Michelle Zavala had a complex pregnancy.
The Pflugerville woman had to keep her hyperthyroidism under control and take progesterone to prevent her from giving birth prematurely. She developed gestational diabetes and had to have her blood tested six times a day.
Still, her daughter Clara was born healthy, and Michelle and her husband Chris were able to take her home right away. But a couple of days later, Michelle suddenly couldn’t breathe. Chris rushed her to the hospital, where doctors took X-rays and told him she needed to be moved to the trauma unit.
“When they wheeled her into that trauma room, I went and held her hand and told her everything was going to be okay, and that was the last thing I said to my wife,” Chris Zavala said.
She died in July — just nine days after giving birth — from a blood clot in her heart. She was 35.
Across the United States, maternal mortality — when a mother dies from pregnancy-related complications while pregnant or within 42 days of giving birth — jumped by 27 percent between 2000 and 2014, according to a 2016 study published in the medical journal Obstetrics and Gynecology.
But researchers were stunned by Texas, where the maternal mortality rate had apparently doubled between 2010 and 2012. That year, 148 women died as the state’s mortality rate hit its highest level since the Centers for Disease Control and Prevention started recordkeeping with its current disease codes in 1999.
The study’s authors called the increase troubling and difficult to explain “in the absence of war, natural disaster, or severe economic upheaval.”
But the state’s real maternal mortality rate is now a matter of debate.
Although the Department of State Health Services website shows that Texas’ maternal mortality rate was 35.2 per 100,000 births between 2012 and 2015 using CDC data, agency officials now say that the number of mothers who died during that period is actually more than 30 percent lower — 24.3 deaths per 100,000 births — thanks to a new methodology the state recently began using to calculate deaths. While state officials say the new, lower mortality rate is more accurate, they stopped short of calling it the official maternal mortality rate because the new methodology is still being refined.
Meanwhile, a study published in the medical journal Birth this month analyzed CDC data from 2006 to 2015 and found that the state’s maternal death numbers are inflated. The study’s authors said that while CDC’s data isn’t reliable, “the fact that maternal mortality increased in Texas is not in dispute.”
Marian MacDorman, a research professor with the Maryland Population Research Center and the study’s lead author, said the new methodology the state is developing is also flawed because it omits women who died after miscarriages or other complications that prevented them from giving birth.
Experts and advocates say maternal deaths are a symptom of a bigger problem: Too many Texas women — particularly low-income women — don’t have access to health insurance, mental health care and other services that could help them become healthier before and after pregnancy.
In October, a task force created to tackle the problem released a report showing that the Texas women most at risk of dying after giving birth include black women over 40; unmarried women; women who use Medicaid, pay for insurance out of pocket, or have no insurance; and women who give birth through cesarean delivery. They’re also more likely to enter pregnancy with health problems like obesity, diabetes and high blood pressure.
Overall, black mothers are at the highest risk of dying as a result of pregnancy, according to the state task force report: While they delivered only 11 percent of the babies in Texas from 2012 to 2015, they made up 20 percent of maternal deaths. White women delivered 34 percent of the state’s babies over the same period and accounted for 39 percent of deaths, while Hispanic women accounted for nearly 48 percent of the state’s births and 38 percent of deaths.
The Tribune’s investigation found that lawmakers have squandered opportunities to help more women access services that could save their lives by cutting or replacing existing health programs, opting not to expand Medicaid under the Affordable Care Act and excluding Planned Parenthood’s clinics from a state family planning program.
Curbing Texas’ maternal mortality rate “isn’t going to be a situation where there’s a single cause and single solution,” said Lisa Hollier, who chairs the state task force. She said it’s “increasingly complicated” to care for pregnant Texas women because more of them have chronic health problems; they’re getting prenatal care late or not at all; and they’re having babies at a later age than Texas women in recent generations.
Kami Geoffray, CEO of the Women’s Health and Family Planning Association of Texas, an organization that works to increase access to family planning programs, said lawmakers haven’t gotten serious about addressing shortcomings in the state’s health care programs for women.
“They have this notion that being uninsured is not a problem,” she said.
Texas has the highest rate of uninsured women ages 19-64 in the nation, according to the Kaiser Family Foundation.
Reproductive rights advocates say Texas women are still feeling the effects of legislators’ 2011 decision to chop $73.6 million from the $111.5 million budget for the Family Planning Program, which offers birth control, pregnancy tests, and screening for cholesterol, diabetes and high blood pressure. The number of people the program served dropped from more than 195,000 in 2011 to fewer than 83,000 the following year.
That same year, state leaders moved to exclude Planned Parenthood from the Medicaid Women’s Health Program, a joint federal-state program that for years provided preventive care — including pap smears, breast exams and contraception — to 105,000 Texas women per year. When the state barred clinics affiliated with Planned Parenthood from participating, the Obama administration kicked Texas out of the program, citing Medicaid patients’ right to choose any provider they want.
The state created its own replacement, the Texas Women’s Health Program — and from 2011 to 2013, the number of women it served dropped 25 percent, according to a Texas Health and Human Services Commission report. In 2016, the state replaced that program with Healthy Texas Women — which aims to provide low-income women with pregnancy tests, birth control, screening and treatment for postpartum depression, plus annual health exams.
Today, more than 220,000 women are enrolled, a 118 percent increase since its launch, according to the state’s health agency. Christine Mann, a spokeswoman for the agency, said in an emailed statement that enrolled women “now have access to a broader array of services.”
The state’s other major option for providing health care to low-income women — expanding Medicaid through the 2010 federal health care law that created the Affordable Care Act — has been a nonstarter in the GOP-dominated Legislature. An estimated 1.1 million Texans would be eligible for coverage under a Medicaid expansion, according to the Kaiser Family Foundation.
Republican leaders, including Gov. Greg Abbott, Lt. Gov. Dan Patrick and former Gov. Rick Perry, have argued that expanding Medicaid would increase health care costs for the state — especially if the federal government breaks its promise to help pay for the surge of newly eligible people.
“I strongly believe we can better utilize current resources and programs to improve women’s health in Texas,” state Sen. Lois Kolkhorst, R-Brenham, said. “When we spend health care dollars more efficiently, more people can be served and better outcomes can be achieved.”
Less prenatal care
Texas women — especially minority women — also aren’t getting adequate prenatal or postpartum care during the critical periods when doctors could help reduce their risk of complications and death, the Tribune found.
“If you don’t seek prenatal care, then you’re much more at risk or you may deliver at a state where your body is that much more unhealthy,” said Kim Baker, a member of Harris County’s Reducing Maternal Mortality Research Team.
According to state statistics, nearly half of black mothers in Texas — 46.2 percent — did not get prenatal check-ups within their first trimester of pregnancy in 2015. Hispanic women were close behind at 42.8 percent, while 29.7 percent of white mothers didn’t attend first-trimester prenatal appointments.
Other states have been more aggressive than Texas in trying to reduce maternal deaths. After 126 California hospitals began using new procedures for addressing pregnancy complications, those complications dropped by nearly 21 percent between 2014 and 2016, and the state as a whole lowered its maternal mortality rate by 55 percent between 2006 and 2013.
Texas Department of State Health Services officials say the state is implementing two bundles: one for hemorrhaging and another for hypertension. They’re also working with other states to develop another bundle for opioid abuse.
Postpartum care is arguably as important as prenatal care. Federal data shows that more than half of maternal deaths happen after a woman gives birth, most often caused by cardiovascular disease, infections and hemorrhages.
A baby’s first pediatric visit usually takes place three to five days after birth, but a mother typically won’t see her doctor until four to six weeks after delivery, if at all — and serious complications often emerge in the first few days and weeks after delivery.
“So many of our patients don’t take care of themselves in the postpartum period because they are taking care of their newborn,” said Houston doctor Sean Blackwell, president-elect for the Society for Maternal Fetal Medicine.
There’s a racial divide in postpartum care in Texas, too. Hispanic women in Texas skip postpartum visits at a rate of 18.9 percent; 10.1 percent of black mothers don’t get postpartum checkups, nor do 9.6 percent of white women, according to the 2015 Pregnancy Risk Assessment Monitoring System.
Insurance coverage also matters. For women who gave birth and paid out of pocket for care or didn’t specify their how they paid, 27.7 percent didn’t show up for their postpartum visit, versus 16.6 percent of women covered by Medicaid, the monitoring system found.
George Saade, chair of the Texas Collaborative for Healthy Mothers and Babies and a doctor at the University of Texas Medical Branch in Galveston, said in an ideal world doctors wouldn’t just have one postpartum visit with patients. They’d have a series of them to check a new mother’s glucose levels and blood pressure and offer nutrition counseling.
“That’s where we fail when we do one visit,” Saade said. “It’s a wellness program. We have to bring them back to healthy lifestyle changes, screenings, medication and treatment.”
Syreeta Lazarus, a Houston woman hospitalized in 2012 when her blood pressure spiked after giving birth to her daughter, said there’s not enough information about which symptoms new mothers should look for after delivery.
“I didn’t know that you can have all of these problems or reactions or issues,” Lazarus said. “I had no clue. I had my mom’s stories to go on, but formally from a doctor? No.”
Chris Essig of The Texas Tribune contributed reporting for this story.