Factors Affecting Maternal Mortality in Texas
It's almost common knowledge now that the Maternal Mortality rate in Texas has doubled since 2011 and is now the highest in the developed world. Here's a few of my thoughts on this horrifying statistic, as I sit in my office in the world's largest medical center.
Analysis
Texas’ maternal mortality task force was just created in 2013. Most other states have had their task forces analyzing data for decades. This means we are way behind in performing a root cause analysis. The task force members (12 physicians, 1 midwife, 1 community advocate and 1 social worker) are trying to find commonalities to answer the question “why are these women dying?” It is not until the “why” is known, that substantial progress will be made (i.e., money budgeted) to address how to prevent the factors causing the problem. We are also behind in analyzing the statistics. The task force is now reviewing medical records, rather than just the death certificates alone, as pertinent information was missed. For example, if the coroner did not know a woman had given birth in the months prior to death, maternal mortality would not have been registered. Of note, the check box for "recent pregnancy" was only added to the death certificate in Texas in 2006. Thus far, the difference in numbers with this more detailed investigation of cause of death is proving to be small, so the observed trend remains unchanged: Texas maternal mortality rate is rising.
Access to Healthcare
Texas has the highest rate of uninsured patients in the country. There is a difference in how Medicaid is distributed in Texas- our eligibility standard has a lower income requirement, meaning that fewer women will be covered by Medicaid compared to other states that participated in Medicaid expansion under the Affordable Care Act. We therefore have more women without health care coverage before pregnancy. Once pregnant, many women will qualify for Medicaid coverage for the duration of their pregnancy. Over 50% of births in Texas are funded by Medicaid.
Since the 2011 cuts in the family planning budget, Texas lost 82 clinics, which may very well have impacted women's access to annual MD visits which enable the detection of medical conditions such as high blood pressure, and for counseling on healthy practices for women of child-bearing age, such as folate supplementation. Additionally, a Texan's ability to be diagnosed as pregnant and to be referred for timely prenatal care may have been delayed by the clinic closures.
During pregnancy, consultations with specialists are hard to obtain. For example, if someone who has a high risk condition such as high blood pressure and needs to see a cardiologist, it can be very difficult to arrange a visit with this specialist because many cardiologists will not accept Medicaid, and for the few that do, the woman may have to wait weeks to be seen.
The temporary Medicaid coverage is terminated at 2 months after delivery. It’s important to note that the majority of the maternal deaths studied from 2011-2012 occurred after this 60-day post-partum coverage period. It is very difficult for many women to get healthcare coverage and without resources, they don’t have the follow-up medical visits that insured patients will have, especially in the setting of pre-existing medical conditions such as diabetes and high blood pressure. As a result, serious medical problems can go untreated. For example, a patient who was admitted to the ICU for dangerously high blood pressure (called a hypertensive emergency) 2 weeks after giving birth will no longer have health insurance 6 weeks later. Her medical needs will still be very profound, but she does not have a way to pay for her medications. Her risk of maternal mortality is high. Patients with high risk conditions such as this also very badly need contraception to avoid repeat pregnancy and its attendant risks. The need to seek out resources for financial assistance for medications, all while dealing with medical problems, physical recovery from childbirth and a newborn is tremendously burdensome. As a result, many put contraception lowest on the list of priorities.
Attributions
As a nation, we are getting heavier with more medical problems like heart disease and diabetes. These medical problems are the leading causes of maternal death, accounting for 30% of all maternal mortality in the US. Our obesity rate has risen an alarming 300% just since 1990. Seventy percent of Texans are overweight or obese. According to U.S. News, we rank as the #8 fattest state in the US. With obesity comes many other chronic medical conditions, including diabetes. These conditions only worsen with age, if left insufficiently treated. So, along with a trend of pregnancy in older women, you can imagine that the complications that go along with this combination will become more apparent.
Conclusions
We await the findings of the Maternal Mortality panel. In the meantime, Congress and the President are proposing further cuts to Medicaid. While the effects of such cuts cannot be studied in advance, it doesn't take a medical degree to imagine that further barriers to health care for Texas women is only going to make matters worse.
Codi Wiener, MD is a practicing OB-Gyn at Texas Children's Hospital in Houston, Texas, and a physician advisor to I'll Have What She's Having.