The latest biennial report on maternal deaths in Texas and a subsequent update show Texas still has a long way to go to adequately protect the health of women in their child-bearing years – especially women who are Black – reinforcing the Texas Medical Association’s long-standing efforts to improve maternal care and access.
Based on preliminary 2019 data, the Texas Maternal Mortality and Morbidity Review Committee (MMMRC) found 59 pregnancy-related deaths – those caused directly or indirectly by the pregnancy. Those 59 cases were identified from a larger pool of 140 deaths identified as pregnancy-associated, meaning they occurred during a pregnancy and up to one year afterward.
For each pregnancy-associated death, there are at least 100 other women who represent a “near-miss” – a person who has severe, often life-altering complications but does not die, says Houston obstetrician-gynecologist Carla Ortique, MD, chair of MMMRC.
“That’s a big number,” she said.
Moreover, 88% of the pregnancy-related deaths were deemed preventable. The top causes: obstetric hemorrhage (22%), mental health conditions (18.6%), and cardiovascular disease (15.3%), according to a follow-up letter the Texas Department of State Health Services (DSHS) sent to Gov. Greg Abbott. DSHS oversees the maternal review committee.
Many maternal deaths are preventable because of problems tied to health care, but nonmedical issues also play a large role, says Houston OB-Gyn Rakhi Dimino, MD, chair of TMA’s Committee on Reproductive, Women’s, and Perinatal Health.
“Many people may think that we must be having trouble in every hospital if we’re having nearly 90% potentially preventable deaths,” she said. “But this report is really a comprehensive look at all the contributing factors to maternal death. That includes physicians and birthing facilities, but also community issues, barriers to access to care, socioeconomic factors, and other challenges that may prevent the best overall care.”
The report’s top recommendation calls for Texas to increase the availability of comprehensive health care coverage during pregnancy, the year after pregnancy, and throughout the time women are able to bear children. One of TMA’s top priorities for the 2023 legislative session is to extend Medicaid postpartum care from two months to 12 months.
In a departure from previous MMMRC reports, the 2022 findings emphasize the problems faced by Black women, Dr. Ortique says. Data collected by MMMRC over time shows that Black women are disproportionately affected by maternal death and illness.
The exact reasons Black women face higher rates of maternal death and illness remain unclear and are being studied by MMMRC’s Subcommittee on Maternal Health Disparities. The 2019 numbers also show that non-Hispanic Black women die at twice the rate of non-Hispanic white women and over four times the rate of Hispanic women. That trend has persisted since at least 2013, the earliest year with data available.
“If we solve that problem, we would see our overall [morbidity and mortality] rates decline as well,” Dr. Ortique said.
To address this issue, MMMRC’s second recommendation calls for the state to “engage Black communities and those that support them in the development of maternal and women’s health programs.” This includes bettering maternal health and safety programs and services aimed at Black women; redesigning graduate medical education to help physicians better address disparities in care; and implementing policies at hospitals and clinics designed to promote more respectful care.
At least some of the problem is caused by racial bias in health care settings, and in many cases that bias is subtle, Dr. Dimino says. For instance, if a physician writes in a patient’s chart that the patient is “noncompliant” with treatment because she hasn’t shown up for appointments, that might cause other staff members to believe the mother lacks interest in her own health or the health of her baby.
“If the reason she didn’t go to her specialist appointment downtown is transportation, we should say the barrier is transportation,” she said. “We should then work to overcome that barrier instead of implying that she is simply skipping her appointments. Documenting ‘noncompliant to care’ may make other care providers believe she is a ‘bad’ patient, so they are more likely to write her off.”
The report does include good news, says San Antonio OB-Gyn Patrick Ramsey, MD, an MMMRC member. For instance, while obstetric hemorrhage was the leading cause of maternal deaths, hemorrhage hospitalizations in severe cases of illness declined to their lowest level since 2017 to 27.5 deliveries per 10,000 delivery hospitalizations.
This decline in morbidity from hemorrhage coincided with the introduction of the Texas Alliance for Innovation on Maternal Health (AIM). TexasAIM provides a “bundle,” or collection of best practices, for treating hemorrhage that was used in 98% Texas birthing facilities starting in 2019.
“That shows at a high level some of the interventions we’re doing in response to prior reports may be having an impact,” Dr. Ramsey said.
Even here though, women who are Black faced bigger obstacles than other women, Dr. Dimino says. While the overall rate went down, among Black women, severe illness caused by hemorrhage rose by 9.8%.
“We still have a good amount of work to do,” Dr. Dimino said.
MMMRC initially reviewed 118 cases preliminarily identified as pregnancy-associated deaths, according to the committee’s report. Then between September and December 2022 – after the report’s completion – MMMRC finished reviewing an additional 22 cases, bringing its analysis to a total of 140 cases, according to the DSHS letter. Seven additional cases remain outstanding, and they will be reviewed in early 2023.