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Texas Maternal Mortality and Morbidity Task Force

A closer look at the maternal mortality report

Dec 29th, 2022
by Charles Kuffner.
1 comment

I take no joy in predicting that the Legislature will take no action on this.

Nakeenya Wilson was at a meeting of Texas’ maternal mortality review committee when she got the call: Her sister, who had recently had a baby, was having a stroke.

Wilson raced to the hospital, leaving behind a stack of files documenting the stories of women who had died from pregnancy and childbirth complications. Many of the women in those files were Black, just like Wilson, who experienced a traumatic delivery herself.

“The whole thing just reminded me, if you change the name on those files, it could be me. It could be my sister,” said Wilson, who serves as the committee’s community representative.

A decade ago, when Texas first formed the Maternal Mortality and Morbidity Review Committee, Black women were twice as likely as white women, and four times as likely as Hispanic women, to die from pregnancy and childbirth.

Those disparities haven’t improved, according to the committee’s latest report, published Thursday.

In 2020, pregnant Black women were twice as likely to experience critical health issues like hemorrhage, preeclampsia and sepsis. While complications from obstetric hemorrhage declined overall in Texas in recent years, Black women saw an increase of nearly 10%.

Wilson said these statistics show the impact of a health care system that is biased against Black women.

“We’re still dying and being disproportionately impacted by hemorrhage when everybody else is getting better,” Wilson said. “Not only did it not improve, it didn’t stay the same — it got worse.”

The causes of these disparities aren’t always simple to identify, and they’re even harder to fix. It’s a combination of diminished health care access, systemic racism, and the impact of “social determinants of health” — the conditions in which someone is born, lives, works and grows up.

Wilson said she and her sister are prime examples. They grew up in poverty, without health insurance, routine doctor’s visits or consistent access to healthy food.

“We started behind the ball,” she said. “We’ve had so many hard things happen to us that have contributed to our health by the time we’re of childbearing age.”

Maternal health advocates in Texas say addressing these disparities will take more than fixing labor and delivery practices. It will require building a comprehensive health care system that addresses a community’s needs across the board, starting long before pregnancy.

In the end, Wilson’s sister survived her postpartum health scare. But the experience reminded Wilson why she volunteers her time to read, review and analyze stories of women who have died from pregnancy and childbirth.

“When you look at the work marginalized people do, they do it because they don’t feel like they have any choice,” she said. “If we want to see things change, and we want to be safe, we have to advocate for our own safety.”

See here for some background. There’s way too much for me to try to capture in an excerpt, so go read the whole thing. Rep. Shawn Thierry, who experienced some of these problems herself a few years ago when she was giving birth, is and has been working on getting legislation passed to address the issues, which includes things like expanding health care access, gathering better information, and strengthening the maternal mortality review process. See above for my assessment of the likelihood of passage. Rep. Thierry will need a lot more like-minded colleagues to make that happen, and we are very much not there yet. But the work is happening, and will continue to happen.

Here at last is that updated report on maternal mortality

Dec 18th, 2022
by Charles Kuffner.
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We’re still really bad at preventing it, especially for Black women.

At least 118 women dead and nearly 200 children left without a mother.

This was just a portion of the death toll from pregnancy and childbirth in Texas in 2019, according to a long-awaited state report published Thursday.

Severe medical complications from pregnancy and childbirth also increased significantly between 2018 and 2020, surging from 58.2 to 72.7 cases per 10,000 deliveries in Texas.

As in past years, the tragedy of maternal mortality unfolded unevenly across the state, impacting Black women worst of all.

This is the fifth biennial report from the state’s Maternal Mortality and Morbidity Review Committee since the Legislature formed it in 2013, and the first to review more timely cases; the previous report reviewed cases from nearly a decade ago.

In 2013, Black women were twice as likely as white women and four times as likely as Hispanic women to die from pregnancy-related causes. A preliminary assessment of 2019 data indicates those trends have persisted.

The report determined that discrimination contributed to 12% of pregnancy-related deaths in 2019. This was the first such report since the federal Centers for Disease Control and Prevention added discrimination, including structural and interpersonal racism, as a potential cause of maternal death. The specific nature of discrimination varied between the cases identified by the committee and did not show a specific trend, the report said.

In 2018, a subcommittee was created to address these continued disparities by helping design a tool to better determine when and if discrimination plays a role in maternal deaths.

The report also found that most of these deaths were preventable — in 90% of 2019 cases reviewed by the committee, there was at least some chance of saving the woman’s life.

See here and here for some background. Easy to see why there might have been political pressure to delay the release of this report until after the election, not that it likely would have mattered. The people who care about this already care, and the people who don’t already don’t. I’ve made my share of pointed observations about the gap between all of the anti-abortion rhetoric and the actual amount this state officially cares about human life; I don’t believe the people who are the problem here are capable of being shamed about it. But as long as we’re talking about abortion:

Obstetric hemorrhage was the leading cause of pregnancy-related death in Texas, accounting for a quarter of cases. While there were fewer severe complications from hemorrhage overall, Black women saw their rate of complications increase nearly 10%.

The most common cause of hemorrhage deaths was ectopic pregnancies, in which a fertilized egg implants outside the uterus. Left untreated, these nonviable pregnancies can rupture, causing life-threatening complications such as severe blood loss and sepsis.

You can expect those numbers to continue to go up. The Lege and Greg Abbott will do nothing about it. The Chron has more.

So why wasn’t that report on maternal mortality released when it was supposed to be?

Dec 10th, 2022
by Charles Kuffner.
1 comment

We’ll never really know, mostly because there’s no one with the power to compel an answer from those who do know that cares enough to use that power.

State health officials had completed a long-awaited report on maternal deaths and were preparing talking points about the findings just days before it was shelved until after the November midterms, according to emails obtained by Hearst Newspapers.

The messages suggest that the agency was moving toward a required Sept. 1 release of the state’s first updated count of pregnancy-related deaths in nearly a decade.

On Sept. 2, however, then-Commissioner John Hellerstedt, an appointee of Gov. Greg Abbott, said the agency needed more time to complete the analysis.

The last-minute delay infuriated maternal health experts who have spent years pressing the state to update its sluggish data review process. Members of the state’s Maternal Mortality and Morbidity Review Committee, which analyzes pregnancy-related deaths, said they were given no heads up about the announcement.

Advocates have since accused Gov. Abbott of instigating the delay in an effort to protect his re-election chances in the midterms.

Some of the strongest condemnation over the hold-up has come from the Black community, where women are three times more likely to die from childbirth than white women. This year’s report would be the state’s first to analyze the causes behind racial disparities among those who die during or after childbirth.

While it’s true that the agency had not completed a full count as of September, as Hellerstedt said, a draft preliminary report on the majority of 2019 deaths was finished and in the final stages of editing, according to the emails. It has been the agency’s practice for years to release findings even before a full analysis is completed, in an effort to speed up public health interventions.

Agency staff were sharing final versions of the draft as late as Aug. 24, according to the emails.

Earlier that month, the health agency had been preparing to brief Abbott’s office and state legislators about the report’s findings.

See here for the background. There are answers to this question – they may vary depending on who is being asked, but they do exist. The problem is that no one who is being asked cares to answer, and no one who wants that answer has the power to make them give one. The people who do have that power – certainly the Legislature and maybe the Attorney General – don’t care any more about it than Greg Abbott does. So, unless someone like former Commissioner Hellerstedt starts telling tales out of school, we’ll never know. In the meantime, we may finally get that report as soon as this coming week, so at least we have that going for us.

State delays report on maternal mortality until next year

Sep 16th, 2022
by Charles Kuffner.
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Sorry, didn’t get to it, other things to do, you know.

Texas health officials have missed a key window to complete the state’s first major updated count of pregnancy related deaths in nearly a decade, saying the findings will now be released next summer, most likely after the Legislature’s biennial session.

The delay, disclosed earlier this month by the Department of State Health Services, means lawmakers won’t likely be able to use the analysis, covering deaths from 2019, until the 2025 legislative cycle. The most recent state-level data available is nine years old.

In a hearing this month with the state’s Maternal Mortality and Morbidity Review Committee, DSHS commissioner Dr. John Hellerstedt said the agency wanted to better align its methodology with that of other states, and that there hadn’t been enough staff and money to finish the review for a scheduled Sept. 1 release.

“The information we provide is not easily understood, and not easily and readily comparable to what goes on in other states,” Hellerstedt told the committee. “And the fact it isn’t easily understood or easily comparable in my mind leaves room for a great deal of misunderstanding about what the data really means.”

In a statement, DSHS spokesman Chris Van Deusen said the agency is reviewing its “internal processes” to try to develop more timely data.

“I expect we’ll be having conversations with legislators about what could be done to speed up the lengthy review process,” he said.

The setback comes four months before the start of the legislative session and two months before the midterm election, which has been dominated in part by the state’s new Republican-led abortion ban. Those restrictions have placed more scrutiny on the state’s maternal mortality rate, which is among the 10 highest in the country, according to national estimates that track pregnancy-related complications while pregnant or within a year of giving birth.

“There are a lot of us that want to know whether or not pregnancy in Texas is a death sentence,” said state Rep. Ann Johnson, a Houston Democrat and member of the Texas Women’s Health Caucus. “If we’ve got a higher rate of maternal mortality, we sure want to figure it out. You can’t figure it out if somebody’s sitting on the numbers, and that’s my worry.”

Like in other states, maternal outcomes in Texas are worse for Black women, who have died at about three times the rate of non-black women. This year’s findings were expected to drill further into the causes behind those disparities.

Rep. Shawn Thierry, a Houston Democrat who has described going through her own dangerous birthing experience, said the data is critical for understanding the role cesarean sections play in maternal deaths and whether implicit bias is playing a factor in the quality of maternal care for Black women.

“There is so much to unpack from the data,” Thierry said, adding that “no woman who chooses life should have to do so in exchange for their own.”

Members of the state’s maternal mortality committee, which compiles the official report, said they were disappointed by the decision to hold the preliminary findings.

“(We) do the work to honor the lives of women who lost their lives, and families that are forever impacted by the loss of a mother,” said Dr. Carla Ortique, the committee chair. “So there’s disappointment on both fronts: that we’re not honoring those women and families, and that we may be negatively impacting efforts to improve maternal health outcomes in our state.”

Pathetic. And typical. But don’t worry, even if the Lege has no current data on maternal mortality to take action on in the next session, they will be fully prepared to make abortion more illegal, because that’s what they care about. Daily Kos has more.

It’s hard being pregnant in Harris County

Apr 29th, 2018
by Charles Kuffner.
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We need to figure this out.

Life-threatening, pregnancy-related complications — the iceberg beneath the surface of the U.S. maternal health crisis — are on the rise in Harris County, according to a new report.

The report not only confirmed the Harris County rate is worse than that of the state and nation, it found that it increased more than 50 percent between 2008 and 2015. Texas’ rate of life-threatening, pregnancy-related complications went up 15 percent in the same time period.

“In subtle and unintentional ways, women’s health in Harris County has been subjugated to the health of babies so profoundly that the health of women of childbearing age is often not prioritized,” says the report, a project of the Houston Endowment.

Dr. Lisa Hollier, a Houston obstetrician-gynecologist and a co-chair of the task force that produced the report, said Harris County’s high rates “point to the need for greater intervention to promote safety around the time of delivery. Such complications are 50 times more common than pregnancy-related deaths, but don’t get near the amount of attention.”

Hollier and Dr. Cecilia Cazaban, the report’s principal investigator, said it is unclear why Harris County’s rate is increasing at such a high rate. They said that analysis is next on tap for the task force.

[…]

The new report focuses on severe maternal morbidity, the term for conditions that require such treatment as a respirator or blood transfusions or hysterectomy during delivery or in the immediate hours thereafter. It can lead to maternal death, but even when the patient survives, it can cause damage, such as kidney or heart failure, sometimes requiring lifelong treatment. It also is costly to the patient and health care system.

Harris County’s rate of severe maternal morbidity in 2015 was 2.4 percent, meaning there were 238 cases for every 10,000 deliveries. The 2015 rate was 1.97 in Texas and 1.46 in the United States.

See here for some background. The task force website is here, though I don’t think this report is on there. I hope there’s no need for me to say anything more than we really need to understand this problem so we can solve it.

Texas’ maternal mortality rate not as bad as previously reported

Apr 12th, 2018
by Charles Kuffner.
Comments are off for this post

Good news, if a bit puzzling.

Several of the state’s top health experts released a report in the medical journal Obstetrics & Gynecology on Monday showing that by using the new method, the number of women who died dropped from 147 to 56.

The study uses an enhanced method of counting maternal deaths that involves cross-referencing birth certificates, death certificates, hospital discharge data and medical records to confirm that a woman who died was pregnant before she died. The state’s current method of calculating maternal deaths includes using specific medical codes and requiring officials to check a box on death certificates indicating whether a woman was pregnant before she died.

The study said the state’s 2012 maternal death numbers inflated the number of women 35 and older who were classified as a maternal death and included reporting errors in which women who had not been pregnant were reported as maternal deaths. The researchers said they also found 2012 deaths that were not included in the state’s original maternal death numbers.

The authors noted that other states have used the same methodology to calculate maternal deaths. They said they chose 2012 for the new analysis because it was the year when maternal deaths peaked in Texas.

The study’s authors said they plan to use the new method to confirm maternal deaths and calculate maternal mortality rates for additional years.

See here for the background. The story notes that even with the revision, which the authors of the new study attribute to “data error” in the initial report, the mortality rate for black women was still double what it was for white women. There are still other serious concerns as well, as expressed by Lisa Falkenberg:

“I would hate to see us lose the momentum that we’ve gained,” said Dr. Lisa Hollier, an obstetrician and gynecologist at Texas Children’s Hospital.

“We still have women dying of preventable causes,” she said. “We still have a two-fold, a doubling, in the risk of death for African-American women. Those things need to change. I don’t think we should accept where we are.”

Hollier, who co-authored this week’s report and also chairs the Texas Maternal Mortality and Morbidity Task Force, points out that deaths aren’t the only measure of the problem. For every maternal death, Hollier says there are 50 women who experience severe complications that can lead to hysterectomies, breathing problems requiring ventilator support and kidney failure, to name a few.

“If there are 50 women who die in a particular year, there are 2,500 women who had severe complications,” Hollier said. “There are so many more women who are affected than just that tiny tip of the iceberg which is mortality.”

All this happens in a state where as Falkenberg reminds us our Republican leadership has refused to expand Medicaid – something like half of all births in Texas are paid for by Medicaid – and have cut back on access to healthcare for women by gutting Planned Parenthood. The definition of “pro-life” in this state is so narrow you could slide it under a lobbyists’ door. So go ahead and be happy that things aren’t as bad as we feared, but don’t be satisfied with it.

UPDATE: Sophie Novack in the Observer makes a lot of really good points about this revised study. Go read what she says.