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MATERNAL
MORTALITY

Maternal Mortality in Texas:

Our Grim Past and Promising Future?

By Patrick S. Ramsey, MD, MSPH

mage the birth of a child… the joy and celebration of the identified related to these maternal deaths include obesity, maternal
I family… the wonder of the new life brought into the medical comorbidities, advanced maternal age, late access to prena-
world. The miracle of birth. In a moment the occasion
tal care and mental health disorders. Similar to national statistics,
turns to terror with onset of torrential vaginal bleeding. the rates of maternal mortality in Texas are highest among women
Efforts to treat and manage the blood loss are futile and hours later of African-American descent.
the mother lays pale and pulseless.
The above scenario unfortunately occurs all too often and leaves Causes for Increasing Maternal Mortality:
a permanent scar on the newborn, family, entire provider care team A number of potential factors which may account for the in-
and our society. Maternal death is a major marker for health of our creasing rate of maternal mortality are noted above. Factors in-
state and nation. Maternal mortality is defined as a ratio of the num- cluding impaired access to care, defunding of family planning
ber of maternal deaths occurring during pregnancy or within the services, and state non-participation in the Affordable Care Act
42 days following the end of pregnancy per 100,000 live births (ACA) exchanges may be partially contributing to the increasing
(some definitions extend the period up to one year following the rate of maternal mortality. Inaccurate data collection and reporting
end of pregnancy). In spite of spending over $98 billion annually may also be a potential cause for the observed increase in maternal
on hospitalization for pregnancy and childbirth, the United States mortality. Concerns have been raised regarding the disparate per-
maternal mortality rate has doubled in the past 25 years (Figure 1). sonnel training and variable completion for death certificates lead-
Today, more women die in the U.S. from pregnancy-related compli- ing to inaccurate coding. In addition, the introduction of the
cations than in any other developed country. Between 2011 and “pregnancy check box” in 2003 has been questioned as partial
2013, maternal mortality in the U.S. was 17.3/100,000 live births. cause for the increase. In the May issue of Obstetrics & Gynecol-
Tragically, there are striking racial/ethnic disparities present with ogy, Baeva and colleagues evaluated the standard approach for col-
African American women being 3-4 times (43.5/100,000 live births) lection of maternal mortality to an enhanced method assessing
more likely to die from a pregnancy-related condition than non-His- for obstetric cause of death codes as evidence of pregnancy and
panic white women (12.7/100,000 live births. Leading causes of data matching with birth or fetal death record. This enhanced ap-
maternal mortality nationally include cardiovascular disease, infec- proach resulted in a corrected maternal mortality estimate for 2012
tion/sepsis, obstetric hemorrhage, cardiomyopathy, pulmonary em- of 14.6/100,000 live births vs 38.4/100,000 live births using stan-
bolism and hypertensive disorders of pregnancy (Figure 2). dard methods. This observation is important to refine our ap-
proach to collect accurate data but in no way diminished concerns
Maternal Mortality In Texas: for maternal mortality. Any women lost as the result of pregnancy
What about maternal mortality in Texas? Between the years of is an unacceptable loss in modern obstetrics.
2012 and 2015 there were 382 maternal deaths recorded during
pregnancy or within the first year following the end of pregnancy Severe Maternal Morbidity in Texas:
in Texas. Of these deaths 38 percent occurred during pregnancy or While maternal mortality is fortunately uncommon, maternal
within 42 days of the end of pregnancy. The leading causes for these morbidities are far more common. It is estimated that severe ma-
deaths included cardiac/cardiovascular events, infection/sepsis, ob- ternal morbidity occurs between 50 and100 more often than ma-
stetric hemorrhage, and hypertension/eclampsia. The remaining 62 ternal mortality making efforts to reduce these adverse outcome
percent of maternal deaths occurred between 43 days and one year highly important in our efforts to prevent maternal death. In Texas
following the end of pregnancy. In contrast to those deaths occur- in 2014, the estimated overall rate of severe maternal morbidity, de-
ring during pregnancy or early following the end of pregnancy, the fined as obstetric hemorrhage, disseminated intravascular coagu-
leading causes for these later maternal deaths included drug over- lopathy (DIC), eclampsia, emergency hysterectomy or
dose, homicide, cardiac events, and suicide. Contributing factors thromboembolism was noted in 195.2/10,000 deliveries. The rate

16 San Antonio Medicine • July 2018