There is a lot of confusion about how maternal mortality and morbidity cases are counted in Texas.
A big part of that confusion can be traced back to the period from 2016 to 2018, when it looked like Texas might have the worst maternal mortality rate in the developed world.
A 2016 report suggested – incorrectly – that the state’s maternal mortality rate had more than doubled over 10 years. The report pegged that rate for 2012 at 38.4 per 100,000 live births, which was considered an alarming jump from the maternal mortality rate of 17.7 per 100,000 registered from 2000 to 2010.
Texas’ rate appeared to be higher than that of many of the world’s poorest countries, so it set off alarms among state health officials and policymakers while generating numerous media reports. But it wasn’t true.
A 2018 study by the Texas Department of State Health Services (DSHS) scrutinized each 2012 case of maternal mortality and found that the death rate on the original report was inflated. The new report found that Texas’ maternal mortality rate for 2012 was actually much lower at 14.6 per 100,000. The national average was 15.9 per 100,000 in 2012, according to the Centers for Disease Control and Prevention (CDC).
“The problem was that [the 2016 report was] using death certificate data alone, and unfortunately, there was a fair amount of overcounting and some undercounting,” said Houston obstetrician-gynecologist (OB-Gyn) Lisa Hollier, MD, chair of the Texas Maternal Mortality and Morbidity Review Committee and a co-author of the DSHS study. “It became clear that using death certificate data alone was not going to provide sufficiently accurate information.”
Because of the errors associated with the death certificate data, DSHS researchers developed an improved method in 2012, says Houston OB-Gyn Carla Ortique, MD, vice chair of the review committee. This method provides a more accurate estimate of maternal deaths that occur during pregnancy or within 42 days postpartum.
Since then, DSHS has released rates for 2013 to 2015 (See “By the Numbers: Maternal Mortality in Texas,” page 29) To add to the confusion, though, rates from those years cannot be compared with 2012 rates because they involved a more refined data-collection methodology, Dr. Hollier says.
DSHS epidemiologists are still finalizing 2016 and 2017 data using this improved method, says DSHS spokesperson Chris Van Deusen.
Data-collection problems at the national level have compounded the confusion about maternal mortality rates even further. Because states gathered the data in different ways, CDC published no national maternal mortality rate between 2007 and 2020. In 2020, the agency published the 2018 rate, which was 17.4 per 100,000 live births. The 2019 rate published since then was 20.1 per 100,000 live births, the highest maternal death rate in the developed world.
While essential, maternal mortality rates show only one piece of the puzzle, Dr. Hollier says. State-based maternal mortality review committees like Texas’ provide the best opportunity to comprehensively assess and characterize maternal deaths. This helps the state understand the causes and contributing factors and identify opportunities for prevention, she says.
“We’re looking at [contributing factors like] when did she come in for her first prenatal visit? Did she have [insurance] coverage before pregnancy? Did she have chronic illnesses?” Dr. Hollier said.
Yet here is another potential source of confusion: The committee finished reviews of 2012 and 2013 and for now will jump forward to doing 2019 and 2020 cases because a grant the committee obtained from CDC requires that maternal deaths be reviewed and completed within two years of the death.
The reviews for 2014 to 2018 may still be completed, but focusing on more recent years will allow the committee to make more up-to-date recommendations, Dr. Hollier says.
Data collection also has hampered the effort to prevent maternal illness, says Patrick Ramsey, MD, chair of TMA’s Committee on Reproductive, Women’s, and Perinatal Health.
“What we really need is some kind of state-level data system in place to inform ourselves about the outcomes for [the treatment of] moms and babies to better direct where we should focus our efforts to reduce maternal morbidity,” he said.
Obtaining funding for that system from the Texas Legislature remains a priority for the Texas Medical Association as well as statewide organizations like the Texas Collaborative for Healthy Mothers and Babies, where Dr. Ramsey is chief medical officer.
However, collecting the data also presents challenges. If a private entity collects the data, there’s no enforcement mechanism to require hospitals to submit information. But if the state collects the information, hospitals fear that data could be turned against them and used to unfairly rank their ability to treat patients.
That could lead to unintended consequences, Dr. Ramsey says.
“How do you make it fair so that hospitals don’t start cherry picking patients?” he said. “‘Well, I’m not going to take that patient. She’s got diabetes and high blood pressure, and she’s got complications. I’m just going to take the healthy mom who’s 21 with no complications.’ That’s where it gets difficult.”