July, 2023 | The Pillbox

A series of briefs by Texas Medical Students

By: Radhika Patel and Sanika Rane

Maternal mortality continues to be one of the more pressing public health issues in Texas. In December 2022, Texas’ Maternal Mortality and Morbidity Review Committee released a report reviewing pregnancy-related deaths in Texas since 2019 ¹. The review found that despite policies implemented to prevent these cases, there has been little improvement in rates since 2013, with Texans continuing to experience above-average rates of pregnancy- & childbirth-related deaths – about 12 deaths per month with 89% of cases being preventable ¹. The report also found that 19% of pregnancy related deaths were attributed to discrimination, with people of color, particularly Black patients being at the highest risk of pregnancy related discrimination and subsequently the highest risk for maternal mortality.

So what gaps remain to be addressed? In a recent issue of Texas Medicine, TMA announced that “women’s reproductive health” and “Medicaid coverage for women and children” amongst its priorities to address in the 2023 legislative agenda ² . The federal administration has developed a Maternal Health Blueprint specifying policies on Extending Postpartum Medicaid Coverage; A Maternal Mental Health Hotline; Investments in Rural Maternal Care; No More Surprise Bills; and Better Trained Providers (addressing implicit bias), and in February, Dr. Jackson Griggs testified on behalf of TMA at the Texas Senate Finance meeting seeking adequate state funding for maternal & child health – the written testimony highlights similar issues regarding maternal mortality in Texas (more below) ³. Currently, there are a number of bills proposed this legislative session to address some
of these issues:

Medicaid coverage

In the last session, House Bill (HB) 133 requesting extension of coverage for 12 months postpartum was passed by Texas’ House of Representatives – but the Senate reduced this to 6 months, causing the expansion to be stuck requiring waiver approval by the federal government ⁴
Due to this, despite Medicaid covering half of births in Texas, insurance still only extends coverage to 2 months postpartum – with nearly one-third of maternal deaths in Texas occurring after this coverage ends ⁵
Medicaid will undergo further “unwinding” this year as Texas restarts disenrollments – currently, a pregnant woman earning up to 198% of the FPIL can be covered by Medicaid through 60 days after pregnancy ⁶; but on day 61, she must earn less than 17% to maintain her coverage ($3,733 for a family of three), leading to loss of coverage for many ⁷. In Texas, rates of delayed and foregone preventive care for children and adults have increased, resulting in potentially missed and delayed diagnoses.
Gregg Abbott has even stated that one of his budget priorities is to request funding for 12 months of Medicaid postpartum services ⁸.
Bills proposed this session to expand Medicaid coverage to 12 months postpartum include House Bill (HB) 56 (currently still in Health Care Reform committee) & Senate Bill (SB) 73 (currently still in Health & Human Services committee).

Racial disparities

Nationally, Black people giving birth are three times more likely to die than their white counterparts – and twice as likely in Texas.⁹
Bills proposed this session addressing racial disparities include:
- HB 663: Creating an unbiased maternal mortality and morbidity data registry for Texas.
  - Passed vote in the House, now in the Health & Human Services committee in the Senate.
- HB 1164: Obtaining funding to conduct a study specifically investigating maternal mortality and morbidity among Black women in Texas.
  - Passed vote in the House, now in the Health & Human Services committee in the Senate.
- HB 1162 & 1165: Establishing requirements for medical provider licensing should include hours for cultural competency and implicit bias training.
  - Both still in the Public Health committee

Life-saving care

Maternal death rates have been found to be 62% higher in contraception-restriction states like Texas ¹⁰
In two Texas hospitals, 57% of patients were reported to have significant maternal morbidity as a result of state-mandated management of obstetrical complications (like access to life-saving medication) compared to 33% in states without such legislation. On average, patients were withheld life-saving care for 9 days, simply being observed instead as their conditions worsened – before they eventually developed complications severe enough to be qualified as an immediate threat to maternal life for physicians to legally take action under Texas law. ¹¹
Bills proposed this session addressing life-saving care include:
- SB 79 & HB 3000: Ensuring that current restrictions will not negatively impact pregnant patients requiring termination for their care, including not being susceptible to criminal penalties.
  - Both still in the State Affairs committee.
- HB 1953: Establishing exceptions to current restrictions to ensure that physicians are able to provide life-saving care to high-risk patients in their third-trimester.
  - Currently still in the Public Health committee.

Mental health resources

84% of pregnancy-related deaths were preventable – leading underlying issues varied by race & ethnicity, including: mental health conditions (23%) (suicide and overdose/poisoning) disproportionately affecting Hispanic & non-Hispanic White people. ¹²
In Texas, rising rates of drug abuse, suicide, and domestic violence reflect the mental anguish and distress so many patients face – suicide and homicide represented 27% of pregnancy-related deaths with homicides most often perpetuated by the individual’s partner ¹
Establishing funding to allow PCPs to provide up to 4 postpartum depression screens in the year following delivery, especially given the current shortage of both adult & child psychiatrists, may help address these issues. ⁸
Bills proposed this session addressing mental health resources include:
- HB 3724: Establishing a maternal mental health peer support pilot program for perinatal mood and anxiety disorder.
  - Currently still in the Health Care Reform committee.
- HB 2873: A strategic plan for improving maternal health, including improving access to screening, referral, treatment, and support services for perinatal depression.
  - Passed vote in the House, now awaiting vote in the Senate.

Maternal health deserts

Texas leads the country in maternal health deserts – communities with limited or no local prenatal and maternity care services, even for insured women – jeopardizing the health of expectant mothers and their unborn babies.⁸
Bills proposed this session addressing maternal health deserts include:
- HB 3626: Implementing a public outreach campaign to increase the number of maternal health care professionals in rural areas.
  - Currently still in the Health Care Reform committee.
- HB 617 & SB 251: Establishing a pilot program for providing telemedicine and telehealth services in rural areas.
  - HB 617 passed & signed into law by Governor Abbott, effective 9/1/2023.
  - SB 251 passed vote in the House, now in the Jurisprudence committee in the Senate.
- HB 1798 & SB 663: Developing a strategic plan for providing home and community-based services under Medicaid to children and mothers, especially in low-resource settings.
  - HB 1798 passed vote in the House, now in the Health & Human Services committee in the Senate.
  - SB 663 currently still in the Health & Human Services committee.

In summary, please consider the following goals for advocacy this session:

Ensuring safe access to life-saving procedures.
Extending Medicaid coverage to 12 months postpartum for all mothers in Texas.
Increasing access to evidence-based community and crisis mental health and substance abuse services.
Addressing gaps in medical education to prevent the impact of racial discrimination on maternal mortality, including cultural competency & implicit bias.
Improving access to comprehensive healthcare in rural settings and maternal health deserts.

Since most of these bills are still being discussed within committees, it is an especially pertinent time to speak with the representatives sitting on these committees and urge them to move the bills forward to be voted on and signed into law. Stay informed about issues pervading your communities, reach out to your local representative to ask for their support on proposed bills, and engage in this legislative session by joining physician advocates at the Capitol!

Resources

Texas Maternal Mortality and Morbidity Review Committee and Department of State
Health Services Joint Biennial Report 2022. Accessed January 26, 2023.
https://www.dshs.texas.gov/sites/default/files/legislative/2022-Reports/Joint-Biennial-
MMMRC-Report-2022.pdf
Texas Medicine March 2023. www.qgdigitalpublishing.com. Accessed April 1, 2023.
https://www.qgdigitalpublishing.com/publication/?m=55178&l=1
House TW. FACT SHEET: President Biden’s and Vice President Harris’s Maternal Health
Blueprint Delivers for Women, Mothers, and Families. The White House. Published June 24,
2022.https://www.whitehouse.gov/briefing-room/statements-releases/2022/06/24/fact-sheet-
president-bidens-maternal-health-blueprint-delivers-for-women-mothers-and-families/
Klibanoff E. Texas health agency says its plan to extend maternal Medicaid coverage is “not
approvable” by feds. The Texas Tribune. Published August 4, 2022. Accessed April 1, 2023.
https://www.texastribune.org/2022/08/04/texas-medicaid-postpartum-application/
Waller A. Maternal health care advocates applaud new state law to extend Medicaid coverage,
but say it doesn’t go far enough. The Texas Tribune. Published August 27, 2021.
https://www.texastribune.org/2021/08/27/texas-medicaid-maternal-mortality-health
Comments on the Status of the Texas Maternal Health Coverage Bill. Texans Care for
Children. Accessed April 1, 2023. https://txchildren.org/posts/2022/5/4/comments-on-the-
status-of-the-texas-maternal-health-coverage-bill
Maternal deaths are public health and health equity problems. They’re also preventable. |
Kinder Institute for Urban Research. Kinder Institute for Urban Research | Rice University.
https://kinder.rice.edu/urbanedge/maternal-deaths-are-public-health-and-health-equity-
problems-theyre-also-preventable
Texas Medical Association. Senate Finance Committee – Senate Bill 1, Article II Hearing
Texas Health and Human Services Commission. TMA; 2023
Salahuddin M, Patel DA, O’Neil M, Mandell DJ, Nehme E, Karimifar M, Elerian N, Byrd-
Williams C, Oppenheimer D, Lakey DL. (2018) Severe Maternal Morbidity in Communities
Across Texas. Austin, TX: University of Texas Health Science Center at Tyler/University of
Texas System.
Declercq, E., Barnard-Mayers, R., Zephyrin, L., & Johnson, K. (2022, December 14). The U.S.
Maternal Health Divide: the Limited Maternal Health Services and Worse Outcomes of States
Proposing New Abortion Restrictions. Www.commonwealthfund.org.
https://www.commonwealthfund.org/publications/issue-briefs/2022/dec/us-maternal-health-
divide-limited-services-worse-outcomes
Nambiar, A., Patel, S., Santiago-Munoz, P., Spong, C. Y., & Nelson, D. B. (2022). Maternal
morbidity and fetal outcomes among pregnant women at 22 weeks’ gestation or less with
complications in 2 Texas hospitals after legislation on abortion. American Journal of Obstetrics
& Gynecology, 0(0). https://doi.org/10.1016/j.ajog.2022.06.060
CDC Newsroom. (2016, January 1). CDC. https://www.cdc.gov/media/releases/2022/p0919-
pregnancy-related-deaths.html