No matter which way you count, the number of Texas women dying after they have babies or unsuccessful pregnancies is on the rise.

Two new studies detailing the disturbing trend have prompted soul-searching from state policymakers and outcry from women’s health advocates, who argue that cuts by the state’s Republican-led Legislature to Planned Parenthood and other women’s health programs are at least partially responsible for the increase.

The first study published this month, citing national data and led by a Maryland-based researcher, found that maternal deaths are increasing across the country but particularly quickly in Texas. It found that in 2012, 148 women in Texas died from pregnancy-related complications — including excessive bleeding, obesity-related heart problems and infection — within 42 days of the end of their pregnancy. Two years before, 72 women died from those causes.



The second study, authored by a state-appointed task force of 15 Texas researchers, examined the causes of individual Texas women who died within one year after the end of pregnancy. The researchers investigated 100 maternal deaths from 2011 and 89 from 2012.

Researchers who study the maternal mortality rate — defined as the number of non-accidental deaths of women within a certain number of days after their pregnancy ends that occur for every 100,000 live births — say the causes are complex and difficult to measure. The usual risks of pregnancy complications, such as heart problems and high blood pressure, continue to be leading contributors to maternal deaths, they note. And black women remain at significantly higher risk of maternal death in Texas — a national phenomenon that is well documented in scientific literature but still poorly understood, experts said.

But some of the recent findings came as a surprise, even to subject matter experts. The Texas Tribune spoke to maternal health researchers for their take on the data. Here are their key observations:

Deaths by drug abuse and suicide are unexpectedly common

Researchers said they were most shocked to see an increase in the number of maternal deaths related to substance abuse and mental health problems. Drug overdoses were the second leading cause of maternal death in Texas in 2011 and 2012, according to findings recently released by the state Task Force on Maternal Mortality and Morbidity, which was created by lawmakers in 2013. Overdoses accounted for 11.6 percent of the mortalities investigated by the task force, trailing only fatalities from heart problems, which claimed 20.6 percent of the 189 maternal deaths studied.

Opioids, a family of drugs including prescription painkillers such as hydrocodone, as well as illicit drugs, such as heroin, were the main culprit.

“That was something I hadn’t expected,” said June Hanke, a task force member and strategic analyst at the Harris Health System in Houston.

Amy Raines-Milenkov, another task force member and a professor of obstetrics and gynecology at the University of North Texas Health Science Center, said the number of babies in Texas born with neonatal abstinence syndrome, which develops when a fetus is exposed to addictive opioids in the womb, has risen over time, suggesting that more women are using the drugs during pregnancy. But she said the drug-related deaths require further study.

“ That was something I hadn’t expected. ” — June Hanke, analyst at Harris Health System

“Was it prescribed? Was it used off the street? We don’t really know,” she said.

The task force's study also found that suicide accounted for 5.3 percent of the maternal deaths, another point that stumped researchers. Task force members who investigated individual maternal deaths said they identified several opportunities where caregivers and social workers could have identified a woman’s mental health issues.

Because so many Texans are uninsured, for many women, “access to health care is not [constant] across the life span,” Raines-Milenkov said. That means during pregnancy, when many low-income women temporarily qualify for publicly funded health services, “you have to seize that opportunity to do really good screenings,” she said.

Hanke said those screenings should be aimed at detecting mental illness and domestic violence in addition to physical illness.

Cuts to Planned Parenthood and other women’s health providers probably aren’t responsible for the increase, experts say, but may have exacerbated it

In 2011, lawmakers cut the state’s budget for family planning by two-thirds.

Some women's health advocates have argued that the cuts have at least contributed to the mortality increases. Because state-funded women's health services can be an entry point for low-income women to the health care system, cutting programs and closing clinics likely prevented women from receiving potentially life-saving medical care, they say.

Political commentators and news media have focused on the timing of the spike in maternal mortality reported in a national study published in the journal Obstetrics and Gynecology. The study found that while maternal mortality rates around the country were steadily rising, the rate in Texas alone nearly doubled in 2011 — the same year, the study’s authors noted, that Texas lawmakers made significant cuts to the state’s women’s health program. The researchers stopped short of saying whether the policy change had any effect on the numbers.

"Still, in the absence of war, natural disaster, or severe economic upheaval, the doubling of a mortality rate within a two-year period in a state with almost 400,000 annual births seems unlikely," they wrote.

But members of the Texas task force cautioned against pinning too much blame for the increased mortality on the budget cuts. Lisa Hollier, the task force's chair, pointed out that the increase noted by the national researchers began at the start of 2011, while cuts to the women’s health program did not take effect until September of that year.

“Maternal mortality is incredibly complex, and there isn’t going to be a single thing that is the cause,” she said. Hanke said attributing the increase solely to the 2011 budget cuts “would not be justified.”

“ In the absence of war, natural disaster, or severe economic upheaval, the doubling of a mortality rate within a two-year period in a state with almost 400,000 annual births seems unlikely. ” — Study published in the journal Obstetrics and Gynecology

Raines-Milenkov said improving women’s access to prenatal care and contraception could help reduce maternal deaths, but she expressed skepticism at the theory as well.

“It’s part of the picture, but it’s not the whole picture,” she said.

Still, George Saade, a professor of obstetrics and gynecology at the University of Texas Medical Branch, said reducing access to women’s health and family planning services could have exacerbated the rising mortality rate. “If you have a patient who has a medical condition that increases her risk during pregnancy, and she has no access to contraception, and she gets pregnant, and she dies, that’s a death that could have been prevented if she had contraception or family planning,” he said.

“So, yeah, no question — it certainly didn’t help decrease the rate of maternal mortality,” he said.

Black women are most at risk

Though births to black women made up only 11 percent of all Texas births in 2012, black women accounted for 29 percent of maternal deaths. That “striking disparity” was one of the task force report’s most important findings, Hollier said.

By comparison, white women accounted for 35 percent of births and 38 percent of maternal deaths. Hispanic women were the lowest risk group, representing 48 percent of births but only 31 percent of maternal deaths.

Though the racial disparities in maternal mortality rates are well known to researchers, the task force report shed new light on specific causes. For example, researchers found that black women were hospitalized at much higher rates for hemorrhages and blood transfusion related to pregnancy and childbirth. Overall, roughly 17 out of every 1,000 obstetric hospitalizations in 2012 was for hemorrhage or blood transfusion, but among black women alone, that rate was about 24 per 1,000 hospitalizations.

The task force report called for increased access to health services for women before conception, during pregnancy, and in the year after the pregnancy’s end. It also called for family planning services to promote birth spacing between pregnancies, particularly the year after delivery, when risk of complications is highest.

The data is messy

Both studies found inconsistencies in the way maternal deaths are reported, making them a difficult subject for study.

While the national study used the World Health Organization’s definition of maternal mortality, which includes deaths within 42 days of the end of a woman’s pregnancy, excluding accidents, the Texas task force took a more expansive view. Its researchers studied deaths within a year after the end of pregnancy.

The researchers said a lack of uniform data from death certificates and other records made it difficult to classify deaths as maternal or obstetric.

Raines-Milenkov said deaths from suicide and drug overdose were particularly hard to study, because “you really don’t know if this was related to the pregnancy or not." The task force also found that homicide accounted for 7.4 percent of maternal deaths.

“We need better data,” Saade said. “But irrespective of the data, we should really be concerned, because the trends all over the country are increasing.”

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