Commentary Maternity and Birthing

What Texas Can Do to Change Its Maternal Health Crisis

Elizabeth Dawes Gay

It's no surprise that Texas experienced a recent rise in maternal deaths after its legislators gutted reproductive-health policies. But it's also not a mystery about how to reverse course, and lawmakers can start with Medicaid.

This piece is published in collaboration with Echoing Ida, a Forward Together project.

New research published in the journal Obstetrics & Gynecology shows that my home state of Texas’ maternal mortality rate doubled between 2010 and 2012. Additionally, a report from Texas’ Department of State Health Services found that Black women accounted for nearly 30 percent of maternal deaths in 2011 and 2012, even though only 11 percent of all births in the state were to Black women.

These troubling statistics are a clear indication that the state is doing something wrong (or not getting something right).

This crisis didn’t come about on its own. Texas’ lack of comprehensive sexual health education, cuts to family planning programs, and the forced closures of abortion clinics all contribute to poor reproductive and maternal health outcomes. It doesn’t take a rocket scientist to figure out that people need access to high-quality care to be healthy—or that playing politics with women’s health was sure to have dire consequences.

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But for those Texas legislators who are actually concerned about their constituents’ well-being, there is enough existing evidence about how to promote good maternal health. With a solid dose of political will, Texas and other states can help to roll back the national crisis of rising maternal mortality by taking three immediate steps: expanding Medicaid to improve health-care access, ensuring a steady supply of maternity care providers, and improving the quality of maternity care.

Step One: Expand Financial Access to Health Care

People need access to health care—period. Of the 50 states, Texas has the highest percentage of people without health insurance coverage. More than 5 million Texans remain uninsured; the majority are people of color.

Even with those statistics and federal government support for the expansion process, Texas legislators have refused to broaden Medicaid as part of the Affordable Care Act and, therefore, have denied help to as many as 1.3 million Texans. Expanding Medicaid would also benefit those who fall into the coverage gap—those who earn too much to qualify for Medicaid under the current system but not enough to afford health insurance on their own.

Opening Medicaid to more Texans means that more low-income women would gain the medical services they need to support a healthy pregnancy. Nearly half of all births in Texas and in the United States overall are already funded by Medicaid. But without Medicaid expansion, far too many people are building their families without health care.

Improving financial access to care also involves reinstating and expanding programs that provided preventive services such as family planning and screenings. Severe budget cuts to Planned Parenthood and other reproductive health-care providers implemented by Republican legislators in 2011 caused a shortage that left women hanging.

The government of Texas is attempting to resolve ongoing problems that resulted from the severe cuts to reproductive health programs with Healthy Texas Women, a program that provides preventive health care—including contraception, pre-conception health screening, and pregnancy testing and counseling—for low-income women. The program launched in July 2016, but the effect of this program remains to be seen. For example, as Rewire has reported, more than $1 million of that funding has gone to a known anti-choice organization.

Amy Hagstrom Miller, founder and CEO of the Whole Woman’s Health clinic network (which has locations in Texas), says there has been some confusion about Healthy Texas Women.

“Sometimes providers who are ‘supposed’ to be part of the program don’t have any expertise in women’s reproductive health care and don’t even know they have been listed as a provider in the program. What we are seeing on the ground is that a lot of women are just feeling isolated and left behind because they can’t get the resources that they need,” Hagstrom Miller told Rewire via email.

Expanding Medicaid and health programs for low-income people can help them access the care they need before, during, and after pregnancy and childbirth. Despite the potential boon to women and families, Hagstrom Miller doesn’t expect progress to be easy. “Year after year, we are playing defense and expect that this will continue because the leaders that are making and passing these laws and cuts are basing their decisions on medically inaccurate information and their own personal ideological views.”

Step Two: Increase the Number of Maternity Care Providers, Including Midwives

A health insurance card is only helpful if you have somewhere to use it. Increasing the number of maternity care providers, along with expanding financial access to care, is key to addressing the maternal health problem.

Unfortunately, provider shortages are increasing across the country. According to the Association of American Medical Colleges, there could be a shortage of up to 90,000 physicians by 2025, affecting the entire health-care system. Currently, almost half of U.S. counties lack an OB-GYN and more than half lack a nurse-midwife. In Texas, 147 of 254 counties have no OB-GYN, according to a report commissioned by the North Texas Regional Extension Center. In an expansive state like Texas, this could mean driving for hours to reach a provider or, for some people, simply going without necessary care.

Bolstering existing programs that encourage providers to practice in shortage areas could help. The American Congress of Obstetricians and Gynecologists and the American College of Nurse-Midwives (ACNM) support a proposal so that OB-GYNs and midwives can benefit from existing federal programs that already provide financial incentives to primary care, dental, and mental health practitioners to provide care in shortage areas. The financial incentives offered by the government include scholarships, loans and loan repayment arrangements, and bonuses.

Additionally, clarifying licensing requirements and relaxing legal restrictions for certified nurse-midwives, certified professional midwives, and certified midwives could expand much-needed access to maternity care. ACNM reports that midwifery care is associated with better prenatal knowledge and readiness for labor and delivery, improved patient satisfaction, and fewer unnecessary medical procedures.

Increasing the number of midwives and encouraging them to practice in shortage areas might be especially beneficial for Black women due to midwifery’s personalized model of care. In a phone interview, International Center for Traditional Childbearing (ICTC) Founder Shafia Monroe told Rewire that “Black women need access to midwives to reduce the high maternal mortality rate. We need more conversation, more empowerment, and more encouragement. We need the time and type of care that midwives provide.”

ICTC plays an important role by training midwives and doulas of color to provide culturally competent care. Still, less than 5 percent of certified nurse-midwives are Black. Supporting Black women to become midwives could also help Black women access midwifery care.

Step Three: Focus on Quality—and Learn From Other Models

When it comes to maternal health, high-quality care is absolutely essential. But what does quality even mean? In maternity care, quality is measured by patient experience and satisfaction, patient outcomes, and the processes and interventions by which those outcomes are realized. Based on the high rates of maternal mortality, morbidity, and interventions like cesarean sections, it is clear that the United States has a quality problem.

Texas can follow the lead of other states and initiatives that have tackled quality issues. In California, where the maternal mortality rate has steadily declined during the past decade, the California Maternal Quality Care Collaborative (CMQCC) has contributed to reducing maternal mortality through data collection and review, the development of evidence-based toolkits, and the implementation of quality initiatives. The California Department of Public Health cites CMQCC efforts as one reason why maternal mortality in the state decreased, dropping from 16.9 deaths per 100,000 live births in 2006 to 6.2 fatalities in 2012.

At the national level, a partnership of organizations called the Alliance for Innovation on Maternal Health has developed safety bundles—a set of best practices, guidelines, and protocols that providers can use to address specific maternal health issues such as hemorrhage, pre-eclampsia, reducing c-sections, and reducing racial disparities. Safety bundles come with guidance to help facilities introduce new practices with their existing resources. One of the main focuses of the Health Resources and Services Administration’s Maternal Health Initiative is to ensure that every hospital that does labor and delivery has access to maternal safety bundles.

Safety bundles are one tactic, but unfortunately they may not be enough to eliminate the racial discrimination, disrespect, and mistreatment Black women experience while seeking maternal health care.

Advocates in the reproductive justice and birth justice movements are working to change how Black women are treated during pregnancy and the birth process. The National Perinatal Task Force, founded by midwife Jennie Joseph, designates Perinatal Safe Spots—institutions committed to providing high-quality, judgment-free services in communities where moms and babies are most at risk. Mamas on Bedrest & Beyond, in Austin, Texas, is one such Perinatal Safe Spot. The cultivation of community-initiated efforts is central to making real progress on the quality of care Black women receive—and lowering their disproportionate representation among women who die or sustain injuries from pregnancy-related causes.

To be sure, there aren’t any quick fixes to rising maternal mortality rates. Changing the United States’ culture on reproductive health and maternity will take time and many stakeholders. But there are opportunities to make a difference in people’s lives right now. Many will benefit from lawmaker action to improve physical and financial access to high-quality, respectful care. We can’t let politics get in the way.

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