High Maternal Mortality Rate in the United States and Texas and Who it is Impacting.
In the United States, particularly Texas, there is a high maternal mortality ratio (MMR) when compared to other states and countries. I want to first explain what MMR is and how its definition has been evolving. I want to explore why this might be impacted women in rural parts, certain socioeconomic status, and race. I want to focus on several causes as to why women of color have a much higher MMR. These causes could be due to medical disparities that women of color face, one article discusses how black women face what is called weathering, but there is also the issue that women do not receive or get health care after the birth of their baby. This is also also an issue for women during their pregnancy. There are also several causes why women in rural parts of Texas and throughout United States seem to have a higher MMR, and this can be compared to women in urban parts. These causes could be due to Medicaid cuts, that have resulted in hospital and clinic closures.
First, I want to introduce maternal mortality ratio and define it. According to World Health Organization, maternal mortality is defined as — “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its managements but not from accidental or incidental causes” (2004). In the United States MMR was not always a statistic that doctors were made to check until the 1980s, but now the CDC measures statistics on it. This is done by death certificates usually. In Gaskin’s article, she brought up United Kingdom’s program about how they handle pregnant mother’s helath but also the child’s health. It is like a report card for the services that are available for mothers, and it also talks about the number of causes for maternal death. Another benefit for this program is the length the authors go into discussing the causes of maternal mortality, but it does it in great detail. Gaskin writes that the UK spends so much detail on these causes that they dedicate a chapter to each cause, while the US and it statistics dedicate “at most — a page each year” (2008, p. 12). This is an unfortunate fact, especially when Gaskin claims that US as a country spends the most for maternity health care when compared globally to other countries. Shouldn’t that be reflected in our MMR? Unfortunately, that is not the case. There seems to be in issue as to what the money is being spent on or where the money is going. This seems to be a common theme for most American policies and programs.
Another interesting thing to note is that there seems to be a shift in changing the use of MMR to pregnancy-related death (PRMR). This is seen in the Maternal Mortality and Morbidity Task Force Biennial Report. The definition is defined by CDC is the same as MMR listed above, but includes a more expanded cause such as: “(a) a pregnancy complication; (b) a chain of events initiated by pregnancy: (c)the aggravation of an unrelated condition by the physiologic effects of pregnancy” (2016, p. 3).
According to Gaskin, the US Department of Health and Human Services wanted MMR to be at 3.3 deaths per 100,000 live births (2008, p. 10). Gaskin further reports the MMR in 1982, 2004, and 2005. In 1982 MMR was 7.8, in 2004 it was 13.2, and in 2005 it was 15.1. This is showing that in the US our MMR in 1982, 2004, and 2005 was not near where the US Department of Health and Human Services deems an ideal number. The number seems to also be increasing, which is not a sign that we want to see. Gaskin also reported the MMR by race, so what is very shocking is that for Black women in 2005, the MMR is 36.5, more than double the overall MMR of 15.1 (2008, p. 10). Another possible cause as why the MMR has changed could be due to the change in the extra checkbox on death certificates. In 2003, there was an additonal question asked: “whether the person who died was currently or recently pregnant” (Maron, 2015). Because of this being added to death certificates that could explain the higher number in MMR. This increase could also show something that was an issue and was not measured until 2003.
Now I want to compare the US MMR to what Texas reports. According to the Maternal Mortality and Morbidity Task Force Legislative Report, the MMR in Texas at 2011 was 24.4 (2013, p. 6). Marian MacDorman states that the MMR in 2010 was 18.7 and in 2012 is 38.7 (2017, p. 1). In Graph 1, the Legislative Report, they show the MMR of white, black, and Hispanic women from 2007 to 2011 in Texas (2013, p. 6). The MMR for Hispanic is 17.4, Black it is 67.3, and white is below 30 (Graph 1). These numbers show an alarming trend of that MMR is showing an upward trend, and another alarming fact is that black women have a risk of more than double compared to white women. This increase is also address by the Texas Tribune, they state that the MMR has risen to 34.2 for the five-year period of 2011 to 2015. The Texas Tribune showed a new risk factor for women, age. They showed that women are having children for the first time over the age of 40 and this age group has a higher MMR.
In the following paragraphs, I want to focus on the issue of how women of certain race or ethnicity and age groups that have a higher MMR when compared. I wanted to discuss socioeconomic status (SES), but since there is such a wide range of categories when involving SES, I found it more difficult to narrow it down, so I decided to focus on the two above characteristics, race/ethnicity and age group. Several of my sources seemed to have a common trend, black women have a shockingly higher MMR when compared to white and Hispanic women. This was addressed in a National Public Radio article by Nina Martin about a black woman named Shalon Irving. Martin also raises the issue of weathering and how black women face difficulties when dealing with doctors, but also lead a more stressful life. Another issue that seems to be showing an upsetting trend is that women who are having children are over the age of 40 are at a much higher risk of dying.
Discussed in the NPR article by Nina Martin about how Black women experience more stress (everyday stress), but she also brought the issue that could be for all women and their health professions. There is an increasing issue of women telling their doctors about symptoms and their doctors and nurses not believing in women’s pain or emotional well-being. This is seen in Nina Martin’s article. In Nina’s article, Shalon Irving had several doctor appointments following the birth of her daughter where she had pain and even unusual swelling in her lower limbs. According to Irving’s mother, the doctors just prescribed antihypertension medicine rather than actually work with patient to find a better diagnosis. Irving died not soon after this doctor appointment. The idea of a doctor not listening to the patient’s symptoms and correct diagnosis is an issue relevant to maternal mortality, but also other medical conditions.
David Williams also discusses the race and ethnic issues. Williams states that “the major racial/ethnic categories in the United States capture differences in socioeconomic circumstances, and SES plays a larger role in accounting for disparities in health” (2008, S40). Williams breaks down the race and ethnicity for women in the United States into white, black, and Mexican American. Williams breaks it down even more, it is stratified by income level and the rates for hypertension and overweight. There were three patterns that discovered from this data, but I want to focus on the first pattern and the third pattern Williams writes about. The first pattern is that there was a strong linkage of hypertension for black women and white women, as well as overweight for white and Mexican American women. The third pattern is that there are still racial differences at every level of SES, and that race is more relevant than SES (2013, S40). Williams discusses that “minority women are less likely to be insured, to have employer-based private insurance coverage, and to have insurance coverage through their spouse’s employment, and they are more likely to have public health insurance coverage” (2013, S43). Having adequate health care is discussed later on in this article when I discuss the issue of women in rural areas having less access when compared to women in urban areas.
In the next few paragraphs, I want to discuss how access to health care for women who reside in rural areas is affecting MMR when compared to women living in urban areas. First I want to just introduce the population distribution in rural communities. According to Rural Health Quarterly, a report done on all the states in the US , Texas has a D, so Texas and rural health care is considered failing. According to Rural Health Quarterly, they base the scores on three categories: mortality, quality of life, and access to care (2018, 13) These are broken down even further. Rural Health Quarterly breaks it down several reasons as to why Texas has a low score. Texas is a big state and the rural population is 11% of the estimated population of over 27 million people. The poverty rate is also much 3% higher in rural settings than in urban. As for race and ethnicity in rural parts it is heavily Non-Hispanic white at 57% and Hispanic/Latino at 32.9%; while black is at 7.9% and American Indian and Asian under 1%.
For the next section I want to primarily focus on the Rural Health Quarterly’s statistics and information on how Texas did for access to care. On the same scale for how they graded Texas all of the four access to care categories: primary care, dental care, mental care, and uninsured care. In Texas, it received the score of F, which means they are ranked at the lowest possible end for access to care in rural parts of Texas. Primary Care is the is the amount of primary care physicians in rural areas within Texas, 39.1 per every 100,000. This is below the national average for 54.5 per every 100,000. Now for the next issue of mental care, mental health care hasn’t really ever been a priority for Texas, and according to the Quarterly it shows it not just at the Texas level but at the national level it is also a small number, Texas is 1.8 per 100,000 while US is 3.4. The next category is dental care, in Texas is below the national average, but not as much as we see in primary care. Texas is 31 dentists per 100,000 people in rural counties, while the national average is 42.8 per 100,000. As for the uninsured Rate in Texas, the percent for rural population that is uninsured and under the age of 65 is 25.3% (2017, 96). Compared to the urban population it is actually pretty similar at 22.6% (this is also ranked last in the country). One of the reasons for this is that Texas (and 19 other states) did not expand Medicaid coverage that was offered in the Affordable Care Act. Overall Texas has the highest number of uninsured people in both urban and rural. According to the Quarterly in all of the rural counties there are only 16 hospitals, but what is worse is the fact that 10% of rural hospitals have closed since 2013.
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In conclusion, I hope that this brings awareness to high maternal mortality rate that US and Texas are facing. The issue of it being a race and ethnic issue signs light on the fact that black women are at a higher risk than white women, but not just when they become pregnant, but other health concerns as well. By addressing this issue of high MMR for all women can make an impact as to how we can help all women have equal care when it comes to other types of treatment, such as cancer. How Texas and other states are not being able to offer health care to rural populations when compared to urban populations is rather shocking. There are several causes as to why and how the government plays a role is key. There are still a few things that need to be addressed, such as how SES plays a role, women having their first child at an older age are also impacted, possible medical causes or risk factors, and how US addresses these issues compared to other countries.
References
Primary:
Gaskin, Ina May. (2008), Maternal death in the United States: A problem solved or a problem ignored?, The Journal of Perinatal Education, 17, 9–13. https://doi.org/10.1624/105812408X298336
Lisonkova, Sarka. Joseph, K. S. (2013), Incidence of preeclampsia: Risk factors and outcomes associated with early- versus late-onset disease, American Journal of Obstetrics and Gynecology, 209, 544.e1–544.e12. https://doi.org/10.1016/j.ajog.2013.08.019
MacDorman, Marian F. (2017), Trends in Texas maternal mortality by maternal age, race/ethnicity, and cause of death, 2006 -2015, Birth, 1–9. https://doi-org.ezproxy.lib.utexas.edu/10.1111/birt.12330
Williams, David R. (2002), Racial/ethnic variations in women’s health: The social embeddedness of health. American Journal of Public Health, 98, S38–S47. https://doi.org/10.2105/AJPH.98.Supplement_1.S38
Secondary:
Andrews, Michelle. (2016, February 24), More rural hospitals are closing their maternity units. National Public Radio. Retrieved from https://www.npr.org/sections/health-shots/2016/02/24/467848568/more-rural-hospitals-are-closing-their-maternity-units
Collins, Christopher. (2018, January 17), Report: If rural Texans want decent health care, they should mosey to New Hampshire. Texas Observer. Retrieved from https://www.texasobserver.org/first-kind-report-puts-rural-health-care-texas-among-nations-worst/
Maron, Dina Fine. (2015, June 8). Has maternal mortality really doubled in the U.S.? Scientific American. Retrieved from https://www.scientificamerican.com/article/has-maternal-mortality-really-doubled-in-the-u-s/
Martin, Nina. Montagne, Renee. (2017, December 7), Black mothers keep dying after giving birth. Shalon Irving’s story explains why. National Public Radio. Retrieved from https://www.npr.org/2017/12/07/568948782/black-mothers-keep-dying-after-giving-birth-shalon-irvings-story-explains-why
Fields, Robin. (2018, January 4), Maternal deaths are increasing in Texas, but probably not as much as officials thought. Texas Tribune. Retrieved from https://www.texastribune.org/2018/01/04/maternal-deaths-are-increasing-texas-probably-not-much-officials-thoug/
More Sources:
Rural Health Quarterly. (2017). 2017 Rural Health Report Card: Texas. Retrieved from http://ruralhealthquarterly.com/home/wp-content/uploads/2017/12/RHQ.1.4_DIGITAL.pdf
Full Frontal with Samantha Bee. (2018, January 10). No country for pregnant women. Retrieved from https://www.youtube.com/watch?v=CA6A3ZlGlH8
Center for Disease Control and Prevention. (2015). Perinatal Quality Collaborative Success Story. Retrieved from https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pdf/perinatal-quality-collaborative-success-story-california-2015.pdf
Center for Disease Control and Prevention. (2017). Pregnancy Mortality Surveillance System. Retrieved from https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html
Texas Department of State Health Services. (2018, February 8). Maternal Mortality and Morbidity Task Force: Legislative Reports. Retrieved from https://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm
