Why are pregnancy and childbirth killing so many Black women in Texas?

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Nakeenya Wilson was at a meeting of Texas’ maternal mortality review committee when she got the call: Her sister, who had recently had a baby, was having a stroke.

Wilson raced to the hospital, leaving behind a stack of files documenting the stories of women who had died from pregnancy and childbirth complications. Many of the women in those files were Black, just like Wilson, who experienced a traumatic delivery herself.

“The whole thing just reminded me, if you change the name on those files, it could be me. It could be my sister,” said Wilson, who serves as the committee’s community representative.

A decade ago, when Texas first formed the Maternal Mortality and Morbidity Review Committee, Black women were twice as likely as white women, and four times as likely as Hispanic women, to die from pregnancy and childbirth.

Those disparities haven’t improved, according to the committee’s latest report, published Thursday.

In 2020, pregnant Black women were twice as likely to experience critical health issues like hemorrhage, preeclampsia and sepsis. While complications from obstetric hemorrhage declined overall in Texas in recent years, Black women saw an increase of nearly 10%.

Wilson said these statistics show the impact of a health care system that is biased against Black women.

“We’re still dying and being disproportionately impacted by hemorrhage when everybody else is getting better,” Wilson said. “Not only did it not improve, it didn’t stay the same — it got worse.”

The causes of these disparities aren’t always simple to identify, and they’re even harder to fix. It’s a combination of diminished health care access, systemic racism, and the impact of “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’s visits or consistent access to healthy food.

“We started behind the ball,” she said. “We’ve had so many hard things happen to us that have contributed to our health by the time we’re of childbearing age.”

Maternal health advocates in Texas say addressing these disparities will take more than fixing labor and delivery practices. It will require building a comprehensive health care system that addresses a community’s needs across the board, starting long 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 from pregnancy and childbirth.

“When you look at the work marginalized people do, they do it because they don’t feel like they have any choice,” she said. “If we want to see things change, and we want to be safe, we have to advocate for our own safety.”

Implicit bias

For more than three months, D’Andra Willis had been waiting for the release of the state’s maternal mortality report. As a doula with The Afiya Center, a Black-led reproductive rights organization in North Texas, Willis has been a vocal advocate for Black maternal health. Doulas are trained professionals who assist 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 trying to convince one of her pregnant clients to go to the hospital, and she didn’t need any more evidence that the health care system was stacked against Black women, she said.

Her client had other kids to juggle and, after previous experiences, was worried about how she’d be treated at the emergency room.

“She’s scared to go, and she needs to go,” Willis said. “She’s fighting for her life. … I see how this happens.”

For the first time, the review committee considered discrimination as a contributing factor to maternal death, finding it played a role in 12% of deaths in 2019. Wilson said that’s likely just the tip of the iceberg.

“That’s 12% as definable by the system we currently use,” she said. “Does that capture everything? Probably not.”

Dr. Rakhi Dimino, an OB-GYN in Houston, said discrimination often shows up in subtle ways that may not be apparent to a health care provider — but make a huge impact on the patient.

“If you asked a hospital, ‘Do you have an employee on staff who is racist?’ they would say, ‘No, we would never allow that,’” she said. “But it’s not always those obvious situations. It’s in the smaller conversations, in the notes, in the chart, and that can be just as dangerous.”

She said patients are sometimes recorded as noncompliant, or leaving against medical advice. But when doctors take time to talk with them, they learn that they have to be home to meet the school bus, or can’t get transportation to a specialist’s office across town.

“These are barriers we can solve for, if we are open to doing so,” she said.

One of the committee’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. Shawn 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 biases.

“In practice, much of this is happening on the unconscious, on the subconscious level,” Thierry said. “We’re never going to be able to correct it until we begin to identify it. It’s the elephant in the room.”

Health care access

Almost two-thirds of Black women are on Medicaid when they give birth, compared with less than a third of white women. The report found women without private-pay health insurance were at a particularly elevated risk for severe maternal morbidity.

Women without consistent health insurance are less likely to access timely prenatal care, contributing to pregnancy and childbirth complications, and more likely to have other health complications, including obesity and gestational diabetes.

Until recently, women who delivered on Medicaid in Texas lost their health insurance after two months. The report found that 15% of maternal deaths happened more than 43 days after childbirth.

In 2021, the Texas House voted to expand postpartum Medicaid for 12 months, the maternal mortality committee’s top recommendation. The Senate knocked it down to six months; the federal government has said that proposal is “not approvable” in its current form.

Currently, no one is being moved off of Medicaid due to the pandemic public health emergency, giving lawmakers a second chance at passing 12 months of postpartum Medicaid before anyone loses coverage.

Thierry said this proposal should be an easy win for lawmakers and Black women alike.

“However, our work does not stop there,” she said. “It is incredibly important that the Texas Legislature understand that that is not enough.”

Thierry is preparing what she’s calling the “Momnibus” — a package of bills aimed at expanding health care access, gathering better information and strengthening the maternal mortality review process. The bills are aimed at improving maternal health across the board, but with special attention to the experiences of Black women.

“Black women should not be a footnote in this report,” she said. “We are the report. That’s my takeaway.”

Thierry, who is Black, has firsthand experience with these issues. While she was undergoing an emergency C-section, a doctor placed the epidural too high. She knew something wasn’t right and begged to be put under anesthesia, which likely saved her life, she said.

For years, she blamed herself and kept quiet about her experience. It wasn’t until she was elected to the Texas Legislature in 2017 and read the maternal mortality report that she started to put her experiences in a larger context.

“I almost died. I was treated terribly. No one saw me,” she said. “I don’t think a woman should have to be a sitting member of the Texas Legislature to feel comfortable sharing their story.”

Post-Roe legislation

The data in the latest maternal mortality report is from 2019, almost 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 estimates that a national abortion ban would lead to a 24% increase in maternal mortality, with Black women experiencing the sharpest increase, at 39%.

A particular concern is the treatment of ectopic pregnancies, which occur when a fertilized egg implants outside the uterus and are life-threatening if left untreated. Ruptured ectopic pregnancies were the leading cause of obstetric hemorrhage deaths in Texas in 2019, the report found.

While ectopic pregnancies are specifically exempt from Texas’s abortion laws, doctors are reportedly delaying care of these nonviable pregnancies due to confusion and fear. According to a letter from the Texas Medical Association, one Central Texas physician was instructed by their hospital to not treat an ectopic pregnancy until a rupture occurred.

Dimino, the Houston OB-GYN, said the new laws are making doctors extra cautious, which inevitably leads to delays.

“We're taking these further out than we used to, instead of providing treatment based on the best evidence that we have,” she said. “If a woman is at home, over a week’s time, this pregnancy can grow and burst open, and you end up with a life-threatening or life-ending situation.”

Qiana Arnold, a doula with The Afiya Center, said she’s particularly anxious, in light of the new abortion bans, to see what happens to the number of women who die due to 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 did not want to have that child.”

In the first post-Roe legislative session, which starts Jan. 9, Democrats are hopeful that proposals to improve maternal health will get more traction than before.

“It is my hope that all of my colleagues in the Legislature will stand and say it is time to prioritize Black mothers,” Thierry said. “These are the women that are bearing life, but they should not have to do so in exchange for their own.”

Disclosure: The Texas Medical Association and The Afiya Center have been 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 the Tribune’s journalism. Find a complete list of them here.