Janet Realini, MD, MPH
As is often the case in Texas politics, there was little agreement during the 85th Legislative Session on which steps are necessary to address the state’s many health care challenges. One area that did see agreement, though, was the recognition that far too many mothers in Texas get sick or die during pregnancy or within a year of a pregnancy ending. Unlike the decline of mortality rates internationally, U.S. maternal mortality rates have been increasing, and Texas’ maternal death rate infamously doubled between 2010 and 2012.
Thankfully, the Legislature moved during special session to extend the state’s Maternal Mortality and Morbidity Task Force, which plays an important role in identifying and addressing the core issues contributing to maternal death and severe illness.
In its July 2016 report, the MMMTF found that black women are at the greatest risk of dying. Although only 11.4 percent of Texas births in 2011-2012 were attributed to black women, 28.8 percent of the deaths occurred among black mothers. For all maternal deaths, the most common causes were cardiac events, drug overdose, and hypertensive disorders.
The number-one recommendation of the MMMTF was increasing access to health care for women during the year after delivery, along with improved continuity of care in the inter-conception period. These are efforts that family physicians can help with, both through our patient care and through our advocacy.
Clearly, primary and preventive care play critical roles in reducing maternal mortality. Primary care access means the possibility of detection and treatment of cardiac risk factors, substance abuse, depression, and hypertension, for example. Unfortunately, many low-income and minority women are uninsured and do not have access to primary care. Medicaid covers many low-income pregnant women, but does not cover most low-income women who are not pregnant. Texas has the highest rate and the highest number of uninsured women (and people) of any state; yet, our state has not taken advantage of the opportunity provided by the Affordable Care Act to expand Medicaid for many low-income adults.
Preventive care that includes contraception is a critical help as well. Access to contraception and other family planning services helps in at least two ways. First, contraceptive counseling and supplies prevent pregnancies that are not wanted or planned, thus reducing the physiological stress and other risks of a pregnancy on women not intending to become pregnant. Second, screenings provided in preventive care detect problems that need treatment, helping women prepare for a healthy pregnancy that is wanted and planned. In addition, planning pregnancy allows for healthy spacing between pregnancies, which means lower chances of preterm birth, low birthweight, and infant mortality. A healthy pregnancy begins well before a woman becomes pregnant.
Texas provides for two preventive health care programs that offer family planning and well-woman screenings for low-income women. Healthy Texas Women features free contraceptive care; immunizations; and screenings for breast and cervical cancer, obesity, hypertension, diabetes, hypercholesterolemia, depression, exposure to abuse and/or violence, sexually transmitted infections, and substance abuse. Limited treatment for hypertension, diabetes, and high cholesterol is also covered. HTW covers women citizens who are 15-44 years old with incomes at or below 200 percent of the federal poverty level. Women who deliver a baby on Medicaid are automatically enrolled into HTW 61 days after delivery, which is when their Medicaid coverage ends. Family physicians can participate in this fee-for-service program in their practices if they are signed up as a Medicaid provider and certify that they do not perform abortions or affiliate with abortion providers.
Texas’ Family Planning Program serves Texas residents, both women and men, including undocumented people, up to age 64 with a similar package of preventive services, including diagnostic breast and cervical cancer services and limited prenatal care. This program is based on a competitive grant and contract system. Family physicians can participate in this program if they are part of an organization (generally a safety-net clinic) that contracts with Texas Health and Human Services to provide these services. Undocumented women who deliver as part of the CHIP-Perinatal program can be referred to an FPP provider organization for contraception and follow-up after their two CHIP-P-covered post-partum visits.
Family physicians who provide maternity care can also ensure that their hospital participates in the Alliance for Innovation on Maternal Health Patient Safety Bundles to improve safety for pregnant and post-partum women. These Maternal Safety Bundles help ensure that the staff and systems are prepared to use best practices regarding common threats to maternal health and life.
Continuity of care is paramount for monitoring and treating women at risk for maternal mortality. Transitions into Medicaid for pregnant women and CHIP-P for women not eligible for Medicaid are often delayed and difficult. Late or no prenatal care, associated with many adverse outcomes, is far too common in Texas and is strongly associated with a pregnancy that is unplanned. In addition, transitions into HTW or FPP after a delivery are often delayed or completely lost. Too few women are made sufficiently aware of these services or perhaps they lack the support they need to access them. As a result, many new mothers fall out of care and miss out on health services at this potentially vulnerable stage of their lives. Better education of both women and providers is needed to bridge these gaps.
The Texas Women’s Healthcare Coalition is a coalition of 77 health care, faith, and community-based member organizations dedicated to improving the health and well-being of Texas women, babies, and families by ensuring access to preventive health care — including contraception — for all Texas women. During the legislative interim, we encourage the Legislature to study how women can be better connected to family planning services postpartum. We are working with providers of all types to improve they system, reduce unplanned pregnancy, and decrease maternal mortality.
Family physicians play a critical role in this work. The TWHC is grateful for the active support and engagement of the Texas Academy of Family Physicians, an indispensable member of the TWHC Steering Committee.
MacDorman MF, et al. Recent Increases in the U.S. Maternal Mortality Rate. Disentangling Trends from Measurement Issues. Obstet Gynecol 2016; 128:1-10.
Joint Biennial Report. Maternal Mortality and Morbidity Task Force and Department of State Health Services. Department of State Health Services, July 2016.
Alliance for Innovation on Maternal Health Patient Safety Bundles. Accessible at http://safehealthcareforeverywoman.org/patient-safety-bundles/.
Janet Realini, MD, MPH, is a family physician in San Antonio, Texas. She is the founder and associate vice president of Healthy Futures of Texas.