Thanks to a report released this week, some people might think Texas' maternal health crisis isn't really a crisis at all.
The Texas Department of State Health Services (DSHS) on Tuesday released a study that revised the state's maternal death rate sharply downward. A 2016 report had 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.
That 2016 report set off all kinds of alarms among state health officials and policymakers. It was also a public embarrassment. News story after news story trumpeted that Texas has the worst maternal death rate in the developed world.
But the DSHS study released Tuesday scrutinized each 2012 case of maternal mortality and found that the death rate on the original report was inflated because of misreporting on death certificates. The new report says Texas' maternal mortality rate for 2012 was actually much lower, potentially ranging from 14.6 to 18.6 deaths per 100,000. The national average was 15.9 per 100,000 in 2012. (Which is shocking in itself when compared with countries like Germany and Canada, with rates of 7 and 8 per 100,000, respectively.)
Journalists love shattering myths, and many of the headlines about Tuesday's report reflected that. "What caused Texas' maternal death rate to skyrocket? Inaccurate data," said the headline in the Dallas Morning News. The Washington Post headline read, "Texas' maternal mortality rate was unbelievably high. Now we know why."
A key state lawmaker chimed in as well:
"It is clear that Texas does not have the worst maternal mortality in the developed world and that previous reports were grossly inaccurate," state Sen. Lois Kolkhorst (R-Brenham), who authored the bill that created Texas' Maternal Mortality and Morbidity Task Force in 2013 to study the issue, said in a statement. "I believe we, as a state, can and are doing more to improve maternal health outcomes."
Casual readers could be excused for thinking, "Well, that problem's pretty much handled."
But Texas physicians know better.
Patrick Ramsey, MD, a San Antonio obstetrician-gynecologist and maternal-fetal medicine specialist who is also a member of the state task force, said even the revised maternal death statistics are nothing to be proud of.
"I think it's important to not let our guard down, thinking, ‘Oh, the numbers are wrong, and we're actually doing well,’" Dr. Ramsey said. "Women are still dying."
Shanna Combs, MD, a Fort Worth OB-Gyn who chairs the Texas Medical Association's Committee on Reproductive, Women's, and Perinatal Health, pointed out that the data in the original 2016 study were always considered suspiciously high and were expected to be revised. But she said even the updated data show that certain groups of women — especially African-American women and those over the age of 35 — still face extremely high maternal death rates.
Tuesday's DSHS report showed that white women in Texas have a maternal death rate of 13.6 per 100,000, which is still high compared with similar large states like California (6.2 per 100,000) and other developed countries, which have rates that tend to fall in the 3 to 7 per 100,000 range. But for African-American Texans, the rate is 27.8 per 100,000 live births, and for women age 35 and over the rate is 32.2.
"I was happy when I saw the [new] data because that means fewer moms are dying, but sad in thinking that we're finally trying to make maternal care and pregnancy better, and now with this new data people thinking 'No, we don't need to do anything,'" Dr. Combs said. "We have a lot of deficiencies and disparities in our state that we really need to work on."
Many of these deficiencies and disparities were addressed at last month's TMA Maternal Health Congress. One of the presenters was Lisa Hollier, MD, who is chair of the state task force and a co-author of Tuesday's DSHS report. She said at the congress that death rates among races are widening, and drug overdose, cardiac disease, hemorrhage, and hypertension are among the leading causes of death.
Dr. Hollier also stressed that all but a handful of maternal deaths and severe illnesses are preventable. She said 41 percent have a good to strong chance of prevention, while 48 percent have some chance of being prevented. Only 11 percent have no chance at all.
Dr. Combs said eliminating maternal deaths in Texas is not only a worthy goal, it's completely doable.
"One death is a death too many,” she said. "We shouldn't be having maternal deaths in the United States and in Texas with all the resources we have available."
On top of that, maternal death rates are seen as a kind of canary in the coal mine for maternal health in general. David Lakey, MD, chair of TMA's Council on Science and Public Health, said that behind every maternal death in Texas are at least 20 to 50 cases of severe maternal illness.
"The data that I've seen tied to severe maternal morbidity — women getting very ill during childbirth — those have not been revised down and are significantly higher than the national average," he said.
DSHS is already addressing the issue of faulty death records, and TMA is collaborating with the agency to make sure physicians find the new electronic system for filling them out user-friendly. (See "Can Texas Do Death Better," January 2018, Texas Medicine.)
However, Dr. Ramsey said medical schools, hospitals, and practices need to prepare physicians better for filling out the sometimes difficult-to-access forms.
"Clearly, documentation of death certificates is an issue," he said. "There needs to be better training of providers."
TMA remains vigilant. At TexMed 2018, TMA’s annual meeting in May, member physicians will look at ways to generate more accurate death records. They'll also look at ways to address the issues that affect women directly, such as better access to health care and enhanced behavioral health services.
Despite Tuesday's revised numbers, maternal death and illness remain serious problems that need a lot of attention, and fortunately, many people understand that. Dr. Combs said it's vital that policymakers and the public don't forget it.
"We're not excelling even with the new numbers," she said. "We're still behind in many respects. As is shown in other developed countries and other states, we can do better, and we should want to do better for our moms."