Maternal mortality in Texas needs an upstream solution

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Photo: J.K. Califf, via Flickr Creative Commons

By Katy Nimmons

Maternal mortality and morbidity is a huge, worsening problem in Texas. Like many issues in our state, its burden is unequally distributed. Black women in Texas are more than twice as likely to die while pregnant, giving birth, or during the postpartum period compared to white women. Overall, Texas women are dying and becoming injured from pregnancy-related causes at rates in line with non-industrialized, developing countries. The reasons for this disparity are many (covered in detail here, here, here, and here), but root causes include poor state policies and lack of access to health care.

In the field of public health, we often talk about “upstream” and “downstream” effects. The terminology comes from a parable about two friends, lost in conversation with each other as they walk along a riverbank, who suddenly notice a flotilla of babies bobbing in the river. Both friends immediately jump in the river and start hauling the unattended infants to safety. Several minutes pass in this way, and there seems to be no end of babies to rescue. One friend moves to climb out of the water.

“Where are you going??” cries the other, with a baby under each arm. “There are still dozens of kiddos in the river!”

“I know,” replies the first. “I’m going to stop whoever is throwing them all in.”

To save the babies (and mothers, and families, and communities) in Texas, we have a similar choice of upstream and downstream approaches. Both are important. An effective response will incorporate elements of each.

Unfortunately, the current proposals from the Texas Task Force on Maternal Mortality and Morbidity do not go far enough in implementing upstream or downstream approaches. In their present form, the proposals will fail to significantly reduce the tragic toll of maternal mortality and morbidity.

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The first shortcoming of the Task Force’s response involves data. When initial reports showed that Texas women were dying from pregnancy-related and pregnancy-associated causes at unconscionably high rates, politicians, advocates, and the public expressed alarm. The 2016 Task Force report stated that 189 women died during pregnancy or within the year after giving birth in 2011-2012. A research team from the University of Maryland used the state’s official data to conclude that maternal mortality had doubled from 2011 to 2012.

After an understandable public outcry, the Maryland researchers and the Task Force revisited the data. They concluded that the number of deaths was lower than 189, due to poor records and inconsistent death certificates. In and of itself, it is scandalous that the state of Texas has such poor data practices that tracking maternal mortality and morbidity is so difficult. Even worse, when the Task Force recalculated the maternal deaths, they shifted the window from [birth and the following 365 days] to [birth and the following 42 days]. They also discovered errors in some death certificates that had incorrectly categorized deaths as pregnancy-related. The recalculated maternal mortality shrunk from 189 to 56. The reduced time frame of 42 days allows for comparing rates across years, but also erases many maternal deaths from the calculation. The Task Force has yet to complete any comparative studies looking at more recent data (2013-present). Unreliable data, statistical manipulation, and incomplete research are all individually shameful. Together, they jeopardize the health of Texas women.

The second shortcoming relates to downstream causes. The Task Force proposes a series of “bundles,” or packaged protocols and systems for hospitals. Effectively preventing maternal deaths from hemorrhages and eclampsia in hospitals is critical, of course. However, this intervention is not yet in place, and once implemented, would only address hospital-based maternal mortality cases — a small portion of the overall total. This is doubly inadequate.

The bundles have been used effectively in California for close to a decade, and the state halved its maternal mortality rate from 2009 to 2013. That an effective set of hospital practices, tools, and resources exist and have not yet been introduced to all Texas facilities is a tragic failure of leadership.

Additionally, focusing on women while they’re in the hospital is necessary but insufficient. Most maternal deaths occur after the new mother leaves the clinical setting. The bundles would fail to make any impact on postpartum deaths beyond the walls of the hospital.

The Task Force also proposes improving access to behavioral health resources for new mothers. This is an effort to reduce postpartum depression and opioid abuse, both of which contribute to maternal mortality. Unfortunately, behavioral health referrals are supposed to take place through the Healthy Texas Women program. The many flaws of Healthy Texas Women are well documented (see the EDPW’s Healthy Skepticism report). Suggesting Healthy Texas Women as a resource for preventing maternal mortality and morbidity is laughable.

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This brings us to the final, most devastating shortcoming. The upstream causes of maternal mortality spring from sources like low access to health care, discrimination, and co-existing health conditions. Along these lines, the Task Force does propose addressing chronic disease and conditions such as high blood pressure and diabetes are associated with poor maternal health and outcomes. Coming from the same state that refuses to expand Medicaid and brags about “defunding” Planned Parenthood, however, the proposal is hypocritical.

Because Medicaid and CHIP benefits for Texas women, parents, and families are so paltry, many women who could benefit from medical attention prior to becoming pregnant do not qualify for services. Without private insurance through employment, individual insurance purchased through exchanges, or public benefits like Medicaid, health care can be out of reach. Even women who do have insurance may find the co-pays and deductibles unaffordable. Texan women who qualify for public benefits have seen their choice of doctors restricted, as Republican state legislators have prioritized removing Planned Parenthood as an eligible provider. Planned Parenthood locations across the state have closed in response, further limiting access to health care for pregnant women and women who may become pregnant in the future.

A true upstream approach to preventing maternal mortality and morbidity would expand access to health care for all Texas women. Chronic diseases cannot be prevented, managed, and treated when women are unable to see a medical professional. Healthy pregnancies, deliveries, and postpartum recoveries are more likely when all mothers have access to affordable, acceptable, accommodating health care. The state’s decision to not expand Medicaid and restrict access to Planned Parenthood is a short-sighted, dangerous combination for Texas women. The implications for maternal mortality and morbidity are clear: The appallingly high rates of deaths and debilitating injuries will continue.

If you’re also outraged by maternal mortality in Texas and underwhelmed by the state’s weak response to the crisis, consider joining the East Dallas Persistent Women in advocating for more attention and resources to be directed to the issue. We’re assembling in Austin on March 15, the day of the next Maternal Mortality and Morbidity Task Force meeting. Let us know if you’d like to join us.

Katy Nimmons is a public health professional and a proud East Dallas resident, voter, and Persistent Woman. She has masters degrees in public health from the University of Texas and in gender and development studies from the University of the West Indies. When not advocating for equal rights and justice, Katy enjoys taking her family to craft breweries.

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