Maternal health eyed in Legislature
Lawmakers pushing to improve situation for Texas mothers
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 as it was supposed to, Thierry said. She still had sensation in her legs. Suddenly, it felt as if the anesthesia was traveling to her heart. She couldn’t breathe.
“I told them, ‘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 her baby girl. Later, a nurse told the first-time mother 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 Texas lawmakers who are pushing to make maternal health a priority amid an uphill battle to close a $1 billion state budget deficit and mend cracks in the state’s economy caused by the coronavirus pandemic.
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 most serious for women of color: Black and Na
tive American women are two and three times more likely to die of pregnancyrelated complications than white women, federal data shows.
Along with issuing an urgent call to action, the U.S. Health and Human Services Department published a plan with three main targets to achieve within five years: cut maternal mortality in half, reduce the C-section rate for low-risk deliveries by 25 percent, and control blood pressure in 80 percent of reproductiveaged 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 outgoing HHS secretary. “Maternal morbidity and mortality is a crisis, and has been for far too long.”
Big challenges in Texas
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 racial disparities, improve access to care in rural areas, close gaps in health insurance coverage, eliminate variations in medical practices and ensure the availability of accurate, up-todate 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 also has the country’s highest rate of uninsured residents. Even if women have insurance, they often have trouble finding a medical provider.
More than 150 counties — home to more than 2 million Texans — have no OBGYN, 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.”
In the current legislative session, Thierry is pushing measures to improve access to health care and shed light on 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 receive 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 to serve as advocates in the delivery room. Their presence is associated with shorter labors, fewer C-sections and decreased need for pain medication. The need for doulas 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.”
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 say 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 cut 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 that treated her.
Hearst Newspapers 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 investigation focused on one Laredo hospital with the state’s highest rate in 2019. Overburdened physicians at Doctors Hospital of Laredo 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, a professor of maternal-fetal medicine at Baylor College of Medicine and 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,” she said.
Hollier and the federal government recommend that hospitals 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 guidance for preventing unnecessary C-sections.
Dr. John Thoppil, president of the Texas Association of Obstetricians and Gynecologists, said the state’s Medicaid program could 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, who practices in Austin. “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.”
About half of all births in Texas are covered by Medicaid. In some other states, Medicaid programs pay the same for vaginal births as for 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 a delivery, which, depending on the length of labor, can sometimes take more than 24 hours.
Billing through Medicaid is more complicated than with commercial insurance. Those factors have pushed roughly half 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.”
High blood pressure
About 1 in 10 reproductive-age women have chronically high blood pressure. The rate is twice as high for Black women. Mothers with high blood pressure experience higher rates of heart attacks, severe bleeding and kidney failure, and their babies are more likely to have problems getting nutrients from the placenta, to be born prematurely and to have birth defects.
But Texas medical professionals say it’s difficult to treat chronic conditions, such as high blood pressure, because of barriers to obtaining health insurance. Texas is among a dozen states that haven’t expanded Medicaid, which means women with low incomes qualify for coverage only after 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 answer, Thoppil said, is 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. As a result, 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.”