Texas lawmakers aim to make maternal health a priority this year
This story was produced as part of a larger project led by Marina Riker, a participant in the 2019 Data Fellowship. Other stories in this series include:
Birth in the time of coronavirus
It's one of the silver livings': How COVID-19 pandemic could boost access to maternal health care
She already had a high-risk pregnancy. Then, COVID-19 struck.
Part 1: Birth on demand
Part 2: More than ‘a little snip’
Part 3: Filling the gap
Our women are dying': Texas lawmakers urged to extend Medicaid to a year after birth for new mothers
Rep. Shawn Thierry and her daughter, Klaire.
Courtesy of Rep. Shawn Thierry
Shawn Thierry can’t recall the moment she gave birth, but she does remember how she almost died.
Her medical team had just administered an epidural to numb her body for a cesarean section. But it didn’t work like it was supposed to, Thierry said. She could still feel her legs. Suddenly, it felt as if the anesthesia was traveling to her heart. She couldn’t breathe.
“I told them, I said, ‘I don’t think I’m going to be able to hold on much longer,’” she said. “‘Please, just put me under.’”
The medical team rushed to put Thierry under general anesthesia. They performed a C-section to deliver the baby girl, who Thierry planned to name Klaire. It wasn’t until after the birth that a nurse told the first-time mother that she’d experienced a life-threatening complication from the epidural that can paralyze the diaphragm, leaving patients unable to breathe.
“Here I am as a lawyer with private health care,’” she said. “As a woman of color, I thought to myself, ‘If I’m experiencing this, I can’t imagine the thousands and thousands of other women who are having even worse outcomes.’”
Eight years later, Thierry, a Democratic state representative from Houston, is fighting to improve care for mothers. She is among several lawmakers who are pushing this year to make maternal health a priority amid an uphill battle to balance a $1 billion budget deficit and mend cracks in the state’s economy that were widened by the coronavirus pandemic.
Their push comes after the federal government last month pledged to make the U.S. one of the safest countries in the world for women to give birth. Today, women in the U.S. are more likely to die from childbirth or pregnancy-related causes than those in other developed countries. The situation is the most dire for women of color: Black and Native American women are two and three times more likely to die of pregnancy-related complications than white women, according to federal data.
Along with issuing an urgent call to action, the U.S. Department of Health and Human Services published a plan with three main targets to achieve within five years: cut maternal mortality in half; reduce the low-risk C-section delivery rate by 25 percent; and control blood pressure in 80 percent of reproductive-aged women.
“Calls to action by the United States Surgeon General are a rare step, reserved for the most serious public health crises facing all Americans,” wrote Alex Azar, the Health and Human Services secretary. “Maternal morbidity and mortality is a crisis, and has been for far too long.”
‘A life or death situation’
Women in the U.S. today are 50 percent more likely to die in childbirth than their mothers were. Yet up to two-thirds of their deaths are preventable, research shows.
To stop women from dying, the federal government says states need to address widespread problems, including: racial disparities; access to care in rural areas; gaps in health insurance coverage; variation in medical practices; and the availability of current and accurate data.
Those challenges are particularly acute in Texas. The state made national headlines in recent years because of its sloppy data collection on maternal deaths. It’s also the most uninsured state in the country, and even if women have insurance, they still can still have trouble finding a medical provider.
More than 150 counties — home to more than 2 million Texans — have no OB-GYN, a situation largely driven by rural hospital closures and physician shortages.
“This really shouldn’t be a Democrat versus Republican issue because if you are pro-life, then it’s all the more important,” Thierry said. “No woman, in order to bring life into the world, should have to die or sacrifice her own.”
This year, Thierry is pushing a number of measures that would seek to improve access to health care and shed light on the reasons why women are dying. One bill, which aligns with the federal government’s goal to improve data collection, would create a statewide data registry in which medical providers could report maternal deaths and severe complications in real time.
Another proposal would require medical professionals to undergo continuing education to address cultural and racial bias, aimed at improving care for women of color. Thierry also introduced a bill that would require Medicaid to cover services from doulas — trained professionals who support women before, during and after childbirth.
In Texas, a growing number of women are hiring doulas, whose presence is associated with shortened labors, fewer C-sections and decreased need for pain medication, to serve as advocates in the delivery room. The need is especially pronounced for women of color, Thierry said: “If you don’t have someone that’s really willing to listen to you, I witnessed the fact that it can become a life or death situation.”
Preventing unnecessary C-sections
Today, the U.S. has one of the highest rates of cesareans in the world. The surgeries save mothers’ and babies’ lives when things go wrong but carry increased risks of infections, blood loss, hysterectomies and complications in future pregnancies.
Medical experts warn some doctors are overusing the invasive surgery. Across the U.S., 25.9 percent of first-time mothers with uncomplicated deliveries undergo C-sections. The federal government wants to drop that to 19.4 percent.
Texas has a long way to go. The state has some of the highest C-section rates in the U.S., where a mother’s chance of undergoing the surgery can have less to do with her health and more to do with the hospital she goes to.
The Express-News recently analyzed C-section rates at Texas hospitals and found that rates of mothers’ first C-sections, even if their deliveries were considered uncomplicated, ranged from 2 percent to 31 percent — a 15-fold variation.
The newspaper’s investigation focused on one Laredo hospital with the state’s highest rate in 2019, where the hospital’s overburdened doctors may have used the surgeries in part to keep up with high patient volumes and manage hectic schedules.
“It’s something that an individual hospital really can work to address,” said Dr. Lisa Hollier, chair of the Texas Maternal Mortality and Morbidity Review Committee. “It would be very important for the hospital to have a quality team that does a review and examination in cases of low-risk cesarean deliveries so that they can understand why this is happening.”
One of the suggestions Hollier — and the federal government — recommends is for hospitals to adopt evidence-based patient safety guidelines.
So far, the state health department and Texas Hospital Association have helped hospitals adopt best practices for preventing and treating hemorrhages, but they haven’t yet pushed the guidance that can help prevent unnecessary C-sections.
Dr. John Thoppil, president of the Texas Association of Obstetricians and Gynecologists, said the state’s Medicaid program could also consider removing financial incentives to perform C-sections.
“It’s not a tremendous difference, but you actually get paid more money for doing a C-section than a vaginal delivery,” said Thoppil. “I can tell you it is many times much easier to do a C-section at 5 p.m. than it is to work all night on a difficult vaginal delivery.”
Roughly half of births in Texas are covered by Medicaid. In some other states, Medicaid programs pay the same amount for vaginal births and C-sections. Others won’t pay for C-sections that are performed without a clear medical need.
Thoppil said the state’s Medicaid program should increase the amount it pays for care, period. Texas doctors receive some of the lowest reimbursement rates in the country — about $600 for delivery, which, depending on the length of labor, can sometimes take more than 24 hours.
Billing is also more complicated when compared with commercial insurance. Those factors have pushed roughly half of the state’s obstetricians to stop treating Medicaid patients, Thoppil said.
“You don’t want to have a system where it’s only hospital systems, subsidized systems and younger doctors who are new in practice that are taking Medicaid,” Thoppil said. “We want the best care provided to everybody across the state.”
‘How can we intervene?’
About 1 in 10 of reproductive-age women have chronically high blood pressure — which doubles among Black women. Mothers who have high blood pressure experience higher rates of heart attacks, severe bleeding and kidney failure, and babies are more likely to have birth defects, issues getting nutrients from the placenta and premature birth.
But Texas medical professionals say it’s difficult to treat chronic conditions, such as high blood pressure, because of widespread barriers to health insurance. Texas is among a dozen states that haven’t expanded Medicaid, which means women with low incomes only qualify for coverage once they become pregnant.
“We can’t fix cardiovascular risk only during a pregnancy time window,” Thoppil said. “By the time that they enter pregnancy, if you have bad hypertension or a heart dysfunction such as cardiomyopathy, that’s already set in place.”
The solution, Thoppil said, would be to expand Medicaid so women can seek medical care before they become pregnant. But because of Texas’ political climate, maternal health advocates are pushing for the next best thing — extending coverage to women a year after birth so doctors can intervene to treat conditions such as high blood pressure, diabetes and depression.
Even though women can die of pregnancy-related causes up to a year after birth, Texas Medicaid coverage lasts for just 60 days postpartum — and typically covers only one visit. It’s meant that serious complications often go undetected, Thoppil said.
“We’ve all realized that we have this embarrassingly high national and state level maternal mortality rate, and we’re looking to say, how can we intervene?” Thoppil said. “These women need access to care.”
[This story was originally published by San Antonio Express-News.]