Between 2012 and 2015, almost 400 women died in Texas within one year of giving birth.
That tragic fact, and others like it, brought leading Texas physicians and policymakers to Austin in March. Their goal: Find an answer to the state’s rate of death and illness among the mothers of newborns.
At the Texas Medical Association’s Maternal Health Congress, convened by TMA President Carlos J. Cardenas, MD, members and health care experts discussed ways to identify options to present in the next session of the Texas Legislature, which begins in January. See the presentations and read more information at www.texmed.org/MHCongress.
Dr. Cardenas said it’s natural for physicians to take the lead on one of Texas’ most pressing public health issues.
“What we thought is that we should bring the thought leaders from across the state to help us try to figure out what’s going on, and what we can do about it,” he said.
Even getting a handle on the scope of the problem can be daunting.
In 2016, the U.S. Centers for Disease Control and Prevention reported Texas’ maternal mortality rate soared in 2012 to 38.4 deaths per 100,000 live births, and subsequent years remained above 30 per 100,000 live births. That is an alarming jump from the maternal mortality rate of 17.7 per 100,000 registered from 2000 to 2010.
However, in April, a follow-up study by the Texas Department of State Health Services (DSHS) scrutinized each 2012 case individually and found that the death rate on the original report was inflated due to misreporting on death certificates. The DSHS report said Texas’ maternal mortality rate for 2012 is actually much lower, ranging from 14.6 to 18.6 deaths per 100,000.
Dr. Cardenas told the congress that state policies have helped deepen the crisis, including drastic funding cuts for family planning starting in 2011. He also pointed out that nearly 1.8 million Texas women don’t have access to routine health care.
“In the last decade, the legislature’s shortsighted and penurious actions have reduced women’s access to health care by more than 40 percent,” he said. “And by health care, I mean the full spectrum of care: screenings, exams, and wellness.”
A reference committee of eight prominent physicians from around the state heard 36 proposals on ways to address maternal mortality and morbidity. The committee then identified key issues and proposed actions that Dr. Cardenas will introduce to the House of Delegates at this month’s TexMed 2018. Proposals adopted at the annual policymaking meeting will help guide TMA’s agenda for the 2019 legislative session.
Lisa Hollier, MD, chair of the Texas Maternal Mortality and Morbidity Task Force, outlined the scope of the problem, saying:
- African-American women have the highest risk of maternal death, and the disparity in death rates between the races is widening;
- Drug overdose, cardiac disease, hemorrhage, and hypertension were all among the leading causes of death; and
- Chronic medical problems like obesity, diabetes, and high blood pressure are all risk factors for maternal mortality.
Improved preconception health and better prenatal care are important for reducing the maternal mortality rate, Dr. Hollier said.
“We cannot expect that in the nine months of pregnancy we change [a new mother’s] entire lifetime of social risk and medical risk,” she said. “However, it is important for a woman to get into early prenatal care so that she can be evaluated, those conditions can be identified, and risk mitigated by the different interventions we can put in place.”
Carla Ortique, MD, vice chair of the state task force, said African-American women face a wide array of potentially dangerous problems during pregnancy and as new mothers. Black women are less likely to enter prenatal care in the first trimester, less likely to receive adequate care, and they generally receive lower-quality care even when access and insurance coverage exist. Black women are two to three times more likely to die of preeclampsia, eclampsia, or placental abruption than white women, even though those disorders have no statistically significant greater prevalence among the African-American population, she said.
“Black women consistently experience four times greater risk of pregnancy-related death than white women,” she said, adding this is independent of factors such as age and education levels.
Even more frightening, severe maternal illness or disease dwarfs the incidence of maternal mortality in Texas. Dr. Hollier said there are 50 to 100 cases for each maternal death.
John Hellerstedt, MD, commissioner of the Texas Department of State Health Services (DSHS), said that explains why “when we’re looking at maternal mortality, we’re looking at the tip of an iceberg.”
Dr. Hellerstedt outlined the actions DSHS is taking to combat both maternal mortality and morbidity, including the state’s Healthy Texas Mothers and Babies program.
The state also is raising standards in health care facilities to ensure women at high risk receive care in facilities that can meet their needs at and around the time of birth. By 2020, hospitals that do not meet these “maternal level of care” designations will no longer receive Texas Medicaid payment for maternal health services.
One of the most important DSHS initiatives involves improving the state’s death certificate process, Dr. Hellerstedt said. (See “Can Texas Do Death Better,” Texas Medicine, January 2018, www.texmed.org/DeathCertificates.) Researchers have found that Texas death certificates frequently misreport a woman’s status as a new mother, skewing data on maternal mortality.
“There is a fundamental problem with the accuracy of death certificates,” he said.
DSHS is planning to replace the current electronic death registry with a new system called TxEVER, which is scheduled to come online in 2019.
Medicaid pays for more than 50 percent of all births in Texas, and many of the proposals offered suggested ways to expand Medicaid access for mothers and young children. Ryan Van Ramshorst, MD, chair of TMA’s Select Committee on Medicaid, CHIP, and the Uninsured, said the number of uninsured pregnant women has decreased by about 7 percent between 2013 and 2016.
“This is optimistic, this is good news,” he said. “And why is this? This is because of investments in Medicaid, CHIP (Children’s Health Insurance Program), the Affordable Care Act, and other similar initiatives that physicians and other advocates have been pushing for, for many, many years.”
But most new mothers lose their Medicaid coverage just 60 days after giving birth. Dr. Van Ramshorst and others recommended extending that for up to one year to better screen for, diagnose, and treat potentially fatal post-partum conditions.
Dr. Hollier, the task force chair, said another piece of good news is that maternal mortality and maternal morbidity are preventable — especially deaths caused by complications like hypertension and hemorrhage. She pointed to the Alliance for Innovation on Maternal Health, or AIM, which has compiled best practices, or “bundles,” for physicians and hospital staff to use when treating pregnant women and mothers of newborns (safehealthcareforeverywoman.org).
Texas is one of 17 states working to implement some of the AIM bundles, which are voluntary for physicians and health care facilities.
“These sets of evidence-based practices consistently are demonstrated to significantly improve outcomes,” Dr. Hollier said. “They create a culture of patient safety. The [medical] teams, because of their interest, because of their desire to participate in the implementation of these bundles, changed the culture in their hospitals. And that makes a profound difference."
Tex Med. 2018;114(5):36-38
May 2018 Texas Medicine Contents
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