Between 2012 and 2015, almost 400 women died in Texas within one year of giving birth.
That tragic fact, and others like it, brought Texas physicians and policymakers to Austin on Saturday. Their goal: Find an answer to the state's soaring 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, TMA members and health care experts discussed ways to identify options for the next session of the Texas Legislature, which begins in January.
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,” Dr. Cardenas said.
The problem is daunting: Texas’ maternal mortality rate has nearly doubled between 2010 and 2015, soaring from 18.6 deaths per 100,000 live births to 32.5 deaths per 100,000, according to the U.S. Centers for Disease Control and Prevention.
Although a January report in the medical journal Birth indicated Texas’ rate might not be as high due to misreporting on death certificates, maternal deaths are considered one of the state’s biggest health concerns.
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 l.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. Proposals adopted by the reference committee 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.”
Click here for more photos and highlights from the Maternal Health Congress
Carla Ortique, MD, vice chair of the Texas Maternal Mortality and Morbidity Task Force, said the problems faced by African-American women are especially difficult. 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 2 to 3 times more likely to die of preeclampsia, eclampsia, or placental abruption than white women, even though they do not have a statistically significant greater prevalence, 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.
A more common problem in Texas is severe maternal illness or disease. Dr. Hollier said there are 50 to 100 cases for each maternal death.
John Hellerstedt, MD, (left) commissioner of the Texas Department of State Health Services (DSHS), said that illustrates 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 is also raising standards in health care facilities to ensure that 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 reimbursement for maternal health services.
One of the most important DSHS initiatives involves improving the state’s death certificate process, Dr. Hellerstedt said. Researchers have found that Texas death certificates may misreport a woman’s status as a new mother, potentially 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 Texas Electronic Registry with a new system called TxEVER, which is scheduled to come online in 2019.
The good news is that maternal mortality and maternal morbidity are preventable — especially deaths caused by complications like hypertension and hemorrhage, said Dr. Hollier, the task force’s chair. 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 the mothers of newborns.
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 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.”