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Texas’s maternal mortality rate was unbelievably high. Now we know why.


For the past few years, Texas’s maternal mortality rate was so high it seemed unbelievable.

As it turns out, according to a study released this week it was, indeed, not to be believed.

This week, the Texas Maternal Mortality and Morbidity Task Force released a study in Obstetrics & Gynecology that found the maternal morbidity figures from 2012 — which had Texas mothers dying at rates that shocked experts and the public — were based on sloppy and erroneous data collection.

So sloppy, in fact, that more than half of the deaths that were recorded as pregnancy-related that year were recorded that way in error.

In 2016, Texas made national headlines after research that was also published in Obstetrics & Gynecology highlighted that the state’s maternal mortality rate had mysteriously skyrocketed between 2010 and 2012. In 2012, for example, 148 Texas mothers died of pregnancy-related complications, compared with 72 in 2010, the study found. The national rate in 2013 was 28 deaths per 100,000 births.

Some thought that perhaps the dramatic spike between 2010 and 2012 in Texas was connected to the state legislature’s decision to slash family-planning funding by two-thirds in 2011.

“Still,” the authors of the 2016 study wrote, noting the changes in funding, “in the absence of war, natural disaster, or severe economic upheaval, the doubling of a mortality rate within a 2-year period in a state with almost 400,000 annual births seems unlikely.”

To correct the statistics, the Texas Maternal Mortality and Morbidity Task Force, which had been established to study the maternal mortality rate issue in 2013, cross-referenced death certificates, birth certificates and a year’s worth of medical records for all 147 women in the state’s records. They found that, in fact, there were 56 deaths that fell under the definition of maternal mortality — any pregnancy-related death while a woman is pregnant or within 42 days of giving birth, excluding accidental or incidental causes such as car crashes or homicide.

After all of the data-collection errors were excluded, Texas’s 2012 maternal mortality rate was corrected from 38.4 deaths per 100,000 live births to 14.6 per 100,000 live births.

The correction, however, was little cause for celebration, other researchers said.

Elliott Main, the medical director of the California Maternal Quality Care Collaborative, told The Washington Post that the data errors found in this single year of data in Texas are indicative of a much more widespread maternal mortality data collection problem on a national scale, which the Texas researchers noted in their article, as well.

Nationwide data collection problems started in the years after 2003 when, in an effort to improve maternal mortality reporting, the federal government added a little checkbox to the U.S. standard death certificate asking whether a woman was pregnant or postpartum at the time of death. Since states have autonomy over their death certificates, each state added the checkbox for these maternal deaths in varying ways over the next decade, and Texas made the change in 2006.

It did not have the desired benefit, Main said.

“What we’re finding now is that it is often checked in error, just like any other checkbox on a big form,” Main said. “Because pregnancy-related deaths are so uncommon, the frequency of the box being checked in error can significantly impact the maternal mortality rate reported.”

ProPublica and NPR, in articles about maternal mortality, documented this data issue extensively in an article titled, “How Many American Women Die From Causes Related to Pregnancy or Childbirth? No One Knows.” The federal government has not released an official maternal mortality rate estimate since 2007, largely because of the differing reporting methods in every state thanks to the new checkbox, the report said.

Citing 2015 research published in the Lancet, NPR and ProPublica reported the U.S. maternal mortality rate to be 26.4 per every 100,000 live births in 2015. Compare that with Britain’s 9.2, Australia’s 5.5 and Finland’s 3.8 per 100,000 live births. As The Post reported last month, the District of Columbia has an estimated rate of 41 per 100,000 deaths, according to a 2010 to 2014 analysis from the United Health Foundation. That has puzzled officials, as well.

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Yet even when the United States’ data collection problems are considered, Main said the United States — and Texas — is still trailing much of the Western world.

“The maternal mortality rate is still higher by anybody’s count than it was in the 1990s,” he said. “No matter how you look at it, even with the conservative estimate, the rate is higher than it should be compared to other high-resource countries. The U.S. has a lot of work to do, but I think a lot of the hype about Texas was driven by politics.”

Marian MacDorman, who co-authored the 2016 Obstetrics & Gynecology study questioning Texas’s alarming increase in maternal mortality, applauded the latest study in Texas — but cautioned in an editorial that it still left many questions unanswered. For example, since the study only focused on 2012, it is still unclear at what rate maternal mortality truly increased from 2010 to 2012 and why. MacDorman also cast doubt on the true mortality rate in a follow-up study published in January in the journal Birth.

Plus, in both the prior and updated mortality rates for Texas in 2012, black women were still severely disproportionately affected: Compared with the overall rate of 14.6 deaths per 100,000 live births, the rate for black women was still double that, at 27.8 per 100,000 live births, according to the study. The same has been true, Main said, for the country as a whole at varying rates.

“The Texas study is important in that it provides a more accurate estimate of 2012 Texas maternal mortality, and it also provides important insight into the nature and magnitude of errors in Texas’ vital statistics data,” MacDorman wrote in her editorial, published in Obstetrics & Gynecology on the same day as the Texas study. “However, as the study examined data from only a single year (2012), questions concerning the maternal mortality increase in Texas in the critical period from 2010 to 2012 remain unanswered, as do questions about more recent trends.”

The authors of the latest Texas study said the Texas Maternal Mortality and Morbidity Task Force intends to continue using its new methods to recalculate rates for additional years to better understand the trends.

Main said that review committees such as the one in Texas and the one for which he works in California — which, by contrast, helped California drastically reduce its maternal mortality rate — are the only way states can both correct overblown data and study the racial and ethnic disparity problem.

Once they are done doing all of that, MacDorman wrote, they can finally “get back to doing the job they were designed to do”: investigating and preventing them in the first place.

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