The maternal mortality rate in Texas—at 23.8 deaths out of 100,000 women—is worse than in Iran or Croatia. And at the same time that the rate has been dropping around the world, it has been rising in the U.S. as a whole. Out of 31 OECD nations, the U.S. ranks 30th, just ahead of Mexico.
A new study tallied the rate—which measures women who die while pregnant, or shortly after giving birth—across the U.S. There was one piece of good news: In California, where half a million babies are born each year, fewer mothers are dying.
In Texas, the rate of deaths doubled between 2010 and 2014, the study found. That happened to be the same period that the state legislature temporarily slashed the budget for family planning clinics by two-thirds, forcing 80 clinics to close and others to cut services. It also cut Planned Parenthood from a state program for low-income preventative health care.
Still, the study didn't look at the reasons for the change, so the researchers can't say definitively that politics were the cause. "The old saying in statistics is correlation is not causation," says Christine Morton, a research sociologist at Stanford University's California Maternal Quality Care Collaborative and one of the authors of the paper.
"I think everybody is at a loss to understand why Texas saw such an increase in maternal mortality rate," she says. "We posited that the documented changes in provisions in women's health services happened in this same time period, but it's hard to know—in the absence of in-depth case review of maternal mortality data in Texas—how that lined up with those changes."
In California, in a separate project called the California Maternal Mortality Review, Morton and fellow researchers deeply analyzed data as the state worked to figure out how to save more mothers' lives. "The state of California, in its wisdom, said, okay, we're not just going to track these deaths—measurement is another issue—but we're going to look at them and see what can be done to prevent them," says Morton.
The researchers worked with medical experts to analyze the causes of maternal deaths, and found five leading medical problems. Then they analyzed how those problems could be prevented. Certain key issues, like hemorrhage, are highly preventable.
"[The California Maternal Mortality Review] enabled us to break out where those preventability opportunities were," she says. "Were they in the readiness of a hospital to address the needs of a high-risk patient? Was it that the patient didn't recognize the symptoms she was experiencing? Was the condition misdiagnosed, or was the wrong treatment provided?"
Those findings led to new data-driven tool kits, and helped hospitals in California adopt new practices. While the new study doesn't show specifically that the changes led to the state's improvements—just like it doesn't show that Texas's actions led to more deaths—it's indisputable that California is showing a clear improvement in the death rate while the rest of the country worsens.
Surprisingly, even though reducing maternal mortality is an international priority, as one of the UN's Millennium Development Goals, the U.S. hasn't published its statistics since 2007. That's partly because the data is messy—the national standard for death certificates, which was changed in 2003 to include a check box for pregnancy, hasn't been adopted in the same way or at the same time across all states.
Part of the reason for the new study was to figure out a way to correctly calculate the maternal mortality rate in the U.S.; previous studies had shown that existing data was wrong. "The data is insufficient on a lot of levels," Morton says. "As we say in the paper, it's a national embarrassment that we haven't been counting maternal deaths accurately."
Morton is hoping that the strategies California has adopted can help lead to better policies across the rest of the country. "This work is really grounded in the data that came, sadly, from women who died," she says. "We see it as a way to honor their lives and make meaning from their deaths, that we can take these lessons to prevent future tragedies."
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