Poverty and limited access to health care continue to make childbirth more risky for American women when compared with other developed nations.

The U.S. maternal mortality rate – the death rate among women who are pregnant or die within six weeks of giving birth – has doubled since the government began collecting statistics in 1987 to 26.4 deaths per 100,000 people in 2015.

Roughly 700 women die annually from pregnancy-related conditions, according to the Centers for Disease Control and Prevention (CDC). In most cases, the deaths could have been prevented.

In December, the Trump administration designated $12 million of funding to help states reduce maternal deaths.

The deaths cut across racial lines, but black women are most at risk of dying from pregnancy-related complications, accounting for about 43 percent of all maternal mortalities. But doctors say this is more about access to care than race.

“I think that’s more of an access issue for sure,” said Dr. Alison Pasciucco, a Fort Worth obstetrician. “It has to do with structural racism across the country.”

“Black women are more likely to be uninsured, face greater financial barriers to care when they need it and are less likely to access prenatal care.”

National Partnership for Women and Families

Access to care in Texas

In recent months, Texas has begun disputing the official number of deaths attributed to pregnancy. Researchers have suggested that deaths were miscoded and that up to 50 percent of deaths linked to pregnancy in 2012, the year reviewed, could be mislabeled.

If this were the case, that year’s projected rate of 14 deaths per 100,000 people would have been more aligned with the national rate. However, that rate still puts Texas, which has one of the world’s largest economies, behind countr such as Saudi Arabia, New Zealand and South Korea when it comes to maternal mortality.

Many women especially young, low-income people of color are affected by lack of publicly-funded health services.

However, maternal mortality is only part of the equation. Countless other mothers experience major complications in the birthing process, and Texas lacks the resources to provide adequate women’s healthcare.

“I know there are multiple counties in Texas that do not have an OBGYN in the whole county,” said Dr. Hollis Bartels, a Fort Worth obstetrician. “That means they have to travel two hours to see their doctor. You can imagine that complications can happen if you can’t get to a facility quickly, and those rural settings aren’t going to have high risk pregnancy doctors or the best resources and high risk pregnancy doctors.”

The uninsured

The Texas Alliance for Health estimates that 17 percent of Texans live without health insurance, the highest rate of uninsured residents of any state.

In Texas, benefits for women with Medicaid end two months after giving birth. The state has also kept its pre-2014 eligibility rules for Medicaid. New eligibility rules would likely greatly increase those who are eligible.

“Women in Texas have not historically had access to health care across their lifespan, so when they’re pregnant and don’t have care, it’s really hard to treat those things in such a short amount of time,” said Amy Raines-Milenkov, chair of the Texas state task force on maternal mortality and assistant professor of pediatrics at the University of North Texas Health Science Center.

Most other states have participated in the expansion of Medicaid. Utah, Idaho, and Nebraska are expected to expand in 2019.

Texas legislature is currently working on several bills that could impact women’s healthcare in the state.

State Rep. Michelle Beckley, D-Carrollton, is sponsoring a bill, which would provide continue Medicaid coverage for at least 12 months after giving birth and miscarrying a pregnancy.

The state also passed a bill to create the Alliance for Innovation on Maternal Health (AIM) and give aid packages to different areas of healthcare, one of which being maternal health. The Texas Department of Health Services requested $2.7 million for AIM funding and additional money to improve the record system used to track maternal mortality.

Doctors at Premier Obstetrics and Gynecology in Fort Worth, where Bartels practices, said pregnancy Medicaid often influences whether a pregnant woman can begin cared for by a physician.

The government funded health insurance program provides healthcare to pregnant women who have no medical insurance or inadequate insurance.

“If you’ve never been to a doctor for the past six years, because you didn’t have insurance and now you do, then there’s the potential for there to be an increase in health issues.”

Dr. Alison Pasciucco, Premier Obstetrics and Gynecology

Bartels said that she has had multiple patients who show up for their initial visit without insurance.

“We confirm the pregnancy, but they want to wait to do their lab work and things like that until they get their insurance, and that usually takes a month or so and delays treatment,” Bartels said.  

According to the Henry J Kaiser Family Foundation, minorities made up 60 percent of the American population that was enrolled in Medicaid in 2013.

“The later you present in care, the higher chance that there has been an undiagnosed issue that hasn’t been managed that could put you at further risk for complications,” Bartels said.

Pregnancy Medicaid can not only cause women to delay their pregnancy care, but it can also lead to an inadequate amount of postpartum care.

“Medicaid only works for six weeks after the birth of the child, but that means only two appointments in the six-week period,” Pasciucco said.

Global perspective

While Texas and much of the U.S. has struggled to reduce maternal mortality, the situation has been improving globally.

Brenda Davis, the producer of the award-winning documentary Sisters which promotes health literacy and maternal health in developing countries, said the U.S. should improve its protocols for pregnant women and new moms.

“First and foremost, health workers and maternal health workers should listen to women,” Davis said.

“All women and families should have access to free health care, respectful care and anti-racist work.”

Brenda Davis

She said any approach to improving maternal health has to be multifaceted.

“Climate change, immigration, poverty, racism, and women’s rights are some of the few issues that are interwoven with maternal mortality,” she said.

Davis pointed out cultural aspects in developing countries that contribute to their maternal health.

“The access to local health care is a huge factor, so the training of local health workers who respect local (non-harmful) practices,” Davis said. “Access to clean and safe delivery and postpartum care are vital to the health of the mother and baby.”

In her documentary, one of the countries Davis focuses on is Ethiopia where officials have been working to improve mid-level health worker training to help deal with emergency procedures and surgeries.

Midwives and community health workers are also helping.

“They use a model where the priority is to observe signs of the mother requiring more care, such as dizziness, fever, bleeding, and high blood pressure,” said Davis. “They also use the ‘chain of survival’ of care set in place.”

Davis said some ways the U.S. could promote health literacy are as simple as respecting women who may need help. The health infrastructures also need to be responsible for maternal mortality as a whole.

“Women’s health as a priority to families, communities, countries is reflected in the maternal mortality rate,” Davis said.

An added risk

Globally, 21 percent of births are Cesarean sections, or surgical procedures, rather than natural births. An over-reliance on this method can reduce its effectiveness and put women at risk for infection.

The suggested number of necessary c-sections is approximated at 19 percent of births, according to The Journal of the American Medical Association’s analysis of childbirth in 194 countries.

If the rate of c-sections increases past 19 percent, researchers have found that cesarean sections start to become less successful in maintaining the health of the mother.

In the United States, nearly one in three births are done via cesarean section. The increase in surgeries is resulting in higher rates of mortality.  

According to a 2014 consensus published by the American College of Obstetricians and Gynecologists, there are about four deaths for every 100,000 women after vaginal deliveries and about 13 deaths for every 100,000 women after cesareans.

The higher rate of morbidity after a c-section is due to infections and transfusions.

This report was compiled by the Spring 2019 Reporting class: Cristian Argueta Soto, Trent Attyah, Ben Auten, Bing Banta, Taylor Brumbaugh, Marley Capper, Riane Cleveland, Tim Daly, James Flowers, Lindsey Follis, Bailey Godber, Emily Gustafson, Nicole Hawkins, Desaray Hickombottom, Jacob Hook, Livia Lavender, Mitchell Lefevre, Marlena Markland, Noah Parker, Brandon Ucker, Olivia Wales