A pregnant woman holds her belly. Photo via Flickr user summerbl4ck.
A pregnant woman holds her belly. Credit: Summerbl4ck / Creative Commons

Texas is one of the more dangerous places in the developed world to give birth.

A 2016 article published by the medical journal “Obstetrics and Gynecology” noted a sharp increase to 33 deaths per 100,000 live births in 2011. The findings sparked discussion among lawmakers and public health professionals across the state, resulting in local and national efforts to combat the statistic.

The Department of State Health and Human Services developed the Maternal Mortality and Morbidity Task Force in 2013. In its 2016 joint biennial report, the task force found that the rate of pregnancy-related deaths in Texas has nearly doubled since 2010. Between 2011 and 2012, 189 Texas mothers died within one year of giving birth.

Since then the task force has been working to address the rise of maternal morbidity, focusing on reviewing trends and making recommendations to help reduce the incidence of pregnancy-related deaths.

The task force reported that the leading cause of maternal deaths in Texas was cardiac problems. The second leading cause was drug overdoses. Researchers and legislators agree there is no simple fix to curbing maternal deaths.

The task force recommendations include increasing screening for and referral to behavioral health services, increasing access to health services during the year after delivery, and increasing provider and community education for women at higher risk of death from childbirth.

Sixty percent of the maternal deaths occurred six weeks or more after delivery. That figure is important because more than half of the nearly 400,000 births in Texas every year are covered by Medicaid, but coverage for many mothers expire 60 days after they give birth.

The Maternal Mortality and Morbidity Task Force reports became the foundation on which lawmakers proposed House Bill 2466, aimed at enabling Texas mothers taking their babies for checkups through Medicaid or the Children’s Health Improvement Program to be able to get postpartum depression screenings and counseling.

The bill was proposed during the 85th legislative session, and on June 14, Texas Gov. Greg Abbott signed House Bill 2466 into law.

About 17% of Texas mothers experience postpartum depression before or after giving birth, according to a 2016 report from the Texas Department of State Health Services. Symptoms may include anxiety, panic attacks, loss of appetite, sleeplessness, and feelings of guilt, shame, or helplessness.

Depression is a risk factor in the well-being of the mother and the well-being, safety, and development of the child.

Kori Eberle, health program manager with the Healthy Start program with Metro Health, told the Rivard Report that “it has always been part of our program [to screen patients] before and after pregnancy to receive mental health services for depression.”

The Healthy Start program provides educational and referral services for mothers who need health services past the point of what their insurance covers. Home visitors link patients to local community providers and help facilitate the process by assisting with paperwork and preventing a gap in services.

“We are not able to serve every woman in San Antonio, so any expansion of services is something that we know will improve outcomes for both mothers and children in the pregnancy process,” Eberle said.

Erica Underferth is a mother of three who gave birth to her first child with Medicaid coverage. Her daughter was born with heart defects and underwent open-heart surgery just five weeks after being born.

“In my mind I knew I should have been thankful about the pregnancy, about the new baby, [but] as soon as we got home I knew that something wasn’t right,” Underferth said.

Having a child with special medical needs was emotionally daunting for Underferth, and it added a layer of personal blame and judgment to her already complicated childbirth experience. When home health workers visited Underferth to check on her and her daughter, fear of repercussions prevented her from admitting that she was struggling with postpartum depression. Instead she consistently reported that she was “fine.”

“I was so afraid that if I admitted that I wasn’t feeling totally fine that it would either make me look bad or it would somehow make me incompetent to be a mother,” Underferth said. “I was afraid of judgment – that they would think that I can’t do it by myself.”

Underferth now has three children, with two being born under private health insurance. She experienced postpartum depression with all three children, and it increased in intensity with each birth.

Regarding services she received after giving birth, Underferth told the Rivard Report that private health insurance felt more personal than her experience with Medicaid. She didn’t feel better educated about depression in either of her three childbirth experiences, comparatively.

Underferth sees lack of education as the biggest barrier for individuals suffering from postpartum depression. She believes that new mothers need to know that “there are no [negative repercussions] for getting help,” and that “mothers don’t have to be scared, that there are no consequences, and [postpartum depression] is totally normal.”

Through the Healthy Start Program, Metro Health intends to reduce maternal mortality in Bexar County. In 2016 officials initiated a fetal infant mortality review process, creating a formal system to track infant mortality.

“No matter what is going on at the legislative level we want to make sure we are doing all we can at the city level [to dig] into the causes that may be why mothers experience problems during and after pregnancy,” Eberle said.

Program officials will hold meetings beginning in August to look into reasons behind poor outcomes for mothers, including mortality and the effects of health equity throughout the county.

Another Metro Health initiative, Healthy Families Network (HFN), is a coalition of more than 40 organizations “pulling together to make sure that women’s health stays a priority.” These organizations meet monthly and discuss how to strengthen community partnerships to reduce infant mortality and support successful birth outcomes for both women and children.

“We really see by looking at the mom and at birth outcomes that the health of a woman is the biggest predictor of good health throughout the reproductive lifetime,” Eberle said. “Anything the community can do at the local level to support women accessing and utilizing healthcare – and what we can do to support lawmakers at the state and local level – is a priority.”

A number of bills aimed at protecting mothers and children died during the most recent legislative session. House Bill 2135 would have provided postpartum depression mental health services as a covered benefit of the CHIP Perinatal program. The bill was passed out of the originating committee, but did not receive a House floor reading.

House Bill 2604 would have implemented a five-year strategic plan regarding postpartum depression screening, referral, treatment, and supportive services for women in Texas, but also did not receive a House floor reading.

One item on the agenda for the Legislature’s July special session is Senate Bill 1929, which would extend the State’s Task Force on Maternal Mortality and Morbidity until 2023.

Roseanna Garza

Roseanna Garza reports on health and bioscience for the San Antonio Report.