TMC PULSE

t m c » p u l s e | j u n e 2 0 1 7 34 But while both decisions undoubtedly created gaps in care for many Texas women, the timing doesn't quite synch. "I put it this way," Hollier said. "The time-course of the increase doesn't fit with the time-course of the clinic closures, so it's unlikely that the clinic closures caused the increase." Disentangling the data It is important to note that the data used for the maternal mortality studies was unusually difficult to analyze and potentially shaped some of the results, since the studies used varying bench- marks for measuring maternal mortal- ity ratios. For the Texas task force's analysis, a pregnancy-associated death was defined as any woman who died within 365 days of birth or fetal death from any cause; the analysis examined all mater- nal deaths during the 2011-2012 time period, excluding motor accidents and non-pregnancy related cancers. By contrast, the national Obstetrics & Gynecology report relied on death certificate questions related to preg- nancy, which changed during the time period measured, 2000 to 2014. A so-called "pregnancy question" was added to the 2003 revision of the U.S. standard death certificate and included checkboxes for whether an individual was pregnant within the past year, preg- nant at the time of death, not pregnant but pregnant within 42 days of death, not pregnant but pregnant 43 days to one year before death (considered later maternal death), or if she was unknown to be pregnant within the last year. Not all states adopted the revised death certificate in 2003, so some data was based on a 42-day standard time frame while some had nonstandard time frames. Texas didn't adopt the new death certificate—and with it, the revised "pregnancy question"—until 2006, and researchers noted that these variations in the death records led to findings that required adjustments. In addition, the Texas task force found that a number of maternal death cases identified in the 2011-2012 evaluation included incorrect classification coding for the cause of death, further muddy- ing the data. The inconsistencies were so perva- sive that both studies acknowledged the fallibility of the data in their reports and the task force dedicated three of its six recommendations for improving maternal mortality rates to the area of data collection. "We identified multiple problems with the consistency of the evaluation of the maternal deaths," Hollier said. "I think there are opportunities for educa- tion as well as standardization regard- ing those evaluations to ensure that the appropriate information is collected at the time of death so that a complete assessment of the cause of death can be made." Access to care Shortcomings in record-keeping aside, experts agree there has been an increase in maternal deaths in Texas. Their challenge is understand- ing why. Sean Blackwell, M.D., explained that the primary issue isn't that medical care in Texas hospitals is worsening or below par, but rather that too many women are not receiving care. "Every maternal death is a tragedy and we should strive for a case rate of zero," said Blackwell, maternal-fe- tal medicine specialist at Children's Memorial Hermann Hospital and department chair for obstetrics, gynecology, and reproductive sci- ences at McGovern Medical School at UTHealth. "But when you look at the data, and all of the improvements in safety and quality on labor and delivery units within Texas hospitals, 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. If anything, I would argue our hos- pitals are getting better. The major current opportunity for improvements is related to making sure women have access to care, especially our most vul- nerable patients who are underserved and have chronic or severe medical conditions. We sorely need to have the system infrastructure and the ability to follow these women through that first year post delivery." For low-income women who qualify for Medicaid, benefits are available during pregnancy and up to only two months after birth, creating an abrupt end of care despite evidence that women remain at risk for the first year after their pregnancy has ended. The task force ranked cardiac events and hypertension/eclampsia as the first and third most common causes of maternal deaths in Texas, statistics experts believe may be exacerbated by a general population that is growing unhealthier across the board, making pregnancies more complex. "The number of women we see who have a BMI over 40, who have diabetes and hypertension, is definitely rising," Blackwell said. "Today, well over half of women who are having babies in the state of Texas are obese. Our popula- tion is getting sicker." There are a lot of physiologic changes that occur with pregnancy, so women who may have more pre-existing dis- ease may be at higher risk. We do know that when we looked at the numbers, we found that high blood pressure, diabetes, obesity, cesarean delivery and late prenatal care were all seen more commonly in those women who died compared to those who did not. —LISA HOLLIER, M.D. Professor of obstetrics & gynecology at Baylor College of Medicine and medical director at Texas Children's Health Plan

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