can be especially acute. Low-income women in some parts of the state may not have access to prenatal care until they go to the hospital to give birth. In addition, rural hospitals in Texas have had a difficult time trying to keep up with the record-keeping requirements imposed on them by the Affordable Care Act. In the past four years, 15 rural hospitals have closed in the state. The ones that remain are often short on resources -- including ones that might be required in obstetric emergencies.
In Texas, black women are three times more likely to die from complications of childbirth than white or Hispanic women.
Texas is not the first state to find itself dealing with a maternal health predicament. In the not-too-distant past, California health officials found that their maternal mortality numbers were alarmingly high. They launched an organization known as the California Maternal Quality Care Collaborative. Webinars and toolkits were rolled out to hospitals to serve as refresher courses on how to handle problems that can arise in childbirth. Projects targeted specific health metrics that were driving California’s mortality rate, such as preeclampsia and hemorrhages. Women identified as high risk for cardiovascular problems were given resources for managing them during pregnancy and postpartum. The collaborative also decided to target unnecessary caesareans, and the state committed to reducing their use for low-risk, first-time mothers to 23 percent.
All of these things made a difference. The study from the journal had to separate California’s numbers from the rest of the data because the state’s maternal mortality figures had dropped so dramatically as to skew the national picture.
Hollier and the team in Texas are hoping to model their efforts off the California Maternal Quality Care Collaborative. But there’s no way that the initiative can be duplicated exactly. “A lot of these factors are localized. What’s driving women’s deaths in California is likely not going to be what’s driving them in Texas, or in New York, for example,” says Elliot Main, medical director of the California program. In Texas, in particular, there will be a need to address drug abuse.
Meanwhile, an effort has begun at the federal level. The Preventing Maternal Deaths Act has been introduced in Congress and has attracted some bipartisan support. The legislation would provide states with resources to identify and treat the common causes of maternal mortality. So far, there has been no significant movement on it. But health-care activists are continuing to promote it. “This isn’t a pipe dream,” insists Eleni Tsigas of the Preeclampsia Foundation. “We know what can work, because California’s numbers are declining. It starts with identifying all the causes and using that to improve the health-care delivery system.”
Texas took a step toward addressing the problem last July when it launched the Healthy Texas Women Program, which is aimed at connecting low-income women with health-care services such as free pregnancy tests and immunizations. The program is starting slowly. So far, there has been relatively little communication to residents about what it actually offers. Still, supporters cite it as a step in the right direction.
There isn’t a clear solution to the maternal mortality problem in Texas because it’s still hard to say precisely how the state got to this point, and so quickly. But Main, who has overseen the policies that worked in California, believes the tide can be reversed. “Maternal deaths are one of the most catastrophic things that can happen in medicine,” he says. “It’s a big deal, and the numbers there catch a lot of people’s attention. But when you improve all-around prenatal care, you can improve the care for multiple health-care issues.”