TX Maternal Mortality Report Calls for Access to Doulas and More

The Texas Maternal Mortality and Morbidity Review Committee (MMMRC) recently published its 2024 report, making clear that state leaders have more work to do to keep moms healthy and alive. In particular, the report found that 80% of the pregnancy-related deaths were preventable and recommended additional patient supports, such as doulas, to help new moms navigate the critical first year of their baby’s life. Our hearts break for the mothers who have been lost and the families who have been left to grieve. Preventing additional tragedies must be a priority for state leaders.

This year’s report analyzes “pregnancy-associated deaths” and “pregnancy-related” deaths in 2020 and “maternal deaths” in 2020 and 2021. 

• The committee reviewed 203 pregnancy-associated deaths, which means the woman died during pregnancy or within a year of pregnancy. 
• Only 85 of the 203 deaths were determined to be pregnancy-related, which means the death was in some way due to the fact that the woman had been pregnant within a year. There were an additional 21 deaths that the committee was unable to determine if the death was related to the pregnancy.
• Maternal deaths are any deaths that occur during pregnancy or within 42 days of the end of pregnancy regardless of cause but excluding motor vehicle accidents. The Texas maternal mortality ratio (MMR) is the number of maternal deaths per 100,000 live births. The MMR increased from 17.2 in 2019 to 27.7 in 2020 and 37.7 in 2021, an increase that the Committee attributes in part to COVID-19. However, the report says the MMR increased even if deaths related to COVID-19 are excluded from the data, with an MMR of 24.2 in 2020 and 23.0 in 2021.

Many of the findings echo past MMMRC reports. For example, the report found:

• For the 2020 cohort, the committee determined that 80 percent of the pregnancy-related deaths were preventable, a slight decrease from the last report, which found that 90 percent were preventable. 
• There continue to be disparities among the leading causes of death in relation to demographics. When 2019 and 2020 pregnancy-related deaths are combined, infections are the leading cause of death for Hispanic moms, while heart issues continue to be the primary cause of death for Black moms, and mental illness is still the top cause of death for White moms.
• The pregnancy-related mortality ratio, which is the number of deaths due to pregnancy per 100,000 live births, continues to be roughly 2.5 times greater for Black women than the ratio for White women in 2020.
• This report highlights that 1 in 4 of the deaths occurred 43 days to one year after the end of pregnancy, which emphasizes a need for continued focus on quality postpartum care. 

Like the findings in the report, the 12 recommendations continue to emphasize themes seen in previous reports. Women need consistent access to health care between pregnancies to ensure they come into pregnancy as healthy as possible. Alarmingly, the report highlights that in 2021, 25 percent of moms with pre-pregnancy obesity had hypertension, diabetes, or both. The committee emphasized a need to prioritize pregnant and postpartum women in future public health emergencies as a lesson learned from the COVID pandemic. Again, the report cited engaging Black communities to help address health disparities, continuing the TexasAIM program, increasing public awareness through the HearHer campaign, and better coordination with emergency medical services to manage obstetric and postpartum emergencies. It also recommended more interpersonal violence screening, awareness, and trauma-informed care. Additionally, the report emphasized addressing things like safe housing, case management, paid sick/family/parental leave, and affordable childcare, which all contribute to an individual’s overall health.

The MMMRC report had a notable emphasis on mental health and substance use. While the majority of the contributing factors for preventable pregnancy-related deaths were at the provider level, for mental health conditions, most contributing factors were due to systemic problems in our health care system. Additionally, 85 percent of the deaths due to mental illness happened 43 days to one year after the end of the pregnancy. These data paint a picture of new moms unable to navigate a confusing system while caring for an infant, a challenge that continues to build throughout that first year of the baby’s life. The committee made some important recommendations on this issue, such as continuing to prioritize integrating medical and behavioral health care, specifically focusing on mental health and substance use, by increasing access to programs like home-visiting nurses and patient-centered postpartum care models, including access to a comprehensive array of providers to support moms like doulas and community health workers.

During the next legislative session, we expect legislators to consider the recommendations of the MMMRC, including proposals to expand access to doulas by reimbursing them through Medicaid for prenatal, birth, and postpartum maternal support. The MMMRC report recommended expanding doula access to help with integrating behavioral health care access and with increasing the maternal health workforce by “enhancing coverage for birth doulas and postpartum doulas….to increase full spectrum maternal support during the pregnancy and postpartum period.”

In Texas, over half of births are covered by Medicaid health insurance. With the passage of HB 12 last legislative session, which extended Medicaid coverage to a year postpartum, new moms now have health insurance when historically they have gone back to being uninsured two months after their pregnancy. This historic change offers an opportunity for our state leaders to rethink postpartum care. The first step was extending the coverage. Now state leaders need to make sure our moms can access it, and that it covers their most pressing health needs in that postpartum period.

Extending Medicaid for new moms for an additional 12 months after pregnancy was a top recommendation of the MMMRC for years. This is the first report since that recommendation finally passed the legislature and was implemented. HB 12 proves that our state leaders can take action on these recommendations. The findings in the MMMRC report continue to highlight there are opportunities to prevent these deaths and keep families together. We look forward to working with state leaders to reduce maternal mortality, including through increasing access to doula support during pregnancy, birth, and the postpartum period.