Fact check: Did state budget cuts in Texas cause an increase in pregnancy-related deaths?
Texas State Capitol (photo by Daniel Mayer, via Wikimedia Commons)
September 12, 2016
By Paul Brennan
Pregnant women and women who have recently been pregnant are dying at a higher rate in Texas than in any other state, according to a study published last month by the journal Obstetrics and Gynecology. The study estimates that the maternal mortality rate (MMR)—the number of maternal deaths per 100,000 births—doubled in Texas during a two-year period starting in 2011.[1][2] The study is being cited in political arguments over women’s health issues, as The Guardian reports.
| “ | In the wake of the report, reproductive health advocates are blaming the increase on Republican-led budget cuts that decimated the ranks of Texas’s reproductive health care clinics.[3][4] | ” |
Are those reproductive health advocates correct? Can the increase be blamed on budget cuts?
In 2011, the Texas Legislature passed a biennial budget that cut overall state spending by 8 percent. The budget reduced funding for family planning programs by 66 percent.[5] The legislature also restructured the way the state’s health programs for low-income women are funded. Under the new three-tier funding system, clinics that specialize in family planning services were placed in the third tier, the tier with lowest priority for receiving funds. By the end of fiscal year 2012, only 23 percent of the tier three organizations were receiving any funds for family planning services from the state, while 67 percent of the organizations in the other two tiers were still receiving such funds.[6]
The new, tiered structure provides funding for the Texas Women’s Health Program (TWHP), which was created in 2012 to provide services for low-income women. It replaced the Women’s Health Program (WHP), which had served that function since 2007. The WHP had received 90 percent of its funding from the federal Medicaid program and operated under a waiver granted by the Centers for Medicare and Medicaid Services. As part of application for a renewal of that waiver in 2012, Texas asked the waiver to be amended to allow the state to exclude clinics that are associated with providers of abortion services from receiving funds through the WHP. That request was denied, and following that denial, the state created the TWHP to replace the WHP. Because the TWHP is totally state-funded, it can and does exclude clinics associated with abortion service providers.[6][7]
In a 2012 speech, then-Gov. Rick Perry (R), described the new TWHP as “a program that not only meets the needs of Texas women, it also respects life and honors the will of Texas voters, ensuring no taxpayer money goes to abortion providers and their affiliates."[8]
According to a 2015 study published in the American Journal of Public Health, following the funding changes, 25 percent of the family planning clinics in Texas closed. Family planning organizations in the state also serviced 54 percent fewer clients in 2012 and 2013 than they did during the previous two-year period.[6]
But the beginning of the rise in the Texas maternal deaths reported by the MMR study predates those changes taking effect, as Dr. Lisa Hollier, professor of Obstetrics and Gynecology at Baylor College of Medicine and head of the Texas Maternal Mortality and Morbidity Task Force, pointed out to the Texas Tribune.[9] The increase reported by the MMR study begins in early 2011, but the first of the changes in funding didn’t 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,” Hollier, who did not participate in the study, told the Tribune.
The authors of the MMR study make note of the funding changes, but conclude there isn’t yet enough information to determine what caused the increase in maternal deaths in Texas. They characterize the increase as “puzzling” and conclude there is a need for further research to “examine Texas data by race–ethnicity and detailed causes of death to better understand this unusual finding.”[1]
Background: maternal death and the MMR study
In response to concerns that maternal deaths in the United States were being underreported, the Centers for Disease Control and Prevention in 2003 added a question concerning pregnancy to the current U.S. standard death certificate, which serves as the model state health agencies use when they create the death certificates for their states. The question has checkboxes to indicate if the deceased was pregnant or had been pregnant within 42 days of the time of death. According to international health reporting standards, deaths during that period may be classified as “maternal death.” There was also an option to indicate if the deceased had been pregnant between 43 days and 1 year prior to death. Deaths in that period may be classified as “late maternal death.”[1]
Between 2003 and 2014, 44 states and the District of Columbia revised their death certificates, adding the standardized question. Because not every state adopted the new format—and the states that did add it did so at different times—it was not possible to determine nationwide trends in maternal deaths from vital statistics published by the states. The study published in the Journal of Obstetrics and Gynecology used a statistical method common in medical research to adjust the data from the states to determine the MMR in the United States between 2000 and 2014. The study did not include data on late maternal deaths.[10]
Texas and the MMR study
The study concluded the MMR had increased in every state except California. The national MMR rose from 18.8 in 2000 to 23.8 in 2014. Those figures were determined using data from 48 states and the District of Columbia. California and Texas were excluded from the national data set in the study. “California because it does not provide comparable data and Texas as a result of uncertainty regarding recent trends,” according to the study.[1]
“The Texas data are puzzling in that they show a modest increase in maternal mortality from 2000 to 2010… followed by a doubling within a 2-year period in the reported maternal mortality rate,” the study says. Adjusting the data to compensate for the fact that Texas did not adopt the new pregnancy question on its death certificate until 2006, the study concludes that the state’s MMR rose from 17.7 in 2000 to 35.8 in 2014.
The maternal mortality statistics published annually by the Texas Department of State Health Services are not directly comparable to the numbers used in the study because they have not undergone the same statistical adjustments, but that data also shows a sustained increase in maternal deaths since 2011. The increase, however, is not as sharp as that reported in the study. In 2010, the MMR was 24.6 maternal deaths per 100,000 births. That rose to 30.6 deaths in 2011 and rose again in 2012 to 31.6 deaths.[11]
The MMR study does refer to the changes in how Texas funds its health programs for low-income women since 2011, but the authors found it unlikely that those changes are the cause for the increase in maternal deaths.
| “ | There were some changes in the provision of women’s health services in Texas from 2011 to 2015, including the closing of several women’s health clinics. Still, in the absence of war, natural disaster, or severe economic upheaval, the doubling of a mortality rate within a 2-year period in a state with almost 400,000 annual births seems unlikely.[1][4] | ” |
Conclusion
A new study of the maternal mortality rate in the United States turned up “puzzling” data showing a doubling in the rate of maternal deaths in Texas over a two-year period starting in 2011. Some reproductive health advocates blame the increase on changes in how Texas funds women’s health services that began in 2011. But the changes in the funding don’t coincide with the start of the increase, and the authors of the study conclude it is impossible to determine the cause—or causes—of the increase without further research.
See also
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Sources and Notes
- ↑ 1.0 1.1 1.2 1.3 1.4 Obstetrics & Gynecology, “Recent Increases in the U.S. Maternal Mortality Rate: Disentangling Trends From Measurement Issues,” August 2016
- ↑ University of North Carolina, Carolina Population Center, “Maternal Mortality Ratio,” accessed September 6, 2016
- ↑ The Guardian, “Texas has highest maternal mortality rate in developed world, study finds,” August 20, 2016
- ↑ 4.0 4.1 Note: This text is quoted verbatim from the original source. Any inconsistencies are attributable to the original source.
- ↑ The New England Journal of Medicine, “Effect of Removal of Planned Parenthood from the Texas Women’s Health Program,” March 3, 2016
- ↑ 6.0 6.1 6.2 American Journal of Public Health, “The Impact of Reproductive Health Legislation on Family Planning Clinic Services in Texas,” May 2015
- ↑ The Medicaid funding continued during the transition from the WHP to the TWHP. It ended in December 2012.
- ↑ Office of the Governor Rick Perry, “Gov. Perry: Texas Stands Ready to Implement State Women’s Health Program,” October 31, 2012
- ↑ The Texas Tribune, “More New Mothers in Texas are Dying; Experts Can't Say Why,” September 4, 2016
- ↑ The study uses Joinpoint regression analysis to determine MMR trends. For the use of Joinpoint analysis in medical research, see University of South Florida, “Trend Analysis and Modeling of Health and Environmental Data: Joinpoint and Functional Approach,” January 2014
- ↑ Texas Department of State Health Services, "Table 5:Resident Infant, Maternal, And Fetal Deaths Texas, 1970-2013," accessed September 6, 2016
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