How Texas Tweaked Their Terrible Maternal Mortality Data

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Hey, you know how in every video I make about abortion bans, I mention the fact that the data shows when you restrict access to abortion, the number of abortions doesn’t decrease but the number of dead women does. Well, now that various states are free to ban abortion, we have even more data to test that hypothesis. Yay for data I guess? And yeah, spoiler alert: restricting access to abortion only hurts more people.

If you’ll recall, back in May of 2019, Texas instituted a ban on abortion after 22 weeks, one of the most restrictive antiabortion laws in the country at the time. There’s always going to be a bit of delay in crunching data so it’s taken until 2022 for us to see how this affected maternal mortality. Texas’s Maternal Mortality and Morbidity Review Committee has been issuing reports for the past five years, and obviously this year’s was going to be very important: not only would it finally be covering maternal mortality from the year 2019, but it was also due to come out in September of 2022, several months after Texas banned abortion entirely and several months before the critical midterm elections.

UNFORTUNATELY, and this is just so unfortunate and random and weird and unexpected, but for some completely unknown reason that report was delayed until well after the midterms were over and done with. In fact, they JUST released it now, in December, right before everyone goes on vacation. Weird! And unfortunate!

Because it turns out that yeah, shit got pretty grim in Texas that year

Severe complications in pregnancy and childbirth increased significantly between 2018 and 2020, from 58.2 to 72.7 cases per 10,000 deliveries. At least 118 women died, and 90% of those deaths were considered preventable by the committee. Black patients saw the worst of it all, with inequality between them and White people getting worse: Black people saw a 10% increase in complications and were twice as likely to die in childbirth compared to White people.

Of course, the report wasn’t ALL bad news: the committee found that prior to the abortion ban, “the enhanced maternal mortality ratio remained relatively stable from 2013-2017.” Now, normally I would not have even noticed this – I’m more interested in what happens to mortality after abortion was banned in the state. But it came to my attention thanks to a post from the Redditor “Lightning” on r/skeptic, which points out the use of the word “enhanced” in that data. Lightning asserts a number of things, some of which I found to be valid after a lot of research. Some of them not so much.

Let’s start with their very valid main point: the committee collected maternal mortality data in a nonstandard way that makes the data impossible to compare to other states or countries. The CDC and World Health Organization consider pregnancy-related deaths and pregnancy-related morbidity to be those cases that occur during pregnancy, delivery, or within 42 days of the end of pregnancy, which probably would not have occurred had the patient not been pregnant. “Morbidity” in this case means severe conditions that, if left untreated, would likely result in the death of the patient.

It’s worth noting that “42 days” post-pregnancy is kind of a random time period, so some researchers push for the data to be considered up to a year post-pregnancy. What’s important is consistency when comparing these figures, since obviously those that follow patients for a year are going to have higher rates.

And that’s a good introduction to Texas’s “enhanced” mortality rates. As with “42” versus “365” days post-pregnancy, there are other ways that organizations like the CDC try to get everyone on the same page so we can compare data from different regions: for instance, the CDC provides a very clear standard for states to follow when reporting this data. Back in 2003 researchers suspected that maternal deaths were being undercounted, so they recommended all states add a simple checkbox to death certificates that would indicate if the deceased had been pregnant within that suggested time period. 

That suggestion was instituted by all states, but there were some hiccups: it took some states a few years to get it done, which meant that the data wasn’t directly comparable between all states between 2003 and 2017 when the last state finally did it. The National Center for Health Statistics (NCHS) found that the checkbox DID improve the accuracy of maternal mortality data, with about twice as many deaths caught with the checkbox. However, “NCHS also found that while the addition of the checkbox allowed more pregnancies to be identified, it also likely introduced errors and overcounting with increasing age. For example, in deaths to women over age 44, NCHS found the rates were as much as 124.1 times those of younger women, and that in many of these cases, there was no accompanying cause-of-death information that supported the conclusion that the death was likely related to pregnancy.”

When Texas introduced the checkbox in 2010, the state saw the maternal mortality rate jumped so much it became big news and politicians started caring about the issue. That can’t happen! Someone debunk these numbers, stat!

Just kidding, but the state did publish a study that appeared to show that most of that jump was due to human error: specifically, authorities clicking that checkbox when the deceased was not, in fact, pregnant.

From what I can tell, it seems that researchers accept that study: there really were a ton of screwups due to a confusing online portal. Presumably that process has been fixed in the past decade, but Texas is still trying to improve those numbers. Whether you think “improve” means “make them more accurate” or “make Texas look less horrible” is up to you, gentle viewer. I honestly cannot tell you, but I can tell you that this new report outright states that Texas’s new “enhanced” maternal mortality “is different from methods used by others to calculate maternal mortality rates or ratios. Therefore, calculated enhanced maternal mortality ratios cannot be compared with other maternal mortality rates or ratios.”

Basically, the researchers took all of the deaths that would normally be included in maternal mortality figures and examined them to figure out whether they should really count. Thus, for 2016, 126 maternal deaths based on death certificates was thinned down to 55, and then that number was actually boosted to 82 by examining the deaths of about 90,000 other Texas women to see if any were missed in the death certificates. So you can see to Texas’s credit it’s not just a one-way “improvement.”

But when we look at the “enhanced” numbers preferred by Texas compared to the “standard” numbers preferred by the CDC, for every single year they are significantly lower: 32.5 standard deaths per 100,000 in 2013 compared to 18.9 “enhanced” deaths. In 2014, 32 to 20.7, then 29.2 to 18.3, 31.7 to 20.7, and 33.5 to 20.2 for 2017. Again to Texas’s credit, the numbers are still pretty consistent over the years. So they have that going for them.

It’s a bit difficult to suss out exactly which cases Texas decided shouldn’t count, but one thing they call out is blood transfusions. That’s a number that some researchers believe overly inflates the maternal morbidity numbers, since it’s the most common emergency procedure on the CDC’s list of indicators, but it doesn’t necessarily mean that the patient is going to die without it. Because of that, transfusions are usually included in the data but also called out as a separate item so you can see the numbers with and without them.

The Texas report also seems to dismiss traffic accidents, unless they’re ruled homicide or suicide. But it does make me wonder how many of the people who died in those accidents would NOT have died if they weren’t pregnant? And moving forward now that abortion is banned in Texas and doctors are required to make truly horrific decisions in life-saving situations, how many of those people were denied medical care in order to prioritize the life of the fetus?

The report is damning even aside from those numbers, but I do appreciate Lightning calling attention to this new “enhanced” maternal mortality and morbidity rate. It means that we can no longer directly compare Texas’s rate to other states, even though the “enhanced” rate would still make Texas worse than California, Illinois, Colorado, Maryland, Massachusetts, Michigan, Nevada, and Pennsylvania, and tied with New York. It will be extremely important to keep that in mind in the coming years when we have more data about how many people will have died thanks to Texas banning abortion this year.

I’ll end with a quick correction: only because I’m thanking that Redditor and pointing to their post, I want to say that they got a few things wrong. Vehicular homicides ARE apparently counted in the “enhanced” data; the fact that they included extra maternal deaths from all females ages 5 and up doesn’t make the data worse, it actually makes it MORE accurate – yes, 5-year olds rarely get pregnant but this is the pool from which they were ADDING excessive deaths that weren’t caught on the death certificates so a wider pool is a good thing; and finally, “probabilistic linkage”  doesn’t mean they’re just making things up – it is an accepted scientific method in which researchers use statistical probabilities to say “this death record most likely matches this birth record,” increasing the chances that a maternal death will be included.

Not huge deals for a Reddit post but because I’m linking to it I just want to be sure we’re being as accurate as possible. I’m annoying like that. 

Anyway, that’s it for today! Please stay safe, especially if you are a person with a working uterus in Texas or one of the many other states where your bodily autonomy has been forcibly removed. 

Rebecca Watson

Rebecca is a writer, speaker, YouTube personality, and unrepentant science nerd. In addition to founding and continuing to run Skepchick, she hosts Quiz-o-Tron, a monthly science-themed quiz show and podcast that pits comedians against nerds. There is an asteroid named in her honor. Twitter @rebeccawatson Mastodon Instagram @actuallyrebeccawatson TikTok @actuallyrebeccawatson YouTube @rebeccawatson BlueSky

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