[dropcap]O[/dropcap]ver the last few years, all eyes have been on Texas women’s health, from the controversial defunding of family planning programs to an increase in maternal mortality rates. Texas not only has the highest maternal mortality rate in the United States, but it also has one of the highest rates among developed countries.
With heightened awareness, there may be some solutions in sight.
Following a special session in the Texas Legislature in August, lawmakers passed a bill to extend the work of the Maternal Mortality and Morbidity Task Force through 2023, created to help reduce pregnancy-related deaths and severe maternal morbidity.
Teams of medical professionals, as well as reproductive advocates, are also working to ensure rural patients aren’t forgotten in this crisis.
According to the Centers for Disease Control and Prevention and the National Center for Health Statistics, the maternal mortality rate in Texas went from 30.2 per 100,000 live births in 2011 to 38.7 in 2012. While the state has since seen improvements, Texas’s mortality rate still remains higher than national rates, which have ranged from 19.3 in 2011 to 21.5 in 2014.
Texas Department of State Health Services data shows that between 2011 and 2012, there were 189 maternal deaths. A majority of the deaths occurred later than 42 days after delivery and Black women made up a disproportionate share of maternal deaths during this period.
The Maternal Mortality and Morbidity Task Force was created in 2013 to address the spike, and initially, was set to expire in 2019. A group of physicians concerned about those numbers had been working on getting legislation two years prior.
“At that time there was a group of us, including physicians with the American Congress of Obstetricians and Gynecologists (ACOG), who were working to establish a maternal mortality study to better understand what we were seeing,” says Dr. Lisa Hollier, medical director at Texas Children’s Hospital and chairwoman of the task force.
In addition to the task force, a Perinatal Advisory Council has also been formed.
WHY IT’S HAPPENING
Medical professionals have acknowledged that maternal mortality has much to do with the incidence of illness in women and limited access to obstetric services.
But it’s not that simple.
“It’s not going to be a single cause,” Hollier says. “We’re not going to identify one thing. It’s very complex and involves a lot of different factors that place together systems.”
The Maternal Mortality and Morbidity Task Force found that the leading causes of maternal death during that spike were cardiac events, drug overdoses, and hypertensive disorders.
However, the task force reported that data quality issues related to the death certificate makes it difficult to identify a maternal death.
Dr. Alyssa Molina, a family medicine physician who provides obstetrical care in rural Eagle Lake, Texas and a member of the Perinatal Advisory Council, wonders if the way in which data is reported paints an accurate picture.
“We hadn’t seen changes (in Eagle Lake) in morbidity or infant mortality rates,” says Molina, who notes that the facility where she works has a low volume of obstetric cases. “Honestly, it surprises me to see those numbers when it came out.”
Molina says one factor that may be underestimated, particularly in rural areas, is the lack of access to mental health services. She believes mental illness may be connected to some of the causes of maternal deaths, such as overdose and suicide. In fact, the task force’s 2016 report noted that chronic illness and depression often co-exist in patients.
“It’s difficult to get psychiatric care for pregnant women or to a treatment facility for substance abuse,” Molina says. “It’s an issue across the state. It affects everybody. We need more mental health care across the board.”
For one thing, there is a stigma attached to mental illness or substance abuse, and care for these issues aren’t readily available in rural areas, especially for patients without health insurance. Texas has the highest rate of uninsured in the country. In addition, women who are on Medicaid—which pays more than half of Texas births—are dropped from the program 60 days after delivery, leaving no access to post-partum care.
While the significantly high maternal death rates seem to be decreasing, the sharp jump a few years ago is still of concern. Plus, there are risks that have increased with time as cultures change.
“Right now, we have moms who are older, more women who have previous infections, and we’ve seen significant increases in obesity, in diabetes and in high blood pressure,” Hollier says.
It doesn’t help that health facilities are becoming a thing of the past in some communities. At least 82 rural hospitals have closed and obstetric services are disappearing from rural facilities across the country, making it harder for women to access services near their home or have urgent care in the event of an emergency. In Texas, at least 18 hospitals have closed since 2013.
While there aren’t many studies examining the impact this has had to mortality rates in rural Texas, those who work there understand its potential harmful effects.
“Closing of rural hospitals is a huge problem,” Molina says. “A lot of those hospitals stop specialties before they close. When a woman can’t get care near her home, it increases the risks.”
The more remote a hospital is, the more challenging it is to handle a birth. Limited resources, coupled with limited ambulance services in rural areas, could be disastrous for a mother and baby going into distress during delivery.
SOLUTIONS ON THE HORIZON
States such as North Carolina are making strides to reduce the maternal mortality rate and have closed the gap between black and white women. Texas officials hope to mirror that same success.
There are two areas the Perinatal Advisory Council hopes to address in regards to rural areas: utilizing telemedicine and implementing levels of maternal care.
The council is creating criteria, based on ACOG recommendations, for this model.
“What that does is standardize care within those levels and helps women go where they need to go to get risk-appropriated care,” Hollier says. “Rural hospitals have been a part of drafting what those rules look like. I think that’s an important piece of the puzzle.”
Molina works at Rice Medical Center, which serves the 3,600 people in Colorado County and some patients from Austin and Wharton counties. She represents rural hospitals on the council.
The key, Molina says, is to be able to identify who is going to be in trouble before she’s actively in labor. It is critical to have a plan to get them to an accommodating facility. It’s a framework already established for neonatal units.
“So we know that when sick babies are in the hospital that are equipped to care for babies they do better,” Molina says. “In other states regional special centers with levels of care outlines, the mortality rate is lower. The idea is to create levels of care to guide centers to make it easier to transfer to hospitals based on acuity of care they can provide.”
The Perinatal Advisory Council meets six times a year, and the next report from the Mortality and Morbidity Task Force will be released in 2018.
THE MOST VULNERABLE
While only 11 percent of births were to black women, they make up about 29 percent of maternal deaths in the state.
To tackle this disparity, the medical community recognizes they must understand and address social determinants that impact health.
“We’re going to have to do that to be more successful,” Hollier says. “The recommendations that we made in 2016 were really looking at access to care, at screenings and referrals for health services, and intervention to improve outcomes. I would really like to see the gap between African American and all other women go to zero.”
But Marsha Jones, executive director at Dallas-based The Afiya Center, who advocates reproductive justice and works to bring awareness about health disparities among black women, thinks closing the gap requires more radical action.
“The issue is not understanding,” she says. “The issue is ‘do we have the political will to change it?’”
Jones grew concerned about the status of black maternal health after reading mortality and disparities reports. She and her staff set out to make this a priority at The Afiya Center.
“The risks in rural areas are greater for women, especially women who are lesser resourced and Black or in other ways marginalized,” Jones says.
Jones points to the state’s handling of family planning services and limited access to Medicaid as having a disastrous effect on black women’s health.
“Texas legislators’ refusal to expand Medicaid has led to the closing of many hospitals in the more rural areas, so this decreases access to health care because of limited financial resources and transportation,” she says.
Texas Gov. Rick Perry began cutting family programming programs in 2011, which resulted in the closing of 25 percent of family planning clinics. Jones says this impacted black women the most.
“It also impacts how and when women will enter into care during pregnancies which limits the abilities for care providers to identify conditions that can be treated ongoing or throughout pregnancies,” she says. “After birthing, if these same barriers to care exist, women cannot remain in care to continue treatment started while pregnant. When you limit resources to your most vulnerable population the outcomes can very easily result in death or serious illness.”
She adds, “When these clinics closed it caused many women to lose temporary access while having to seek out other, and for some, permanent access until they became pregnant or some other health conditions, which most likely meant using the ER as your first resource. Closing these clinics under the guise of preventing abortions carries a much bigger burden and we are seeing the results now.”
Jones says cultural incompetency and racism dictate how Black women are treated, even when they have resources and access to care.
“It is centered in racial discrimination” she says. “It is a direct result of how Black women are received when they enter the health care system that is riddled with bias about Black women’s bodies.”
Jones says she hasn’t seen the results she would like to see, but her organization has suggested some strategies. It begins with using a reproductive justice framework. This includes allowing women to decide when and if she will have a child, and the conditions in which she’ll give birth.
Social support to improve maternal outcomes include safe environments, healthy communities and fear from of any form of violence, she says.
“Using this framework would allow for the centering of Black women’s voices, experiences, traditions, leadership, and ingenuity to create solutions and strategies to address this issue,” Jones says. “(We should) look at the successes of other states as best practices for Texas legislators to replicate creating policy that’s effective.”