TMC PULSE

t m c » p u l s e | j u n e 2 0 1 7 32 Maternal Mortality in Texas Unpacking the truth behind the state's spike in pregnancy-related deaths I t's 8 a.m. on a Thursday, and Jammie (pronounced Jay-me) has just finished a prenatal checkup. She is 19 weeks and three days pregnant— with twins—and has been coming to The Center for Children and Women in Southwest Houston for her prenatal appointments. It's a unique clinic— part of Texas Children's Health Plan— designed to provide a full spectrum of health care under one roof. Without the center, Jammie isn't sure she'd be able to get all the services she needs, especially while carrying multiples. In Texas, that could mean the difference between life and death. Worst in the nation In 2016, the publication of two inde- pendent reports suggested that the maternal mortality rates in Texas had doubled within the past decade, rank- ing Texas the worst in the nation and on par with economically underdeveloped countries. The findings were shocking to investigators and the public alike, sparking a media frenzy that pointed to the state's severe anti-abortion leg- islation and reintroduced the phrase "everything's bigger in Texas." But the reality is far more complex than any headline could suggest, and investigators are still analyzing data to truly understand the facts behind the numbers and, most importantly, how to reverse the trend. Original research published in the September 2016 issue of the medi- cal journal Obstetrics & Gynecology launched the first public outcry. When examining maternal mortal- ity trends in the U.S. between 2000 and 2014, a group of Maryland-based researchers found Texas to be an outlier. According to their data, Texas maternal mortality rates showed "a modest increase" from 2000 to 2010, from a rate of 17.7 in 2000 (calculated per 100,000 live births) to 18.6 in 2010. But after 2010, "the reported maternal mortality rate for Texas doubled within a two-year period to levels not seen in other U.S. states." According to data collected by the Centers for Disease Control and Prevention (CDC) and the National Center for Health Statistics, the rate of maternal mortality in Texas jumped to 30.2 per 100,000 live births in 2011, then spiked to 38.7 in 2012 and remained above 30 through 2014— a rate significantly higher than the CDC's annual national benchmarks over that same period, which ranged from 19.3 in 2011 to 21.5 in 2014. That 2011 increase in Texas was the focus of the other major report, published prior to the Obstetrics & Gynecology research, by a state- appointed Maternal Mortality and Morbidity Task Force and the Department of State Health Services. Comprised of 15 Texas-based multidis- ciplinary experts and chaired by Lisa Hollier, M.D., professor of obstetrics & gynecology at Baylor College of Medicine and medical director at Texas Children's Health Plan, the task force used additional metrics to analyze the deaths between 2011 and 2012. In addi- tion to finding an increase in reported deaths during those years, the task force found racial disparity among the mothers dying in Texas. Black women were found to bear the greatest risk for maternal death, with a rate nearly three times higher than other women. In 2011 and 2012, black women were responsi- ble for 11.4 percent of births in Texas, but they also claimed 28.8 percent of all maternal deaths. By comparison, white women accounted for generally equal proportions of total births and total maternal deaths, and Hispanic women and women of other ethnic and racial groups accounted for a lower propor- tion of total maternal deaths than total births. Based on death certificates, the task force also determined that cardiac events, drug overdoses and hyper- tensive disorders like pre-eclampsia (formerly called toxemia) were the leading reasons for the maternal deaths recorded, and that the majority of the deaths didn't occur in the delivery room or shortly thereafter, but more than 42 days after delivery. "These findings were informative and concerning," Hollier said. "They reinforce the need for detailed reviews of maternal deaths so that the problems can be understood and the right solu- tions identified to correct them." Advocates for women's reproduc- tive rights were quick to blame Texas lawmakers for the state's spike in pregnancy-related deaths, citing the 2011 decision to slash the state's family planning budget by more than $70 mil- lion and the 2013 mandate that abortion clinics meet ambulatory surgical center requirements—resulting in the shutter- ing of numerous women's health clinics throughout the state. (continued) B y A l e x a n d r a B e c k e r Facing page: Erica Giwa, M.D., an OBGYN with Texas Children's Hospital and assis- tant professor of obstetrics and gynecology at Baylor College of Medicine, examines a patient during a prenatal checkup at The Center for Children and Women. Reprinted with permission from the DSHS Office of Program Decision Support Center for Children and Women. Every maternal death is a tragedy and we should strive for a case rate of zero. But when you look at the data ... it suggests that the potential increase in maternal deaths is not occurring at delivery or in the immediate postpartum period, but the time period from 42 to 365 days after birth—thus, outside the hospital. — SEAN BLACKWELL, M.D. Maternal-fetal medicine specialist at Children's Memorial Hermann Hospital and department chair for obstetrics, gynecology and reproductive sciences at McGovern Medical School at UTHealth

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