Texas’ maternal mortality ratio significantly lower than reported, but disparity still exists

April 10, 2018

After two independent studies were published two years ago suggesting that the maternal mortality ratio (MMR) in Texas had doubled within the past decade, an updated report released today in the journal Obstetrics & Gynecology found that the MMR in Texas was significantly lower in 2012 than previously reported due to data collection error. The identification of this error illustrates an important role of the maternal mortality review process – ensuring accurate data on which to base interventions.

Comprised of 15 Texas-based multidisciplinary experts and chaired by Dr. Lisa Hollier, chief medical officer at Texas Children’s Health Plan and professor of obstetrics and gynecology at Baylor College of Medicine, the Maternal Mortality and Morbidity Review Task Force used an enhanced methodology that combined data matching and records review for identifying maternal deaths. After meticulously reviewing 2012 data, investigators determined that the MMR in Texas was 14 to 18 deaths per 100,000 versus the 37 deaths per 100,000 previously reported.

“Our analysis found there were data quality issues,” said Hollier, who also is president-elect of the American College of Obstetricians and Gynecologists. “When we examined the data, it showed that some deaths were mistakenly coded as “dying while pregnant,” when there was never a pregnancy. Beginning in 2010, Texas transitioned from paper to electronic death certificates, so unintentional user error in reporting pregnancy status may be responsible for the inaccurate data.”

Texas’ current electronic death registration system displays pregnancy status options as a dropdown list. The “pregnant at time of death” option is directly below the “not pregnant within past year” option. The investigators concluded that this could have led to erroneous selection, and could explain why pregnancy at time of death was reported for nearly 76 percent of the 74 obstetric-coded deaths with no evidence of pregnancy upon review.

The task force determined that a total of 56 Texas resident maternal deaths occurred during pregnancy or within 42 days postpartum in 2012. The most common causes for these deaths were drug overdose and cardiac events.

While the MMR is lower than initially reported, the updated report confirms a vast disparity still exists – black women had a higher MMR (27.8 per 100,000 live births) than did women of other racial and ethnic groups. Black women in Texas have more than double the risk of dying during pregnancy or within 42 days postpartum.

As one of the nation’s premier facilities for women’s, fetal and newborn health, Texas Children’s Pavilion for Women remains actively involved in grassroots advocacy at state and national levels with the goal of improving health outcomes, quality of care and patient safety for women and newborns across Texas and the nation.

Through the efforts of the Maternal Mortality and Morbidity Review Task Force, Texas Children’s maternal-fetal medicine physician leadership is helping to review cases and study trends in maternal deaths so that we can better understand the problem and make recommendations to help reduce the MMR across Texas.

While these results published in the new report likely have national implications – since miscoding of obstetric deaths may occur in other states and affect the accuracy of their MMRs – the updated data demonstrates that Texas is more in the middle of the pack when it comes to MMRs across the nation.

“We believe future efforts should focus on improving the quality of death certificate data, especially pregnancy status,” Hollier said. “It is also critically important we don’t lose the unfortunate truth that even this updated data demonstrates a huge disparity between the MMRs faced by black women compared to women of other racial and ethnic groups. We need to continue work to identify why this disparity exists and create strategies to remedy it.”

Click here to read the report in the medical journal Obstetrics & Gynecology.