What’s Going on with Texas’ Maternal Mortality Rate?

When data released in 2016 indicated that the rate of Texas mothers dying of pregnancy-related causes had spiked to inexplicable heights, the issue dominated headlines and made its way into stump speeches and legislative hearings. Texas was said to have the highest maternal mortality rate in the developed world, though experts couldn’t explain why. On Monday, state researchers released a report saying the maternal death rate in 2012 is actually less than half of what was previously believed, leading journalists and politicians, including Governor Greg Abbott, to repeat the state’s claim that the problem was overblown. “Texas’s Horrific Maternal Mortality Rate in 2012? It Wasn’t Actually True,” read one headline. Another: “What caused Texas’ maternal death rate to skyrocket? Inaccurate data.”

But the truth is more complicated than the headlines would suggest. So what’s actually happening? We break it down here.

There’s lots of conflicting information about how bad the maternal mortality problem is in Texas. What does the research say?

First, some context: Quality maternal mortality data is sorely lacking, so much so that the U.S. government hasn’t published an official nationwide rate since 2007. Researchers, including Texas’ maternal mortality task force, primarily rely upon the National Vital Statistics System, which compiles data from each state based on death certificates filled out by doctors and coroners. This data is deeply flawed and inconsistent.

In July 2016, the state task force issued a report identifying 189 maternal deaths during pregnancy or within a year after birth, from 2011 to 2012. Black women were three times as likely to die as white women, it found.

Two months later, independent researchers led by Marian MacDorman, a professor at the Maryland Population Research Center, published a study based on the vital statistics data that found the rate of pregnancy-related deaths in Texas had doubled over two years, reaching “levels not seen in other U.S. states.” The researchers noted that they couldn’t explain such a spike “in the absence of war, natural disaster, or severe economic upheaval.”

This January, MacDorman’s team released a follow-up report, which found that while the state’s maternal mortality rate had increased significantly, their study had overestimated the rate due to errors on death certificates. MacDorman called Texas’ situation a “dual public health emergency,” referring to the state’s serious data problems and its still-troubling maternal death rate.

Then this week, members of the state task force published a study that used a more precise methodology to check the 2012 numbers. The Texas team confirmed 56 deaths that year, instead of the 147 that the Maryland study identified. The lower number of deaths is good news, of course, but it also illustrates the magnitude of the data problems Texas is dealing with, and how much we still don’t know. Women’s health advocates worry that the latest figure is being used to diminish what is still a substantial health problem.

Is this confusing?

Yes! But stick with me…

OK, so why did the new study find a drastically lower maternal mortality rate?

The short answer is that there are frequent errors in Texas’ vital statistics data. Those filling out the death certificates had mistakenly marked patients as pregnant or recently pregnant who were not.

But the state researchers also seem to be shifting their own goalposts. The new study only includes maternal deaths that occurred up to 42 days after birth, in order to make an apples-to-apples comparison with the earlier study. But the task force has previously said it counts maternal deaths up to a year after birth, because a large portion occur after the 42-day mark. Drastically limiting the time frame in the new study cut the state’s confirmed death count for 2012 by a third, erasing many deaths that the task force had already confirmed.

Why does the Texas study only look at 2012? What about other years?

Researchers point to an alarming lack of data and analysis about maternal mortality in recent years. The state team focused its energy on 2012 in an attempt to get to the bottom of, and potentially debunk, the inexplicable spike identified in the University of Maryland study. However, the Texas task force is only just now looking at the numbers for 2013, 2014, 2015, 2016 and 2017. At the current rate, the state is actually falling further and further behind — in part because the Legislature hasn’t adequately funded the research. As a result, we simply don’t know if the maternal mortality problem is getting better, worsening or staying the same.

How is the state talking about the new report?

Some state officials have framed the new data as evidence that the maternal mortality problem in Texas isn’t really so bad. “Turns out the Texas maternal mortality rate spike scare was grossly exaggerated. Analysis shows actual rate was far less than half of the exaggerated report,” Governor Greg Abbott tweeted. “Nevertheless, Texas remains committed to lowering it even more.” The subject line of a press release from the state health department: “New data refutes inflated Texas maternal mortality rate.”

Turns out the Texas maternal mortality rate spike scare was grossly exaggerated. Analysis shows actual rate was far less than half of the exaggerated report. Nevertheless, Texas remains committed to lowering it even more. #txlege https://t.co/FDAyVBIDnd

— Greg Abbott (@GregAbbott_TX) April 10, 2018

While officials seem to be laying blame on the Maryland researchers, that study was based directly on data collected by the state. The Texas health department insists both that the maternal mortality rate isn’t especially bad, and that Texas isn’t an outlier in its errors on death certificates. These can’t both be true. The Texas results for 2012 are perplexing and unusual; either the state data is particularly bad, the number of deaths is particularly high, or a little of both.

What has the Legislature done to address maternal mortality?

Very little. Since creating the task force in 2013, the Texas Legislature has mostly punted on addressing maternal mortality, despite clear recommendations from the task force. Last session, the task force itself nearly fell victim to the “bathroom bill” fight. Senate Republicans used its continued existence as a bargaining chip to force a special session over the bathroom bill. Measures to improve death certificate coding were ultimately successful, as was a limited bill to allow mothers postpartum depression screenings through their child’s Medicaid or CHIP plan. But lawmakers largely ignored the task force’s main recommendation of expanding access to care. Bills to extend Medicaid for new moms from 60 days to a year after childbirth didn’t get a hearing.

Is maternal mortality still a problem in Texas?

Yes! If the state’s new number of confirmed deaths in 2012 is right, that’s still 56 new mothers who died mostly preventable deaths in Texas in a single year. It’s hard to know how we stack up to other states, because this new counting methodology has only been used for one year, and only in Texas.

“I would hate to see us lose the momentum that we’ve gained,” Lisa Hollier, chair of the task force and co-author of the new report, told the Houston Chronicle about its release. Plus, mortality is just the “tiny tip of the iceberg,” she said. “If there are 50 women who die in a particular year, there are 2,500 women who had severe complications.”

With the highest uninsured rate in the country, Texas is abysmal on women’s health. One-third of women don’t have access to care before pregnancy. The state’s repeat teen pregnancy rate is the highest in the United States. Rural hospital closures have left swaths of the state without access to care, and obstetrics-gynecology centers are particularly hard-hit.