Save the Mothers

The United States has the worst maternal mortality rates of any wealthy country, by a lot, and the rates are increasing. The rate of Black mothers dying is more than twice as high as that for white women. Texas’ rate is about the 12th worst among American states.

Americans have heard this before, but they don’t seem to understand or know what they can do about it. Perhaps when we realize that in the United States 20 new mothers die every year for every one Dutch mother, for instance, we can begin to grasp the scale of the problem. And for every Dutch mother who dies, 50 Black American mothers die. Researchers have found that the majority of these deaths are preventable. That means that in this country every year, hundreds of young women die needlessly, each death a tragedy for her and her family, and for her newborn. There are things we can do to change that.

Like other states, Texas has a Maternal Mortality and Morbidity Review Committee (MMMRC) that analyzes maternal deaths and regularly reports its findings and recommendations. Sometimes legislators and stakeholders pay attention, find some money, and take action. The committee is important and potentially powerful.

I am a midwife. Before that, I worked as a hospital nurse, so I know the medical system from the inside. But now I work in the community, attending births at a birth center and in homes. Many of my clients depend on Medicaid for their healthcare coverage. This gives me an inside-outside perspective as well as a deep, lifelong commitment to women and to making maternity care work for them. I have been following the work of our Texas committee for the last several years and have become acquainted with some of the professionals and with a community representative, all of them volunteers. Their work is thankless, difficult, and depressing.

In Texas the work is made much more difficult by a requirement that nurses redact the death records prior to review, due to a statute designed to protect nurses from liability. The resulting delays make it difficult for the committee to review them in a timely manner, and the data that the committee publishes can suffer. The Legislature considered a bill to change that requirement this year but didn’t pass it.

Given the depth of the crisis in the African-American community in Texas, I was shocked when I first went to a committee meeting. The lack of diversity on the panel was jarring. Thankfully, the committee now has a slightly more diverse professional membership, and there is a Black community activist who is also a survivor of serious childbirth complications. But she cannot represent all the women and families of Texas. Such committees in other states not only are more diverse racially but also include more members of the public, as well as doulas and community-based midwives.

In order to truly see a system, a significant portion of the committee should come from outside of that system. The current MMMRC in Texas is overwhelmingly composed of specialized maternity care professionals. Obviously their technical expertise is essential. But to change a system that is not working, more people who can see the system from the outside are needed. At the moment, this change can only happen by statute. Other states have nominating committees to ensure breadth and depth of membership.

Texas is one of very few states that rely entirely on health records and vital statistics as their main sources in death reviews. Other states also use court records, emergency medical service records, mental health records, and much more. But perhaps most important are the family interviews. A record cannot truly reveal whether and in what ways racism influenced the death of a mother. Racism is something that is assessed by hearing from the people who were there—and only in that way. It cannot be guessed at from what is written down. When three times as many Black women as white women are dying, no review is complete without understanding racism’s potential effect. The Texas MMMRC must begin using interviews to fully understand what happened, as 20 other states already do and as the CDC recommends.

In reviewing maternal mortality committee reports from other states, I learned that when Arizona officials broke down death data by mode of birth, they discovered that 70 percent of women who died had experienced caesarean section. As they point out, this absolutely does not imply causality. But it is true that two of the leading causes of maternal deaths in all U.S. states are hemorrhage and infection. Both causes are significantly increased in the case of caesarean births. It has been a nominal goal of U.S. obstetricians to decrease the rate of caesareans for decades, but it remains stubbornly stuck at about a third of all births. Our Texas MMMRC would do well to add analysis of birth methods to its review of maternal deaths.

It was heartening to see that the Texas Legislature approved extending Medicaid coverage for new mothers from the current two months postpartum to a full year. Many of the women who die of causes related to childbirth do so in the first months after they give birth. Getting insurance coverage for that time is an essential step in improving outcomes. The Texas MMMRC has noted this in several biennial reports. But that’s not enough. The committee has concurred with the American College of Obstetricians and Gynecologists in saying that women should be assessed for the need for more than the conventional single office visit at six weeks postpartum. (A significant portion of women do not even show up at the six-week visit.) But all women need assessment and support in their own homes postpartum. This is part of the magic sauce that is standard of care in European healthcare systems. And it could be done here.

Texas has an amazing, underused program called Nurse-Family Partnership in which nurses visit mothers both before the birth and for an extended time afterward in their own homes. But there are restrictive rules about who can access the program and when. All mothers deserve such care; it has been shown to save lives. Texas also has an underutilized community health worker program that could provide in-home assessment and support. When women are dying of preeclampsia (hypertension) a week after they give birth and leave the hospital, it is not enough to assess, three weeks after the birth, whether they need more office visits. Women must be assessed at home in person within days. The MMMRC can recommend that we do so. International and not just interstate comparisons are important when maternal mortality is in crisis across this country. The World Health Organization recommends midwives as an evidence-based way of reducing maternal mortality. The Texas MMMRC could look into whether funding midwifery programs and increasing the midwifery workforce would save Texas women’s lives.

The Texas public must monitor and support the work of the MMMRC. The statute requires that at least one meeting a year be open to the public (check the Texas Department of State Health Services website for the next meeting date). It makes a difference when more people show up. Come and join me.

Correction August 2, 2023: Previous versions of this story incorrectly named the Nurse-Family Partnership.