Texas pregnancy-related deaths inflated, new study finds

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Texas’ crisis of pregnancy-related deaths is not nearly as bad as previously reported, according to a new study.

The new data, calculated by state health officials and published in the journal Obstetrics & Gynecology Monday, found the actual number of maternal deaths is less than half that reported in a 2016 study that drew national attention to the issue in Texas.

Study authors who reviewed the cases said dozens of women erroneously were identified on their death certificates as being pregnant at the time of death, a misclassification that occurred because doctors, medical examiners and coroners selected the wrong option in the electronic reporting system. Such information was the source for a high-profile 2016 study.

"It is clear that Texas does not have the worst maternal mortality in the developed world and that previous reports were grossly inaccurate,” said state Sen. Lois Kolkhorst, R-Brenham, who authored 2017 legislation to extend a task force investigating the issue “We as a state can and are doing more to improve maternal health outcomes.”

The new data found 56 pregnancy-related deaths among Texas residents in 2012, compared to 147 the health department previously supplied to national databases. As a result, the 2012 rate becomes 14.6 deaths per 100,000 live births, significantly down from the the previously reported rate of 38.4.

Under the old data, the 2016 study found a doubling of the number of deaths in just two years that its lead author said was hard to explain “in the absence of war, natural disaster, or severe economic upheaval.” Some observers attempted to link the increase to the closure of some women’s health clinics at the time, but state officials noted the closures did not occur until after much of the spike already had occurred.

The study nevertheless made headlines around the country and globe and put pressure on state legislators to address maternal mortality.

Sonia Baeva, a Texas health department maternal mortality and morbidity epidemiologist and the lead author of the study, attributed the erroneous death certificate information to human error at the time of a more than 40 percent increase from 2010 to 2012 in the proportion of death certificates that were submitted electronically. On a drop-down list in the electronic system, the “pregnant at the time of death” option is directly below the “not pregnant within the past year” option.

"We encourage death certifiers to double-check the pregnancy status assigned before submitting electronically,” Baeva said. “This rather small-scale type of error can have a significant effect on statistics. Simply increasing awareness of this error can result in better public health data for our state."

Baeva said it is unclear how Texas’ maternal mortality problem compares with other states because their data may reflect the same erroneous information if they haven't reviewed cases individually.

Dr. Lisa Hollier, a Texas Children’s Hospital obstetrician-gynecologist, head of the state task force and a co-author of the new study, said her sense is that “Texas is now probably in the middle of the pack, as opposed to being near the near the top nationally.”

She added, however, that a significant number of the deaths are preventable. She said the better data illustrates the importance of having the task force carefully review cases, necessary to better understand the causes and contributing factors so the state can implement the best solutions.

Kolkhorst alluded to the task force’s work, saying the Texas Legislature has been taking “a smart approach on maternal mortality — instead of overreacting to sensationalized reports in the media, we directed better data collection in order to develop targeted, evidence-based strategies to more effectively improve the lives and health of mothers in Texas."

Pregnancy-related deaths have emerged as an issue around the nation in recent years. The Texas task force has found that excessive bleeding, high blood pressure, drug addiction and sepsis are the most common causes of death.

Texas health officials have begun ramping up efforts to reduce the numbers. In December, the state joined a national program focused on improving the safety and care of pregnant women through the use of standardized plans and instructions to use in patients with severe pregnancy complications, such as hemorrhaging or high blood pressure. The guidelines have been credited with reducing the number of mothers dying during childbirth by up to 22 percent in other states.

Hollier also drew attention to the fact that even with the new numbers, black women still face the highest risk. The new study found that the rate of black mothers dying during or within 42 days of pregnancy in 2012 was 27.8 per 100,000 live births, compared to 13.6 for white mothers and 11.5 for Hispanic women.

Marian MacDorman, a professor at the University of Maryland Population Research Center and the author of the 2016 study, called the work of the task force “laudable, necessary and appropriate given the state of Texas’ vital statistics data” in an editorial accompanying the study.

“The Texas study is important in that it provides a more accurate estimate of 2016 Texas maternal mortality and also provides important insight into the nature and magnitude of errors in Texas’ vital statistics data,” she wrote. “However, as the the study examined data from only a single year, 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.”

In a January 2018 study, MacDorman wrote that efforts to curb Texas’ maternal mortality problem were undermined because the data was so bad. She acknowledged in the study that the previous estimates of the problem were inflated but did not provide new numbers.

Baeva said the researchers will be reviewing cases after 2012, but said it was not feasible to look at the cases before.

The Texas health department is implementing legislation aimed at improving the quality of death data by developing best practices for investigating and reporting maternal deaths and creating new training for those who certify death certificates. A new registration system being developed will prompt such officials to confirm the pregnancy status before allowing a death record to be submitted.