By Perdita Henry
In 2017, the Houston Endowment convened a steering committee with leaders with backgrounds in healthcare, behavioral health, social services, research, business, government and philanthropy, to understand more about the maternal mortality and morbidity rates in Harris County.
“The goal of the planning process was to develop a comprehensive, long-term strategy that incorporates clinical, community-based and systems change strategies; capitalizes on existing initiatives and funding streams; tests innovative methodologies; and embraces advocacy when necessary,” Director of Improving Maternal Health, Alicia Lee says.
In 2018, the Improving Maternal Health in Harris County: A Community Plan was released. In it, the committee laid out nine recommendations that aimed to improve women’s overall health, with special attention focused on the prenatal, intrapartum, and postpartum time frame.
“The most significant recommendation from the Community Plan was to shift the focus of our community efforts from reacting to postpartum issues to putting greater emphasis on prevention and prenatal care,” Lee says. “This can be done by increasing awareness about the issue, improving the overall health of women, ensuring that women access prenatal care sooner, and recognizing the critical role of providing culturally-appropriate care, mental healthcare, and social support to women during and after pregnancy.”
In the two years since the community plan’s release, the Improving Maternal Health initiative has advocated for the improvement of the general health of all women by increasing access to primary health services, created awareness strands to support and encourage women to prioritize and care for their own health, developed a data registry pilot project to improve data collection and analysis on women’s health, addressed implicit bias in maternal health, and much more. It’s why I wanted to sit down with Lee to talk about what these things mean to the Houston community health and Texas as a whole.
You all recently launched the Mothers First series. Why were you inspired to record the stories of mothers who’ve faced implicit bias in the healthcare system?
Implicit bias is unconscious stereotyping – it happens below the level of conscious thought and thus is extremely difficult to recognize and control. While evidence suggests that healthcare providers experience implicit bias at the same level as the rest of the U.S. population, the consequences of implicit bias in the healthcare sector can be profound. In its groundbreaking 2003 report, Unequal Treatment, the U.S. Institute of Medicine concluded that unrecognized bias by healthcare providers adversely affects their communication with, and the care they offer to, members of stereotyped groups, including Black people, people in poverty, and women. Hundreds of research studies have since supported that conclusion, demonstrating that implicit bias related to gender, income, and race results in significant disparities in care, especially for Black women.
These disparities can affect women in many aspects of their life. For example, implicit bias causes Black women to experience more stress throughout their lifetimes, which adversely affects their health. Their reproductive health may also be impacted; social and demographic biases have been shown to affect practitioners’ recommendations for long-acting reversible contraceptive (LARCs) methods. Providers are more likely to recommend a LARC to Black and Latina women of low socioeconomic status than to white women with low socioeconomic status.
During labor, Black women tend to be offered pain medication later than white women. Black women are also less likely to be diagnosed and appropriately treated for heart disease, which is a leading cause of maternal death, both before and after delivery. Postpartum depression and anxiety are also under-diagnosed and undertreated in Black women.
Most recently, researchers in The Giving Voice to Mothers study found 1 in 6 pregnant women has reported experiencing one or more types of mistreatment such as: loss of autonomy; being shouted at, scolded, or threatened; and being ignored, refused, or receiving no response to requests for help. They also found that mistreatment is experienced more frequently by women of color, when birth occurs in hospitals, and among those with social, economic or health challenges.
None of this is surprising to the more than 50 women we spoke with during the research and planning phase for development of the Community Plan. We observed that women from different race/ethnic groups experienced a stark contrast with providers. Among participants, African-American women were more likely to cite a lack of empathy or care in their exchanges with providers than Latina and white participants.
It’s important for women to speak up for themselves, to have a list of questions to ask the doctor, and if she doesn’t like what she is experiencing, to find a new healthcare provider. A recent education guide from the New York Times, Protecting Your Birth: A Guide for Black Mothers: How racism can impact your pre- and postnatal care — and advice for speaking to your Ob-Gyn about it, written by a doula and an obstetrical and gynecological physician, offers pregnant Black women agency when planning their care.
What are some of the reasons for the high maternal mortality rate in Houston?
We know across the country, in the United States, maternal deaths are happening at roughly one-third during pregnancy, one-third during delivery and up to one week postpartum, and one-third between one week and 365 days postpartum. That’s not the case in Texas, though. From 2012 – 2015, the supermajority of maternal deaths happened after one week postpartum, with more than half of all deaths occurring 60 to 365 days after a woman has delivered.
We also know that maternal mortality rates are only part of the story; that is, maternal deaths are a tragic outcome related to a much bigger problem. Every maternal death started as a complication, and life-threatening complications are as much as 50 times more common than maternal death. Between 2008 and 2015, the rate of severe maternal morbidity in Harris County increased by 53 percent, greater than the overall increase across Texas of 15 percent.
In Houston/Harris County, we believe several factors are contributing to the rise in severe maternal morbidity and ultimately maternal mortality:
The health of women before pregnancy is compromised by multiple unmanaged or untreated health problems. These conditions can be the source of severe complications during childbirth or after delivery, threatening the lives of women;
Reproductive health has become so disconnected from women’s general health that it’s often not included in women’s regular primary care, which limits women’s access to critical health services;
Barriers to enrollment in publicly funded insurance and confusion about insurance coverage play a detrimental role in maternal health;
While many innovative programs to improve the quality of maternal healthcare are in place in Harris County, these practices need to be adopted by more providers to have a greater impact;
Safety-net providers do not appear to be providers of choice for many women seeking obstetric care;
In subtle and unintentional ways, women’s health has been subjugated to the health of babies so profoundly that the health of women of childbearing age is often not prioritized; and
The high rate of disparities in care and outcomes for Black women is driven in part by implicit bias around women, income and race that is endemic throughout the healthcare system.
Will you advocate during the upcoming 87th legislative Session? If so, what are some of the policy priorities you plan to champion?
The greatest opportunity to improve maternal and infant health occurs before and after a woman becomes pregnant. Unfortunately, in Texas, the lack of affordable options for health coverage and the state’s limited Medicaid eligibility requirements have impeded the ability of low-income, childless women to find coverage, allowing potentially treatable conditions to worsen until pregnancy is already established. As a result, uninsured women enter pregnancy in poor health with chronic conditions (e.g., pre-pregnancy obesity, diabetes, and hypertension) that increase the risk of poor maternal health outcomes. After delivery of the baby, many women in Texas lose health coverage and are no longer able to receive care from their healthcare providers. Between 2015 – 2016, nearly 30 percent of new mothers in Texas were uninsured, the highest rate in the country.
The State of Texas should expand Medicaid eligibility to remove the barriers to coverage that low-income women face, so that they may have access to continuous care before pregnancy, during pregnancy, and after delivery.
Recent studies have shown states with Medicaid expansion were shown to have 1.6 fewer deaths per 100,000 pregnant or postpartum people, a meaningful decrease. Expanded Medicaid coverage also led to improvements in addressing certain preconception health risks among low income women, including increased preconception health counseling, increased folic acid intake the month before conception, and effective postpartum contraception use.
How would including coverage for doula services through Medicaid improve health outcomes for mothers and infants?
A doula, sometimes referred to as a birth coach or birth companion, is a trained professional who provides continuous support for women before, during, and after childbirth. They offer education, as well as physical and emotional support, to mothers.
A growing body of evidence suggests continuous support during pregnancy reduces the likelihood of adverse birth outcomes for mother and baby. Women receiving doula services throughout their pregnancy are less likely to have a caesarean birth (a 28 percent reduction in caesarean births on average), lower odds of preterm birth, require less pharmaceutical care during delivery, and spend less time in labor. The negative birth outcomes and procedures that are averted as a result of doula services add up to significant cost savings for hospitals, insurers, and state health programs.
Why is it important for your organization to be a TWHC member?
Being part of a statewide collaborative allows us to be part of the larger community addressing women’s health issues. Cross-sector legislative issues need to be addressed at the state level, and if we can all work in concert with each other, we can lift all Texas women. While we can bring the perspective from Houston and Harris County, we know we need all voices to be together in working to ensure we have a statewide health coverage program for low-income postpartum women that has a robust, diversified provider network.
What does an ideal future for women’s health look like according to Improving Maternal Health Houston?
The ideal future for a woman would be one where she is healthy both physically and mentally prior to pregnancy. She has access to and receives high-quality, respectful, unbiased, nonjudgmental care before, during, and after her pregnancy; and she is prepared for the postpartum experience during her prenatal care. She has connections to social services resources that meet her social determinants of health needs, as prioritized by the woman. During a woman’s interconception care, reproductive health and contraceptive care would be completely integrated into primary care, with women having autonomy to make their own decisions.