A Disturbing Trend

Medicine Examines Causes for Spike in Texas' Maternal Mortality Rate

Texas Medicine Logo(1)

Public Health Feature — December 2016

Tex Med. 2012;112(12):49-55.

By Joey Berlin

Fort Worth obstetrician-gynecologist Shanna Combs, MD, has never lost a pregnant or new mother, but she's had some harrowing close calls over the years when moms battled complications, including one she still talks about with colleagues years later.

When Dr. Combs was a young physician in training, she delivered a baby to a mother who was having her third cesarean section. The mother had both placenta previa and placenta accreta. Those conditions produced bleeding during the C-section, forcing the patient into intensive care and necessitating a hysterectomy. Anxiety followed "probably for a couple days," Dr. Combs says, with the mother's family by her side and worries persisting "that she might not turn the corner from significant bleeding." 

"There's some anesthesia personnel that I still see, and every now and then when we see each other, we still remember that day," Dr. Combs said. "It was a very scary time during that surgery, when things were hit or miss. And thankfully for her, she had good health on her side and ended up pulling through."

That mother was fortunate, but a distressingly increasing number of mothers in Texas and the United States aren't. When the Texas Department of State Health Services (DSHS) and its Maternal Mortality and Morbidity Task Force released their Joint Biennial Report in July, it reflected what Dr. Combs sees all too often.

As one of the supervisors and trainers at the obstetrician-gynecology residency program at John Peter Smith Hospital in Fort Worth, she comes into extensive contact with the indigent and underserved population. She has seen mothers and mothers-to-be with the potential for cardiac problems and hypertensive disorders. She has also seen more and more moms battling narcotic addictions.

Upon reading the task force's research and its identification of the top causes of maternal death in Texas, Dr. Combs' reaction was that it was "basically, reinforcement of things we're already seeing in day-to-day practice."

The task force is now attempting to find out why Texas' maternal mortality rate is on the rise while the nation itself is a sad international outlier. A study published in the September issue of Obstetrics and Gynecology estimated Texas' maternal mortality rate had doubled within the past several years; another study published the following month backed up that finding with mortality data through 2014.

The uncertainty compounds the tragedy. But the Maternal Mortality and Morbidity Task Force is diving deeper, conducting detailed case reviews to find out what factors are putting Texas mothers at risk and exploring potential problems with the data. Meanwhile, the Texas Medical Association's Committee on Reproductive, Women's and Perinatal Health, which Dr. Combs chairs, is monitoring the state's progress.

"I think that our detailed case reviews are really going to help us understand why the increase occurred," said Houston OB-Gyn Lisa Hollier, MD, chair of the Maternal Mortality and Morbidity Task Force. "In some of the analyses that we've done so far, we have concerns about the validity of the numbers that were reported. And the best way to resolve those data concerns is to do the specific reviews so that we can understand the degree of change that has occurred over the last five years." 

Depressing Numbers

The World Health Organization (WHO) defines a maternal death as the death of a woman either during her pregnancy or within 42 days after termination of pregnancy "from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes." WHO defines a death from direct or indirect obstetric causes as a late maternal death if it occurs more than 42 days but less than one year after pregnancy termination. 

The September study in Obstetrics and Gynecology estimated that Texas' maternal mortality rate had doubled between 2010 and 2014. In October, the same journal published a second study using actual state-by-state mortality data for all years between 2005 and 2014. 

According to supplemental data for the October study, Texas had 19 maternal deaths per 100,000 live births in 2010, but jumped to 30 per 100,000 the next year, then 39 per 100,000 in 2012. In 2014, the last year the study examined, Texas had 34 maternal deaths per 100,000 live births, the seventh-highest rate among U.S. states. Georgia ranked first in 2014 with 68 maternal deaths per 100,000 live births. (See "Maternal Mortality by the Numbers.") Over the 10-year period of the study, New Jersey had the highest maternal mortality rate among U.S. states, and the District of Columbia had a higher rate than any state, with 38.8 deaths per 100,000 live births.

Meanwhile, international maternal mortality rates are going in the opposite direction. An analysis by the United Nations Maternal Mortality Estimation Inter-Agency Group, released in November 2015, found that global maternal mortality fell nearly 44 percent between 1990 and 2015.

The Maternal Mortality and Morbidity Task Force's July report analyzed data from 189 maternal deaths in Texas between calendar years 2011 and 2012. Its key findings were: 

  • African-American women are at greatest risk for maternal death;
  • The leading causes were cardiac events (20.6 percent), overdoses by prescription drugs (11.6 percent), and hypertensive disorders (11.1 percent);
  • Most maternal deaths occur more than 42 days after delivery; and
  • Data quality issues related to death certificates make it difficult to identify maternal or obstetric deaths. 

African-American women accounted for just 11.4 percent of all births in Texas during 2011–12 but accounted for 28.8 percent of all maternal deaths, according to the task force's research. The percentage of all births attributed to Caucasian women was similar to the Caucasian maternal mortality percentage of 37.8 percent, the report said. Hispanic women and women of other racial and ethnic groups accounted for maternal death percentages lower than their demographic total birth rate. Hispanic women accounted for 30.8 percent of maternal deaths, and women of other racial and ethnic groups accounted for 2.6 percent. (See "Top Maternal Mortality Causes in Texas.")

The task force found close to 60 percent of maternal deaths in Texas during 2011–12 occurred after the 42-day mark, saying it was "clear that women remain at-risk for the first year after their pregnancy has ended. It is possible that lack of continuity of care plays a role in these later maternal death outcomes."

The task force made six recommendations to help reduce pregnancy-related deaths and severe maternal morbidity: 

  • Increase access to health services during the year after a delivery and between pregnancies;
  • Increase awareness among practitioners and the community of health inequities and implement programs that allow women to better self-advocate;
  • Increase screening for and referral to behavioral health services;
  • Increase staffing resources to support the task force;
  • Promote best practices for improving the quality of maternal death reporting and investigation of those deaths; and
  • Improve the quality of death certificate data. 

Possible Root Causes

As they wait to see what the closer look at case reviews will reveal, Texas OB-Gyns have their own observations that inform theories about the underlying causes of increased maternal mortality. Dr. Hollier says the case reviews are crucial to figuring out why new mothers in Texas are at such an elevated risk.

"The detailed reviews are going to be really important here because we need to understand more detail about the causes of death. For example, we need to understand the contribution of hypertensive heart disease vs. congenital heart disease vs. other cardiac diseases," she said. "If you look at the maternal mortality review in Utah, for example, cardiac events are a leading cause for them, as well. But for them, the cardiac events are almost exclusively among women who are survivors of congenital heart disease. I don't think that's going to be the case in Texas. I think ours is going to be much different, more diverse."

The task force report hit home for Dr. Combs in part because the common risk factor she and her colleagues see among mothers is obesity and its accompanying potential to contribute to reduced cardiac function and hypertensive disorders.

"And then also with opioid use and abuse, we're seeing more and more moms coming in for pregnancy with an opiate addiction, and we have even had moms who got addicted to narcotics from a prior pregnancy due to kidney stones and needing chronic narcotics for kidney stones, and in subsequent pregnancies they've needed methadone for management of chronic pain and addiction throughout their pregnancy," she said. "We're seeing a huge impact in that area. And then even afterwards, we're having to see babies stay admitted for long periods of time for a narcotic withdrawal after delivery."

Dr. Combs says medicine has transitioned slowly to the concepts of pre-conception and inter-conception care, and lack of access to health care or insurance means women often aren't receiving health care when they're not pregnant. 

"By the time they're pregnant, we're playing catch-up throughout the pregnancy to try to fix the medical problems that they had but may not have known they had because they weren't seeing a doctor," Dr. Combs said.

Houston OB-Gyn Rakhi Dimino, MD, a member of TMA's Council on Science and Public Health, says other factors along with obesity and high blood pressure likely have added to the danger pregnant women and new mothers face. There's been a change in the childbearing environment that has contributed to maternal mortality, she says, "some of which we can help and some of which we can't." 

Dr. Dimino points to women waiting until older ages to have children and the increased popularity of infertility treatments, which lead to higher-risk pregnancies. She says there's also been a change in how OB-Gyns approach pregnant patients who develop complications such as high blood pressure toward the end of their pregnancy.

"Ten years ago, if we found a patient who had elevated pressures or another problem in pregnancy, we would call it quits fairly early and deliver slightly preterm or barely term, around 34 to 37 weeks," she said. "We've tried to balance the adverse effects on babies when they are delivered before 39 weeks. Now we try to get as close to 39 weeks as we can, which means we try to push mom's medical problem as far as we can go before we absolutely have to deliver. And because we're taking more risks to get to 39 weeks, we are going to see more complications for moms."

Simultaneously, Dr. Dimino says, there's been an increase in the desire for more natural deliveries outside of a hospital setting, something she says has especially played a role in Texas.

"Moms who elected to deliver at home or in a birthing center outside a hospital used to be low-risk, uncomplicated mothers," she said. "But now you see the out-of-hospital deliveries really pushing the envelope, as well. Some high-risk moms with previous C-sections, twins, or breech babies are attempting to have vaginal deliveries outside the hospital. These are things that are risky to manage even in the hospital environment with the ability to act quickly with lifesaving measures, and they're trying to do it in a home environment. This has really increased the risk to those moms and babies, so they may get transferred into a hospital in dire straits."

The task force report found hemorrhages and blood transfusions were major drivers of severe maternal morbidity in Texas; mental and behavioral health issues also contributed. It noted the National Institute of Mental Health's link between depression and chronic illnesses, including cardiovascular disease, diabetes, and stroke.

In looking at a possible relationship between the national opioid epidemic and Texas' maternal mortality, the task force observed postpartum substance abuse for several of the deaths. Fourteen of 19 women with Medicaid coverage during pregnancy who later died of drug overdoses died more than 60 days post-delivery, when Medicaid coverage typically expires.

The September Obstetrics and Gynecology report noted "some changes in the provision of women's health services in Texas from 2011–15, including the closing of several women's health clinics." In 2011, the Texas Legislature made dramatic cuts to the state's family planning program. But the report didn't single out those cuts as a potential cause, saying that "in the absence of war, natural disaster, or severe economic upheaval, the doubling of a mortality rate within a 2-year period in a state with almost 400,000 annual births seems unlikely."

As part of a new state approach to women's health, last July the Texas Health and Human Services Commission (HHSC) launched Healthy Texas Women, a consolidation of HHSC's old women's health program with DSHS' Expanded Primary Health Care Program. (See "Playing Catch-Up," April 2016 Texas Medicine, pages 22–29.)

Lesley French, HHSC's associate commissioner for women's health services, says the services covered in the state's new women's health configuration can help reduce the maternal mortality rate. Ms. French says stakeholders stressed the programs needed to address hypertension, diabetes, and cholesterol because of the potential for those factors to affect a pregnancy, and she says HHSC designed the programs to cover those services.

"They cover so much more than what we did in the previous programs. We are really looking at that continuity of care for a woman," Ms. French said. "When she enters our program, she is not anticipating having a baby right away, but if she changes her mind and chooses to have a baby, there is a continuity of care through the pregnant women's Medicaid program and the Title V [federal block grant] programs, as well."

Opportunities for Screening

Dr. Combs says the Committee on Reproductive, Women's and Perinatal Health will continue looking to the state task force for guidance as the committee prepares to meet in January at TMA's Winter Conference in Austin.

"One of the things that was mentioned at our last meeting in moving forward and looking [to the legislative session] is that the task force itself can't actually lobby and advocate for certain things. But we, as a committee and TMA, can do those things," she said. "And I think [our plan] coming forward, and especially in our upcoming meeting in January, is seeing what some of the recommendations are coming out of the task force and seeing if there's anything legislatively that we could advocate or lobby for."

Dr. Hollier says the case reviews the task force has done so far have already revealed steps physicians can take to help curb maternal mortality. The cases revealed "a lot of missed opportunities for screening" for substance abuse and depression, she said. The U.S. Preventive Services Task Force recommended all women be screened for depression during the perinatal period.

"As practicing OB-Gyns, one of the problems that we've often had is that there's a limited number of behavioral health providers," she said. "Sometimes you screen and your patient is positive, and it can be really tricky to get your patient in to see someone. It is really important to be sure that we have an adequate number and distribution of clinicians who are providing behavioral health services." 

Joey Berlin can be reached by phone at (800) 880-1300, ext. 1393, or (512) 370-1393; by fax at (512) 370-1629; or by email.

December 2016 Texas Medicine Contents
Texas Medicine Main Page