Texas has one of the highest maternal mortality rates in the country. Between 2010 and 2012, the rate doubled. And the rate in Texas between 2012 and 2014 remained high, with approximately 35 maternal deaths per 100,000 live births. Texas' rates are about seven times greater than in Canada and European countries.

As a result, the Texas Legislature established the Maternal Mortality and Morbidity Task Force in 2013. This 15-member task force of mostly physicians and healthcare experts set out to find out why pregnancy-related deaths have skyrocketed and what can be done to decrease them.

In a July 2016 report, the task force indicated that the most common causes of maternal death were cardiac events, overdose from illicit drugs (mostly opioids) and hypertensive disorders. Though cardiac events and hypertensive disorders are not surprising, it was surprising to see the opioid epidemic is now one of the leading causes of pregnancy-related deaths.

The task force also found that black women were three times more likely to suffer from maternal mortalities.

"I was mortified," said Rep. Shawn Thierry (D-Houston) when she read the report. "And no one was doing anything to figure out why black women were more likely affected."

That's what compelled her to introduce HB 11, the "Texas Mothers Matter" bill. One of the primary directives in this bill is for the task force to prioritize why black women are disproportionately more likely to die.

"I was talking to other doctors, ob/gyns, and they didn't know about this statistics," she said. "I spoke to African-American women in the community, and they didn't know."

Unfortunately, the health disparity of black women dying disproportionately as a result of pregnancies is nothing new. The risk of maternal mortality in black women has been 3 times to 4 times higher in the United States for the past six decades.

"There are likely multiple factors, and more detailed reviews are needed to figure out why," said Dr. Lisa Hollier. She is a maternal and fetal medicine physician at Baylor College of Medicine, and she is the chair of the task force.

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Black women are more likely to have preexisting medical conditions, such as high blood pressure, diabetes or obesity. They are also less likely to begin prenatal care in the first trimester and less likely to receive adequate care.

They also have high rates of being uninsured and having access to health care. One significant issue in the United States that especially among African Americans and Hispanics is that access and affordability to health care are abysmal.

THE UNINSURED rates around the country have improved significantly since the Affordable Care Act (ACA). But Texas continues to have the largest uninsured rate in the country. One major reason why Texas did not have a more significant decrease in the uninsured population, from 23 percent to 18 percent, was because the legislature refused Medicaid expansion. That has been costly. If Texas were to expand Medicaid, it would provide coverage to more than one million uninsured Texans.

But the state legislature rejected billions of dollars in federal aid to expand Medicaid, calling the program "broken." Now, the state is asking the White House to renew a deal that brought in more than $6 billion a year under Medicaid to help the poor.

More than half of all Texas women giving birth are covered under Medicaid. Medicaid allows low-income women to receive coverage when they become pregnant, but they lose their coverage 60 days after delivery.

And that loss is significant because the task force found that the majority of maternal deaths occurred between 42 days to 52 weeks after delivery.

If Texas accepted Medicaid expansion, though, then all low-income women would be covered regardless of the need to become pregnant or the 60-day cutoff afterward. Importantly, many mothers at risk of dying after the 60-day cutoff would continue to have access to their health care under Medicaid.

Interestingly, most of the states that have refused expansion have been in the South – the very places where mortality rates and uninsured rates are the highest. The states that have accepted expansion have seen positive impacts. They have seen improved access to healthcare, affordability and financial security among their low-income population. Medicaid expansion has also significantly helped reduce the gap of racial disparities.

It has also improved treatment for substance use disorders. Medicaid's improved access to the life-saving drug Naloxone has been a major player in reversing opioid-related overdoses.

And it has also improved mortality rates. In a long-term study of expansion in New York, Arizona, and Maine, researchers found increased coverage of care from Medicaid expansion resulted in a 6 percent decrease in mortality rates.

And in 2013, the American College of Obstetrics and Gynecology (ACOG) produced a committee opinion that increasing access to healthcare for women through Medicaid expansion would allow for better continuity of care, decrease complication rates from pregnancies and enable women to seek appropriate medical help when needed.

SO THE Texas maternal task force recommended increasing access for women through the first year after delivery and throughout their reproductive lives to improve maternal health.

They also stated that increasing Medicaid coverage to one year after birth would reduce costs in the Medicaid program by decreasing unintended pregnancies, managing chronic diseases like high blood pressure or mental health illness like depression and prevent its complications.

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But the state of Texas has taken a different approach. In 2016, Texas launched a state-run program called Healthy Texas Women. This program provides some limited care for low-income women. The funds came after the State Legislation cut two-thirds of the family planning budget and stopped funding Planned Parenthood in 2011.

As the state of Texas has struggled with having the highest uninsured rates and one of the highest maternal mortality rates in the developed world, state lawmakers like Rep. Thierry are continuing to push fellow lawmakers to put the maternal health and disparities – especially among black women – as a high priority.

In the meantime, as we wait to see whether the task force gets an extension to 2023 so it can complete their findings and recommendations, Texas has the opportunity for another step in the right direction in women's health by accepting the Medicaid expansion.

Dr. Behrouz Zand (@Behrouz_Zand) is Assistant Professor in the Department of Gynecologic Oncology at MD Anderson Cancer Center. He also blogs about the health care system, patient experiences and population health.

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