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Report: Black women in Texas experience disproportionately high rates of maternal morbidity, mortality

August 25, 2016 — The Texas Maternal Mortality and Morbidity Task Force last week released a report finding a disproportionate rate of maternal mortality and morbidity among black women in the state between 2011 and 2012, ProPublica reports.

The report follows a separate study that found a spike in the state's maternal mortality rate in 2011, the same year the state cut funding for Planned Parenthood and other women's health programs (Martin, ProPublica, 8/24).

Background

The state Legislature in 2011 cut the state's family planning budget by two-thirds and blocked funding to Planned Parenthood and other women's health clinics. As a result of the cuts, 82 of Texas' family planning clinics closed, according to the Texas Policy Evaluation Project (TxPEP). Of those clinics, about one-third were Planned Parenthood affiliates.

Following the cuts, Texas' program for women's health could serve only half the number of women for whom it had previously provided health care services (Women's Health Policy Report, 8/22).

In 2013, the state established the Maternal Mortality and Morbidity Task Force to identify and assess instances of maternal mortality and morbidity (ProPublica, 8/24). The task force is scheduled to release findings and recommendations on a biennial basis (AP/Sacramento Bee, 8/23).

National study

According to the Obstetrics & Gynecology study, maternal mortality increased slightly between 2000 and 2010 and almost doubled between 2011 and 2012. Specifically, the researchers found that the number of Texas women who died from pregnancy- or birth-related complications increased from 72 women in 2010 to 148 women in 2012.

The researchers noted that the increase coincided with the 2011 funding cuts, but they did not directly link the two events. Moreover, according to the researchers, the budget cuts alone could not account for the substantial increase. Calling the increase "puzzling," the researchers wrote that it was out of line with trends in the maternal mortality rate in other states (Women's Health Policy Report, 8/22).

Details on latest study

For the latest study, the Texas task force assessed death and birth certificates to identify 189 maternal deaths between 2011 and 2012. According to ProPublica, the task force used the Centers for Disease Control and Prevention's definition of maternal fatality, which defines a pregnancy-related death as one occurring to a woman within one year of pregnancy "from any cause related to or aggravated by ... pregnancy" or "a chain of events initiated by pregnancy." The task force examined specific maternal deaths; it did not calculate the overall rate of maternal mortality for 2011-2012.

The task force also collected data on the rate of severe maternal morbidity by examining obstetric hospital discharge data for 2012, focusing on discharges that cited at least one indicator of a major health issue, such as stroke or sepsis (ProPublica, 8/24).

Key findings

The task force found that between 2011 and 2012, black women in the state gave birth to 11.4 percent of all infants, but comprised nearly 28.8 percent of maternal fatalities (ProPublica, 8/24). In contrast, over the same time period, Hispanic women gave birth to 48 percent of births and accounted for 31 percent of maternal fatalities, while white women gave birth to 35 percent of births and accounted for 38 percent of deaths (AP/Sacramento Bee, 8/23). According to the report, black women also experienced a disproportionately high rate of maternal morbidity.

Lisa Hollier, a professor of obstetrics and gynecology at Baylor College of Medicine and head of the task force, said, "The disparity in the rates for African-American women is incredibly important and not widely recognized" (ProPublica, 8/24).

The report found that the leading causes of maternal fatalities included cardiac events, drug overdose and health care disorders related to high blood pressure (AP/Sacramento Bee, 8/23). The task force said the primary drivers for severe complications were hemorrhages and blood transfusions.

The task force also highlighted the role of mental health and substance use disorders in the overall maternal mortality and morbidity rates (ProPublica, 8/24). According to the task force, providers "repeated[ly] missed opportunities" to screen women for such problems and arrange follow-up care (AP/Sacramento Bee, 8/23).

In addition, the task force found that about 60 percent of the maternal deaths did not occur in the hospital or immediately after birth, but rather at least six weeks post-delivery. According to ProPublica, the finding is significant because the state's Medicaid program covers about half of Texas' 400,000 births per year, but many women lose their benefits 60 days after delivery (ProPublica, 8/24).

The task force recommended increased access to health care services both in the year following a delivery and the time between a woman's pregnancies (AP/Sacramento Bee, 8/23).

Task force mulls reasons for maternal mortality, morbidity

The task force said the overall rate of maternal mortality, as well as the specific number of maternal deaths and the reasons behind the increase between 2011 and 2012, remain unclear. "The short answer is, I don't know," Hollier said, adding, "The longer answer is I think it's unlikely that there is a single explanation. The problem is complex and the increase is likely due to a multitude of factors."

While the task force did not examine the effect of the 2011 family planning cuts on the mortality rate, they acknowledged that the cuts were harmful for women who relied on Planned Parenthood and other affected providers for care. Nancy Sheppard, a social worker with Seton Healthcare network and task force member, said Texas' track record on women's health is "horrific ... relative to the rest of the nation, and there's absolutely no excuse for it."

Sheppard also raised concerns about limited access to mental health care and drug misuse services. "[T]here are no mental health services and even less addiction drug and alcohol services" for women in the state, she said, adding, "A lot of time the drugs are being used to self-medicate because [pregnant women and new mothers] cannot get mental health treatment."

In addition, Sheppard pointed out that a woman who loses Medicaid coverage might be unable to continue to afford prescribed antidepressants. "To quit antidepressants cold turkey is very bad. You have to be weaned off that," she said, noting that ending such treatment quickly after a birth "is a perfect storm."

The task force also said women's lack of insurance could be exacerbating the state's maternal mortality and morbidity rates. June Hanke, a strategic analyst and planner at the Harris Health system and task force member, said, "If a person had been in regular care, maybe those cardiovascular (problems) would have been identified" before a woman died. She added that without insurance, "if you need medication, can you really afford it? Do you even know your blood pressure is high?" (ProPublica, 8/24).

Comments

State Rep. Armando Walle (D), author of the bill that established the task force, said the report "confirms what we feared -- that many of these deaths could be prevented ... It's a travesty that this is happening."

Walle said he hoped state lawmakers would consider the report when the Legislature reconvenes for 2017. "I'm not naive to the fact we haven't expanded Medicaid, but something needs to be done to increase access [for] pregnant women," he said, adding that state lawmakers cannot continue "letting federal dollars go to other states while these women are dying."

Separately, Marian MacDorman, research with the University of Maryland and lead author of the Obstetrics & Gynecology study, said while her research and the task force findings used different sources and analyses, both show "that maternal mortality is a serious problem in Texas" (AP/Sacramento Bee, 8/23).

Hollier echoed MacDorman's conclusion, noting that the key issue "is that the [maternal mortality] rate is rising" (ProPublica, 8/24).