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Nakinya Wilson was at a meeting of the Texas Maternal Mortality Review Board when she got the call: her sister, who had recently given birth to a baby, was having a stroke.
Wilson rushed to the hospital, leaving behind a pile of files documenting the stories of women who died from pregnancy and childbirth complications. Many of the women in those files were black, just like Wilson, who herself had experienced a traumatic birth.
“The whole thing just reminded me that if you change the name of these files, it could be me. It could be my sister,” said Wilson, who serves as the community representative on the commission.
A decade ago, when Texas first formed the Maternal Mortality and Morbidity Review Committee, black women were twice as likely to die from pregnancy and childbirth as white women and four times as likely as Hispanic women.
Those differences have not improved, according to the commission’s latest report, released Thursday.
In 2020, pregnant black women were twice as likely to experience critical health problems such as hemorrhage, preeclampsia, and sepsis. While obstetric hemorrhage complications have declined overall in Texas in recent years, black women have seen an increase of nearly 10 percent.
Wilson said these statistics show the impact of a health care system that is biased against black women.
“We’re still dying and disproportionately affected by hemorrhage while everyone else is getting better,” Wilson said. “Not only did it not get better, it didn’t stay the same – it got worse.”
The reasons for these discrepancies are not always easy to identify, and even more difficult to correct. This is a combination of reduced access to health care, systemic racism and the impact of the “social determinants of health” – the conditions in which someone is born, lives, works and grows up.
Wilson said she and her sister are prime examples. They grew up in poverty, without health insurance, routine doctor visits, or consistent access to healthy food.
“We started behind the ball,” she said. “So many difficult things happened to us that contributed to our health while we were of childbearing age.”
Maternal health advocates in Texas say addressing these disparities will take more than adjusting labor and delivery practices. This will require building a comprehensive health care system that meets the needs of the community in all areas, starting well before pregnancy.
In the end, Wilson’s sister survived her postpartum health scare. But the experience reminded Wilson why she volunteers her time to read, review and analyze stories of women who have died in pregnancy and childbirth.
“When you look at the work that marginalized people do, they do it because they don’t feel like they have a choice,” she said. “If we want to see things change and we want to be safe, we have to stand up for our own safety.”
For more than three months, D’Andra Willis waited for the state’s maternal mortality report to be released. As a doula at The Afiya Center, a black-run reproductive rights organization in North Texas, Willis has been a vocal advocate for black maternal health. Doulas are trained professionals who help pregnant women, physically and emotionally, during childbirth.
But when the report was finally released Thursday, Willis didn’t rush to read it. She was busy convincing one of her pregnant clients to go to the hospital and didn’t need more evidence that the health care system was biased against black women, she said.
Her client had other children to juggle and, after previous experiences, was worried about how she would be treated in the emergency room.
“She’s afraid to go, and she needs to go,” Willis said. “She is fighting for her life. … I can see that happening.”
For the first time, the review panel looked at discrimination as a contributing factor to maternal deaths, finding it played a role in 12 percent of deaths in 2019. Wilson said that was likely just the tip of the iceberg.
“That’s 12% determined by the system we use now,” she said. “Does that capture it all? Probably not.”
Dr. Rakhi Dimino, an obstetrician-gynecologist in Houston, said discrimination often manifests itself in subtle ways that may not be obvious to the health care provider, but have a huge impact on the patient.
“If you asked a hospital, ‘Do you have a staff member who is racist?’ they would say, ‘No, we would never allow that,'” she said. “But it’s not always these obvious situations. It’s in the smaller conversations, in the notes, in the chart, and that can be just as dangerous.
She said patients were sometimes booked as non-compliant or leaving against medical advice. But when doctors take the time to talk to them, they learn that they have to be home to meet the school bus, or that they can’t get a ride to a specialist’s office across town.
“These are barriers that we can overcome if we are willing to do so,” she said.
One of the commission’s recommendations was to diversify the state’s maternal health workforce. Willis also wants to see more black women using doulas who can advocate for a pregnant patient who may be experiencing discrimination.
State Rep. Sean Thierry, D-Houston, has introduced a bill for the upcoming legislative session that would require health care providers and medical students to be trained in cultural competency and implicit bias.
“In practice, a lot of it happens on an unconscious, subconscious level,” Thierry said. “We’ll never be able to fix it until we start identifying it.” This is the elephant in the room.
Access to healthcare
Almost two-thirds of black women are on Medicaid when they give birth, compared to less than one-third of white women. The report found that women without private health insurance were at particularly high risk of severe maternal morbidity.
Women without permanent health insurance are less likely to access timely prenatal care, which contributes to pregnancy and birth complications, and are more likely to have other health complications, including obesity and gestational diabetes.
Until recently, women who gave birth on Medicaid in Texas lost their health insurance after two months. The report found that 15% of maternal deaths occurred more than 43 days after birth.
In 2021, the Texas House voted to extend postpartum care for 12 months, the main recommendation of the Maternal Mortality Commission. The Senate reduced it to six months; the federal government said the proposal was “unacceptable” in its current form.
No one is currently being moved from Medicaid because of the pandemic public health emergency, giving lawmakers a second chance to pass 12 months of postpartum Medicaid before anyone loses coverage.
Thierry said this proposal should be an easy win for both lawmakers and black women.
“However, our work does not stop there,” she said. “It is critical that the Texas Legislature understands that this is not enough.”
Thierry is preparing what she calls the “Momnibus,” a package of bills aimed at expanding access to health care, collecting better information and strengthening the maternal mortality review process. The bills aim to improve maternal health everywhere, but with a special focus on the experiences of black women.
“Black women should not be a footnote in this report,” she said. “We are the report. This is my takeaway.”
Thierry, who is black, has first-hand experience with these issues. While she was undergoing an emergency C-section, a doctor placed the epidural too high. She knew something was wrong and asked to be put under anesthesia, which likely saved her life, she said.
For years she blamed herself and kept quiet about what she had experienced. It wasn’t until she was elected to the Texas Legislature in 2017 and read the Maternal Mortality Report that she began to put her experience into a larger context.
“I almost died. They treated me terribly. No one saw me,” she said. “I don’t think a woman has to be a sitting member of the Texas Legislature to feel comfortable sharing her story.”
Legislation after Roe
The data in the latest maternal mortality report is from 2019, nearly three years before Texas became the largest state in the nation to ban nearly all abortions. These bans are expected to have a disproportionate impact on black women, who nationally account for about 40% of all abortions.
One study from the University of Colorado Boulder estimated that a national abortion ban would lead to a 24 percent increase in maternal mortality, with black women experiencing the steepest increase of 39 percent.
Of particular concern is the treatment of ectopic pregnancy, which occurs when a fertilized egg implants outside the uterus and is life-threatening if left untreated. Ruptured ectopic pregnancies were the leading cause of obstetric hemorrhage deaths in Texas in 2019, the report said.
Although ectopic pregnancies are specifically exempted from Texas abortion laws, doctors reportedly delay caring for these non-viable pregnancies due to confusion and fear. According to a letter from the Texas Medical Association, a central Texas doctor was instructed by his hospital not to treat an ectopic pregnancy until it ruptured.
Dimino, the Houston obstetrician-gynecologist, said the new laws make doctors extra cautious, which inevitably leads to delays.
“We’re taking them further out than before, instead of providing treatment based on the best evidence we have,” she said. “If a woman is at home, for a week, that pregnancy can grow and open and you end up in a life-threatening or life-threatening situation.”
Kiana Arnold, a doula at The Afiya Center, said she is particularly concerned, in light of the new abortion bans, to see what happens to the number of women who die by homicide or suicide. In 2019, violence accounted for 27% of pregnancy-related deaths.
“People are going to kill themselves,” she said. “People will kill themselves because they don’t want to have this child.”
In the first legislative session since Roe, which begins Jan. 9, Democrats hope proposals to improve maternal health will gain more traction than before.
“I hope all my colleagues in the legislature will stand up and say it’s time to prioritize black mothers,” Thierry said. “These are the women who bring life, but they don’t have to do it in exchange for their own.”
Disclosure: The Texas Medical Association and the Afiya Center are financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in Tribune journalism. Find a full list of them here.