How Texas and Longhorns Are Tackling Maternal Mortality in Texas

By Anna Daugherty in Features, March | April 2019 on March 1, 2019 at 1:45 pm | No Comments

At my first prenatal appointment, I was given a pink folder. On it were two dolphins jumping and the words: “Have the birth of your dreams.” To be clear, I had never exactly “dreamed” of giving birth. While I knew mothers with positive experiences, I knew others with traumatic birth stories as well. For me, the most difficult part turned out to be pregnancy itself.

After dealing with debilitating hip pain and a case of prenatal anxiety, I switched from my original birth center plans to a hospital for peace of mind. One long week past my due date and 21 hours of labor later, I had a fairly dreamy delivery after all and was soon carrying my daughter out of the hospital in my own arms—something not every mother gets to do.

Two years later, in late 2018, I was expecting a second baby, and sitting in my doctor’s office, discussing care for my pregnancy. After going over the medical basics, I mentioned I was researching maternal mortality and my doctor laughed. “That’s terrible timing,” she said. She had a point; spending my pregnancy knee-deep in stories of mothers dying wasn’t as pleasant as dolphins wishing me a nice birth. And the fact that I lived in United States, and in particular, Texas, certainly wouldn’t do much to ease my prenatal anxiety.

With the worst maternal mortality rate in the developed world, the U.S. ranks 46th out of 184 countries documented—meaning a quarter of the world is doing a better job at keeping new mothers alive than us. While the rest of the world’s rates are dropping, the U.S. is one of the few countries with an increasing rate (the others are mostly in sub-Saharan Africa and South Asia). Defined as the death of a woman during or within a year of pregnancy from any cause related to or aggravated by pregnancy, the U.S. currently has a maternal mortality rate of approximately 26.4 deaths per 100,000 births (about 0.02 percent). Though the numbers are difficult to track, anywhere from 700-900 women per year die from a pregnancy-related cause.

Texas, meanwhile, has developed a reputation as the weak link in the country, with a maternal mortality rate of 18 per 100,000—not a great number for the state with the second-highest number of births in the nation. California, on the other hand, has the most births and recently dropped its rate to just 7 per 100,000 after implementing a maternal care initiative.

The numbers themselves vary, too. The Centers for Disease Control and Prevention changed death certificate reporting standards in 2003, which states then implemented at different times, making it difficult to track a national maternal mortality rate. By 2007, the U.S. stopped publishing an official maternal mortality count due to inconsistencies.

As a top research university, UT is working to find its place in the call to improve the quality of maternal health care, as professors, researchers, and alumni step up to address the issue with everything from nonprofits to government partnerships. Radek Bukowski, the associate chair for investigation and discovery at the Dell Medical School’s Department of Women’s Health, is leading much of the university’s research in maternal health. When I ask him why the mortality rate is so high, he calls the question itself an intellectual shortcoming (I try not to take it personally). “There’s never one single cause,” he says. “Nowadays, if someone dies, it’s almost always multiple things aligned.” The top 12 causes of maternal deaths in Texas vary widely; the top five are drug overdoses, cardiac events, homicides, suicides, and infections.

“We know something is not right, that we have too high of rates, and they are rising when they shouldn’t,” Bukowski says. “But the more important question is what can we actually do about it?”

The question about what can be done extends beyond maternal deaths, to other birth incidences like severe maternal morbidity—the close calls, injuries, and unexpected effects on health. There are anywhere from 50 to 100 instances of severe morbidity for every mortality, putting the rate close to 2 percent of all births—well over 50,000 women per year. The U.S. doesn’t rank well in infant mortality (55th worldwide) or preterm birth (54th) either. But one number makes all the others sting even more: national and state review committees estimate 60-80 percent of maternal deaths and morbidities to have been preventable.

When I spoke with fellow Texas moms, I  heard it all—hemorrhages, blood clots, emergency hysterectomies, and preterm labors. For many, their child’s birth brings back memories of a day more frightening than joyful. One mom felt her experience with an emergency cesarean section and hemorrhage contributed to her postpartum depression. Another said her doctors brushed off her symptoms throughout labor before finally discovering a blood clot in her lung—an infection followed and she was put in isolation, away from her newborn, for two days. One shared her story of an ectopic pregnancy which led to a ruptured fallopian tube and an emergency surgery; after losing the baby and half of her reproductive system, her doctor said she “shouldn’t be so emotional, it happens all the time.”

When looking for the causes, reports typically distinguish between patient factors, the provider, and overall systems of health care. Bukowski says a death can occur when there are failures at multiple points in the system. “There’s no silver bullet thing we can fix and then all the problems disappear,” he says. Bukowski admits the U.S. suffers from some risk factors more than other countries. “We consume more opioids and pain medication than other countries and have more obesity, for example.” He also points out America’s money problem—we spend five times more on health care per capita than other countries with similar life expectancies. “We have to do things smarter,” he says.

In 2018, Bukowski brought together a multidisciplinary team from the Dell Medical School, the Texas Advanced Computing Center (TACC), and the Institute for Computational Engineering and Sciences (ICES). The group is working on a study of pregnant women’s behavior and the pregnancy outcomes, using a smartphone app to collect participant data and create digital profiles of pregnancy.

Bukowski suggests personalization and prediction are the future and answer to many health care problems. “In order to prevent a problem, one has to predict it,” he says, and most risk factor models are too general to be truly useful. Bukowski hopes developing digital profiles will improve individualization to better identify patients at risk.

David Lakey, vice chancellor for health affairs and chief medical officer for The University of Texas System, says maternal health is an important barometer of the overall health in a society. “If we can’t do this key component well, then we probably aren’t doing a lot of other things very well, either,” he says.

Lakey is the head of the UT System Population Health program, which studies Texas’ most critical health needs—including maternal and infant health. Researchers track the rates of risk factors such as obesity, smoking, and lack of prenatal care, as well as severe maternal morbidity cases, broken out by zip codes. “We need to have data-driven public health interventions,” Lakey says. “It’s hard to know if we’ve made a difference in these areas if we can’t measure it.”

When Lakey was the commissioner of the Texas Department of State Health Services (DSHS), he says they realized they couldn’t focus solely on infant health. “We had to find out what was happening to moms,” he says. The state legislature passed funding for a maternal mortality task force in 2013, shortly after Texas’ maternal deaths seemed to almost double to 34 per 100,000. The task force discovered that changes in the online reporting system had led to deaths being wrongly labeled as pregnancy-related. If even a handful of deaths are misclassified, it can drastically affect the rates.

Manda Hall, associate commissioner for community health improvement at DSHS, says the task force is “the gold standard” for identifying maternal mortalities. While death records may simply show if a woman was pregnant within the past year, it’s up to the task force to review individual cases. “They look at underlying causes to determine if the death was really related to the pregnancy,” Hall says. “They have to ask the question, ‘If she had not been pregnant, would she have died?’”

Improving  Texas’ maternal health would have lasting economic effects, too. Between 54 and 58 percent of births in Texas are covered by Medicaid, which becomes expensive for the state when those mothers need intensive care. Between 2012-15, nearly 60 percent of maternal mortalities occurred in women on Medicaid. For most adult women in Texas, Medicaid coverage begins when they become pregnant, and ends 60 days postpartum, though according to the state task force, most maternal mortalities occur after 60 days.

Hall believes increasing access to health care would help address many maternal risk factors, such as depression, drug use, or contraception. “We have to think about opportunities we have in preconception and interconception care,” Hall says. The Texas Medical Association, among others, is backing House Bill 241 in the 2019 legislative session, which would extend Medicaid coverage to one year postpartum, hoping to save the state money in the long run by helping women prepare for safer future pregnancies.

Hall is also leading the new TexasAIM initiative, part of the national Alliance for Innovation on Maternal Health, which provides hospitals with resources and trainings. “The momentum behind TexasAIM has been tremendous,” Hall says. “Which I think really speaks to the commitment we have here in Texas around this issue.” To address drug overdoses, the leading cause of maternal mortalities in the state, the AIM program is piloting a new information packet on opioid use disorder this year.

While Texas approaches health care from a policy-making perspective, several Longhorns are meeting maternal needs through nonprofit work. Michele Rountree, an associate professor at UT’s Steve Hicks School of Social Work, works to engage local black women and educate providers and policymakers on the risks to black mothers. According to the DSHS task force, black mothers have a risk of mortality 2.3 times higher than white mothers, regardless of income, education, or other health factors. Rountree says black women are also less likely to be screened or treated for postpartum depression.

Rountree is the founder of the Black Mamas Community Collective in Austin, which provides resources for black women in the community, with home visits by black doulas, and a monthly “sister circle” to bring black mothers together. They also work on educating the community on maternal health disparities. “Instead of saying there’s something wrong with black mothers, we’re shifting the conversation to how institutions can better serve them,” she says. “A complex issue needs to be approached in a complex manner.”

Tackling the mental health piece, Elaine Cavazos, adjunct professor in UT’s Steve Hicks School of Social Work, is providing resources for mothers struggling with postpartum depression and anxiety as the president of the Pregnancy and Postpartum Health Alliance of Texas (PPHA). The group offers psychiatric care vouchers, a postpartum doula program, and therapy vouchers. They also provide information for families and formal training for healthcare providers.

Depression and anxiety in the postpartum period can escalate rapidly, as drastic life changes, sleep loss, and a sense of shame or fear to confess negative thoughts can inhibit the healing process.

A therapist herself, Cavazos recalls working with a woman who struggled with intrusive thoughts, mainly the graphic mental image of harming her baby with a knife any time she walked through the kitchen. “I’ve not yet worked with a woman who has actual intent to harm her child,” she says. “But these thoughts can feel very real.” Cavazos says a mother may become convinced she isn’t safe around her own baby—and perhaps the baby would be better off without her around.

“It’s normal to have frightening thoughts to some degree,” she says. “But for these women, it gets to the point where it’s their every thought, they see it every time they close their eyes.” Psychoeducation can help women realize that the risk of these thoughts becoming real is very low; in fact, many times these mothers are highly protective of their children.

The numbers on postpartum depression and anxiety are hard to nail down. While the CDC says postpartum depression affects one in nine mothers, there isn’t a national standard for anxiety screening. Cavazos argues that if anxiety was included, the number would jump to one in four. For many women, the only time they speak with their doctor after birth is at the traditional six-week postpartum appointment.

The American College of OB-GYNs now recommends providers see women more frequently throughout the postpartum period. And since Medicaid cuts off two months after delivery, the American Academy of Pediatrics suggests pediatricians screen mothers for depression when they bring their babies in for appointments throughout the first year. “But then what do you do if the screening is positive?” Cavazos asks. “Do providers have the resources for a woman who is depressed? We are working to grow our network so when a woman is struggling, she can find help.”

Morgan Miles, BSW ’13, takes a preventative approach to postpartum mental health. Miles is the executive director for Giving Austin Labor Support (GALS), which offers on-call labor-support doulas, a prenatal doula program, and birth support for incarcerated pregnant women. When a mother experiences a traumatic birth, combined with major hormonal changes, Miles says they may have trouble processing the event and struggle to take care of herself or her child. “We tend to think of birth as ‘Let’s have a baby,’ but let’s also focus on the mom.” Miles, a doula herself, says simply having a designated labor support person can improve birth outcomes, reduce c-sections, and boost a mother’s overall experience. When that person is trained, like a doula, those results increase.

While doulas are not medical substitutes, they help mothers learn to advocate for themselves and build a communicative relationship with their doctor. “When new evidence and research comes out with best practices for birth, it sometimes doesn’t trickle down to hospital protocol for many years. We help moms make it become best practice by advocating for themselves.” For Miles, this goes beyond hospitals. “We need to be improving the quality of care for every woman, in any setting they choose,” including providing alternative options like home births and birthing centers.

Learning to advocate for myself didn’t come easily in my first pregnancy. When I was 22 weeks along, I began to experience intense pelvic pain that made it nearly impossible for me to walk. My hips seemed to lock up, and the simple act of moving a leg forward felt more like I was ripping it out of its socket. I repeatedly asked for a physical therapy referral but was told that “aches and pains are normal.”

When I finally demanded a referral and met my therapist, she diagnosed me with a pelvic disorder. She said unless I continued therapy, I would never be able to give birth without a c-section. Twice-weekly appointments for the last 12 weeks of my pregnancy helped me stay mobile, and eventually have a peaceful, uneventful birth.

For other moms, getting the care they needed didn’t come as easily. Texas mom Becca Shipman’s once-peaceful birth took a dramatic turn after her daughter was born and Shipman began to hemorrhage. When attempts to stop the bleeding weren’t working, an anesthesiologist was called to prepare her for an emergency hysterectomy. At the last minute, her doctor was finally able to slow the bleeding—after she lost more than 1,000 ml of blood. Cold and too drowsy to hold her daughter afterward, it wasn’t until later Shipman realized she “had been dying in that bed.” She and her husband have decided not to have any more children.

“That will be my one and only birth experience,” she says. “I wish it were positive and beautiful and calm. But it’s not and I will never have a chance to get that.” Shipman says she didn’t realize she could protest certain interventions, like her induction, which she now feels contributed to the situation.

Becky Ferrell, another Texas mom, experienced a hemorrhage with her first child, a subchorionic hemorrhage and preterm birth with her second, and placenta previa (with the placenta lying low in the uteris, covering the cervix and requiring a c-section) and hemorrhage with her third. After having her second child, Ferrell says she became better at advocating for herself. “Now I make sure to educate myself as much as possible so I know I’m getting the best care possible in the future.”

Miles believes this is where change will truly begin—with mothers. “When we are supporting each other, we are going to see change happen,” she says. “In the world of health care, it’s hard to slow down and prioritize imagining a better future if we’re always putting out fires. But when we as women continue advocating and spreading this message, we can speak up for each other.”

Due to have my second baby this summer, I only half-jokingly told my husband we should head to Scandinavia, with some of the lowest maternal mortality rates in the world. My idea didn’t hold up to financial scrutiny, however. I offered California instead, which achieved the lowest rate in the country after creating a maternal care collaborative in 2006, but he wasn’t quite willing to give up our child’s true Texan status. At the very least, I suggested we spring for a prenatal and postpartum doula. He agreed.

It could be argued that maternal mortalities are a relatively rare occurrence overall,  but Bukowski says it’s not enough to be right 99 percent of the time. “We have to get it right every single time.”

When the nurse laid my daughter on my chest, I wished her happy birthday as she took her first breaths; it’s a moment I cherish and hope to repeat with my second baby. It’s a moment every mother deserves to experience—until maternal disasters are entirely replaced with happy birthdays.

Illustration by Anita Kunz