Most pregnancy-related deaths in Texas in 2012, which saw the highest number of maternal deaths to date, could have been prevented, according to a new state report.
The most common causes of pregnancy-related deaths were heart issues, hemorrhaging, and infection. Among women whose deaths were related or associated with pregnancies, 69 percent were in the Medicaid program at the time of delivery, according to researchers with the Texas Maternal Mortality and Morbidity Task Force as well as the Department of State Health Services.
“Eighty percent of the pregnancy-related deaths had at least some of chance of being prevented. This really is a call to action to closely evaluate and implement the recommendations of the task force,” said task force chairwoman Lisa Hollier, adding that the latest report, issued Monday, takes the first deep-dive into maternal deaths the state has seen.
A total of 118 women died in Texas during pregnancy or in the year after pregnancy in 2012. Researchers focused their analysis on the first 89 cases of maternal deaths they identified and found that 38 percent of the 89 cases were related to pregnancies and 56 percent were associated with pregnancies, but researchers could not determine if there was a causal relationship. They couldn’t identify whether 6 percent of the deaths were related or associated with pregnancies.
Researchers examined multiple sources of data including birth and death certificate and hospital records to cobble together information about each death. They found that factors that contributed to maternal deaths, whether associated or related to pregnancy, were “a complex interaction of personal, provider, facility, systems and community factors,” researchers said.
Although heart issues, hemorrhaging, and infection were the leading cause of pregnancy-related or pregnancy-associated deaths in 2012, the most common cause of maternal deaths from 2012 to 2015 combined was drug overdose.
“Those situations that are pregnancy-associated also give us insight into other deaths that may be preventable through public health programs. Opioid deaths is one example,” Hollier said.
African-American women were most affected by pregnancy-related deaths — their mortality rate was 2.3 times higher than the rate for white women in 2012. Over the years, black women were at increased risk regardless of income, education and marital status as well as other health factors — a finding that state Rep. Shawn Thierry, D-Houston, said was shocking.
“While we knew that black women were dying from pregnancy-related deaths at much higher rates than all other women, we did not conclusively know that pre-disposed medical conditions or socioeconomic variables were not causing the rate increase,” said Thierry, a leading voice at the Capitol to reduce maternal mortality rates, in a statement.
The World Health Organization defines a maternal death as one that happens during pregnancy or within 42 days of a pregnancy ending. The definition is widely used in studies, including a high-profile study released in 2016 that first identified the high maternal mortality rate in Texas. The study reported that 147 women died during pregnancy or up to 42 days after delivery in 2012, but the Texas Department of State Health Services in April refuted the findings, saying that the actual death count was much lower — 56.
The cause for the discrepancy, state researchers had said, was likely due to mistakes made by physicians, justices of the peace and medical examiners, who incorrectly reported in the state’s electronic death registration system that some women were pregnant at the time of their death, even though they weren’t.
Texas researchers for the most recent report found that most maternal deaths occurred after the 42-day standard as set by the World Health Organization, so they expanded their analysis to deaths that occurred within 100 days of the pregnancy ending.
Researchers recommend increasing access to health services for women during the year after their pregnancy and improving screenings for maternal health risks, postpartum care education for patients and families, programming to target at-risk populations like black women and improving the process of reviewing maternal deaths, among other steps.
State health officials also will request from state lawmakers an additional $7 million in the 2020-21 budget, in part to expand the Texas Alliance for Innovation on Maternal Health.
Under the alliance, more than 180 hospitals, including Seton Medical Center and three St. David’s hospitals, are starting to use standardized protocols that prevent and respond to pregnancy complications, according to the state health department. Among the first bundles of protocols that were implemented addressed maternal hemorrhaging and future ones will address opioid use and high blood pressure among mothers.
If a woman starts hemorrhaging, her team of medical providers know, for example, to order units of blood and test her for clotting disorders, said John Harkins, an obstetrician/gynecologist with Dell Seton Medical Center.
Getting all Texas hospitals on the same protocol can reduce maternal deaths, Harkins said.
“If a patient has an acute obstetrical hemorrhage, why should there be a difference in that patient’s outcome in a large tertiary care center and a small community-based hospital? These bundles and protocols are going a long way to leveling that playing field,” Harkins said, adding that Dell Seton Medical Center has been using such standard protocols for years. Seton hospitals have also implemented policies to prescribe Motrin and Tylenol instead of opioids depending on the patients’ pain level.
“I don’t think we will ever get maternal mortality down to zero,” Harkins said. “But I’m very pleased with the push the state of Texas, national organizations and Seton is doing to lower that number.”