Texas’s Rising Maternal Mortality Rate
Using women’s health data for political purposes

Elsewhere I’ve written a sort of series about the US Maternal Mortality Rate (MMR)scares. No, the US doesn’t have the worst rising MMR in the developed world. Yes, MMR is rising in the US and that is likely due to rising maternal age. We must confront this truth because the causes of maternal death in older mothers are different than the causes of death in younger mothers, and require different responses.
While I have been researching and writing, my home state of Texas has been debating its own MMR problem, a very odd, worrisome, and still undetermined case of our rate doubling from 2010 to 2012. Our state legislature is in Special Session. One of the items on the session agenda concerns Medicare. Thus, one of the trending arguments is that the Lege needs to approve the Medicare expansion so that women can have better mental health care well after childbirth. Postpartum depression sometimes sets in after 60 days, beyond the current cutoff, you see. It is part of the pattern of women’s health data being used for political purposes.
Because looking into the reports, the causes of maternal death in Texas are in order, cardiac issues and blood pressure — the advanced maternal age causes — at 32%, bleeding and infection at 18%, drug overdose at 12%, homocide at 7%, and suicide at 5%. Focusing on mental health, as we seem to be doing, is nibbling a the edges as it is not a leading cause of maternal death, and certainly not from late onset postpartum depression.

Alas, the underlying cause doesn’t matter. The political cause does. A Texas task force was refreshingly straightforward about this in May, in a maternal mortality report released in anticipation of the Special Session: [emphasis mine]
The reasons for the deaths and the severe maternal morbidity are complex. Researchers point to numerous contributing factors. For Texas, the main causes for the deaths have been cardiac problems followed by substance use and hypertension, heart problems, obesity and drug overdoses.
Many women’s health advocates point to the 2011 state cuts to Planned Parenthood and other family health clinics along with the lack of Medicaid expansion. Nationally, experts say multiple causes such as obesity, age and inequitable access to health care all play a role. But the overall maternal mortality rate and the actual number of maternal deaths remain uncertain, as does the underlying reason for the sudden jump in 2011 and 2012. Among the challenges encountered by task force members as they try to find answers are recent changes aimed at keeping better track of maternal deaths, such as checked boxes on death certificates noting that a woman was recently pregnant. These changes have led to confusion and more inaccuracies. “The short answer is, I don’t know” what caused pregnancy-related deaths to rise sharply in that period, Hollier said. “The longer answer is I think it’s unlike that there is a single explanation. The problem is complex and the increase is likely due to a multitude of factors.”
No matter the cause, the issues associated with maternal mortality and severe maternal morbidity are of great concern…
The report then goes on to discuss human rights, demographics and education disparities, HIV, and political power. These things are not irrelevant, but that a third of the deaths resulted from cardiac or blood pressure complications seems to have gotten lost in the analysis after “no matter the cause.” Tellingly, California’s achievement in lowering its MMR, which is also in the news, resulted from the efforts of a large medical community task force that researched the causes of maternal death and targeted the top two: blood pressure and bleeding. (Heart problems look like they are up next.)
Here in Texas we are playing the old game: there is this scary and upsetting fact in the news and we will use it to push an agenda, not get to the bottom of the scary fact.
And finally, about that scary fact, in an interview with a health site, the lead researcher on the report that found Texas’s MMR doubled from 2010–2012 provided this extra insight:
A large share of the national increase does have to do with better reporting, MacDorman said. Since 2003, U.S. states have been slowly adopting a revised standard death certificate that includes several pregnancy “check boxes.”
But, she said, about 20 percent of the increase reflected a “real” rise in women’s deaths.
When I read the Gates Report mention of the better reporting accounting for some of the US rise and I reported that in my own articles, I admit I was thinking of reverse proportions, that about 80% was a real rise and 20% was better reporting. But MacDorman suggests that only 20% is real and most of the increase is an illusion of better reporting.
Well, even I wasn’t expecting that.
UPDATE: I wrote a follow up at Arc when the task force announced their findings: Texas’s jump was in large part due to data entry mistakes that happened as Texas updated its system to account for late maternal deaths.
Banner image caption at The Lancet:
Figure 8
Expected relationship between cause-specific maternal mortality ratio (MMR; number of livebirths per 100 000 livebirths) and SDI (left) and proportion of maternal deaths due to each underlying cause and SDI (right)
These stacked curves represent the average relation between SDI and each cause of maternal mortality observed across all geographies over the time period 1990–2015. In each figure, the y axis goes from lowest SDI up to highest SDI. To the left of the midline are maternal mortality ratios (MMR; number of deaths per 100 000 livebirths), and the right-hand side shows the proportion of the total in order to highlight the different cause pattern in high SDI locations. SDI=Socio-demographic index.

