As doctors frantically tried to revive her 21-year-old daughter Cassaundra Perkins, Cheryl Givens-Perkins couldn’t watch. She turned her back and looked out the hospital window.
“I was just thinking, is this really happening? Is this really fixing to happen?” Givens-Perkins said.
At 1:05 p.m. on Sept. 5, 2014, Perkins was pronounced dead. She had given birth to twins less than a month before and had a 2-year-old daughter.
During her pregnancy, Perkins contracted an infection and her liver started failing, so her twins had to be delivered at 6 months. An autopsy determined that she died in part because of liver failure and because placenta tissue was left inside her body.
Perkins’ death is one of many cases of maternal mortality in Texas — the state has the highest maternal mortality ratio in the United States. Texas had 35.8 deaths per 100,000 live births in 2014 compared with 23.8 for the rest of the country, excluding California and Texas, according to a report published in Obstetrics and Gynecology. Different definitions of maternal mortality are used, but the World Health Organization’s definition is when a woman dies while pregnant or within 42 days of her pregnancy ending.
A state task force formed in 2013 to examine the complex causes of maternal mortality in Texas was left to expire by lawmakers during the regular legislative session that ended in May. But, Gov. Greg Abbott has asked lawmakers during the special session now underway to keep the task force in operation.
For Givens-Perkins, the impact of maternal mortality can’t be expressed by numbers on a page; Perkins’ death radically changed every aspect of her mother’s life. At 55, she was suddenly raising three young children: a 2-year-old and prematurely born twins, one of whom has special needs.
She immediately had to quit her job as a teacher and was catapulted into caring for the children and a custody battle that consumed nearly all of her life savings. She was already caring for her elderly father, who had Alzheimer’s and was living with her. The family moved from San Antonio to Austin to escape memories of Perkins. Givens-Perkins called the family’s financial situation “pitiful.”
“I did what I was supposed to do and worked all my life,” Givens-Perkins said. “I should be somewhere building sand castles, but this is the hand that God has dealt me.”
The task force
Texas’ Maternal Mortality and Morbidity Task Force was created to study deaths like Perkins’. The Legislature authorized the task force after Texas’ maternal mortality ratio nearly doubled between 2010 and 2012, and it is set to expire in 2019. Experts have been unable to explain the spike. The ratio decreased slightly from 2012 to 2014, but it remains much higher than 2010 levels.
Volunteer task force members conduct detailed case reviews on maternal deaths in Texas and give reports to the Legislature every two years. In its 2016 report, the task force found that in the two-year span from 2011 to 2012, 189 women died in Texas while pregnant or within a year after the pregnancy ended. Of the cases they reviewed, they found the top causes of death were cardiac events, drug overdoses and hypertension, and that the majority of maternal deaths happened more than 60 days after the end of pregnancy.
The task force’s progress has been slow. The group wrote in its 2016 report that privacy redaction and inconsistent death certificate reporting were slowing down the review process.
Dr. Lisa Hollier, the task force chairwoman, said the group needs more time to complete case reviews and, if extended, could measure the effectiveness of policy solutions.
“If you implement a particular program in 2017, and we continue the reviews, we can evaluate the effectiveness of that intervention,” Hollier said.
State Rep. Shawn Thierry, D-Houston, learned about the task force as soon as she was sworn into office in January, and said she immediately knew she wanted to make combating maternal mortality one of her legislative priorities.
While Thierry was giving birth to her daughter, she had an adverse reaction to a routine epidural, and her heart started racing. She had to be sedated, and her daughter was born by emergency cesarean section.
“I was hurt and disappointed that I was not conscious during her birth, but I felt blessed that I had survived for my child,” Thierry said.
Thierry also said she was drawn to the issue because of the racial disparity that exists in the maternal mortality ratio; based on cases from 2011, the task force found that African-American women are nearly three times more likely to die than the average Texas woman.
During the regular legislative session Thierry introduced House Bill 2403, which would have extended the task force until 2023 and required it to specifically investigate race and socio-economic status.
However, her bill, which passed out of committee unanimously, was killed by the House Freedom Caucus. It was one of more than 100 largely noncontroversial bills axed by the group of conservative lawmakers in retaliation for what they considered unfair treatment by the Republican House leadership. The move was informally dubbed the “Mother’s Day Massacre.”
In a last-ditch attempt to save her bill, Thierry amended parts of it to a similar Senate measure authored by Sen. Lois Kolkhorst, R-Brenham. That bill died at the end of regular session as Lt. Gov. Dan Patrick forced a special session.
After conversations with Freedom Caucus members, Thierry said she determined that they had no specific opposition to her bill. So she wrote a letter to Abbott requesting that extending the work of the maternal mortality task force be put on the special session agenda. Kolkhorst joined Thierry as a co-writer of the letter.
Abbott listed the issue as No. 20 on his 20-item agenda. It’s the only issue, aside from extending operations of five state agencies, that is expected to receive broad bipartisan support.
“I’m very optimistic that we will have an opportunity to work to pass something meaningful,” Thierry said.
Donna Kreuzer has become a familiar voice on the issue of maternal mortality in the Legislature. She testified on several bills regarding maternal mortality and postpartum depression during regular session.
Kreuzer said she testifies to “speak up for those who cannot speak for themselves any longer.” After a 5-month battle with postpartum depression, her daughter Kristi Couvillon-Wise ended her life.
Couvillon-Wise was a lawyer and social worker who worked with low-income people. She had experienced periods of depression before getting pregnant, and her family was aware that she might be at risk for postpartum depression. Before she gave birth, Kreuzer said family members sat down with her to express their support.
“She knew, and we discussed in that meeting, that you should never let stigma stop you from getting help,” Kreuzer said.
Though Couvillon-Wise knew she was experiencing symptoms just days after her daughter’s birth, she waited to seek treatment for two months. She then received aggressive treatment, but it was too late.
Kreuzer knows not all women have the support and resources her daughter had.
“I don’t care what socio-economic status you come from, it happens all across the board. But the more marginalized mothers need our help the most,” Kreuzer said.
In its 2016 report, the task force identified a lack of mental health screenings as a “missed opportunity,” and also recommended that Medicaid benefits should be extended from the current 60 days after birth to a year after birth to assist low-income mothers.
Rep. Garnet Coleman, D-Houston, introduced HB 2135, which would have fully implemented the task force’s recommendations on screening for postpartum depression and expanding Medicaid coverage. The price tag for the bill would have been more than $76 million through 2019.
Coleman’s bill passed out of committee 8-2, but did not get a House vote.
Coleman said he thought the main opposition to his bill stemmed from opposition to Medicaid.
“For someone who looks at the world the way I look at the world, I see nothing wrong with Medicaid,” Coleman said. “For some of my colleagues, it’s a failed program, and why would we want to add to it?”
Rep. Stephanie Klick, R-Fort Worth, a member of the House Public Health committee, said she voted against Coleman’s bill because “the fiscal leg on it was huge.”
Medicaid isn’t a popular program in Texas government; the state spurned expansion available under the Affordable Care Act. Medicaid is at the center of the maternal mortality discussion because, according to the 2016 task force report, more than half of births in Texas are covered by Medicaid.
However, Klick did vote for another bill addressing postpartum depression that did not have any extra cost: HB 2466, authored by Rep. Sarah Davis, R-West University Place. HB 2466 had a much more limited scope and covered screening for mothers with children on the Children’s Health Insurance Program or Medicaid, but not treatment.
Davis’ bill passed, and Abbott signed it into law. Kreuzer testified in favor of the bill, but said that screening is only the beginning.
“We will tackle those next bigger steps at next legislative session. It’s vitally important that they know, but it’s more important that they get help,” Kreuzer said.
Givens-Perkins, Perkins’ mother, said she hopes extending the task force isn’t a “Band-Aid” on addressing maternal mortality.
“I am hoping that (maternal mortality) is something that is followed through on, and that something good can come out of it,” Givens-Perkins said. “I don’t want to see it forgotten about and pushed under the rug the way some things happen.”