Maternal healthcare in Texas

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Mother and newborn sharing a moment. Mother and newborn sharing a moment.jpg
Mother and newborn sharing a moment.

Maternal healthcare in Texas refers to the provision of family planning services, abortion options, pregnancy-related services, and physical and mental well-being care for women during the prenatal and postpartum periods. The provision of maternal health services in each state can prevent and reduce the incidence of maternal morbidity and mortality and fetal death. [1] [2]

Family planning planning of when to have children, and the use of birth control and other techniques to implement such plans

Family planning services are defined as "educational, comprehensive medical or social activities which enable individuals, including minors, to determine freely the number and spacing of their children and to select the means by which this may be achieved". Family planning may involve consideration of the number of children a woman wishes to have, including the choice to have no children, as well as the age at which she wishes to have them. These matters are influenced by external factors such as marital situation, career considerations, financial position, any disabilities that may affect their ability to have children and raise them, besides many other considerations. If sexually active, family planning may involve the use of contraception and other techniques to control the timing of reproduction. Other techniques commonly used include sexuality education, prevention and management of sexually transmitted infections, pre-conception counseling and management, and infertility management. Family planning as defined by the United Nations and the World Health Organization encompasses services leading up to conception and does not promote abortion as a family planning method, although levels of contraceptive use reduces the need for abortion.

Abortion is the ending of a pregnancy by removal or expulsion of an embryo or fetus before it can survive outside the uterus. An abortion that occurs without intervention is known as a miscarriage or spontaneous abortion. When deliberate steps are taken to end a pregnancy, it is called an induced abortion, or less frequently "induced miscarriage". The unmodified word abortion generally refers to an induced abortion. A similar procedure after the fetus has potential to survive outside the womb is known as a "late termination of pregnancy" or less accurately as a "late term abortion".

Pregnancy time when children develop inside the mothers body before birth

Pregnancy, also known as gestation, is the time during which one or more offspring develops inside a woman. A multiple pregnancy involves more than one offspring, such as with twins. Pregnancy can occur by sexual intercourse or assisted reproductive technology. Childbirth typically occurs around 40 weeks from the last menstrual period (LMP). This is just over nine months, where each month averages 31 days. When measured from fertilization it is about 38 weeks. An embryo is the developing offspring during the first eight weeks following fertilization, after which, the term fetus is used until birth. Symptoms of early pregnancy may include missed periods, tender breasts, nausea and vomiting, hunger, and frequent urination. Pregnancy may be confirmed with a pregnancy test.


The maternal healthcare system in Texas has undergone legislative changes in funding and the provision of family planning and abortion services, in relation to other states in the United States. The system in Texas has also received attention in regards to the state's maternal mortality ratio, currently the highest in the United States. [3] Maternal deaths have steadily increased in Texas from 2010, with more than 30 deaths occurring for every 100,000 live births in 2014. [4] The diverse demography of Texas has been identified as one factor contributing to this mortality rate, with mortality being higher among ethnic minorities such as African-American and Hispanic women. [5] In 2013, Texas legislation established the Maternal Mortality and Morbidity Task Force to begin investigating the causes of the maternal mortality rates in the state as well as suggesting ways in which it could be reduced or averted.

Texas State of the United States of America

Texas is the second largest state in the United States by both area and population. Geographically located in the South Central region of the country, Texas shares borders with the U.S. states of Louisiana to the east, Arkansas to the northeast, Oklahoma to the north, New Mexico to the west, and the Mexican states of Chihuahua, Coahuila, Nuevo León, and Tamaulipas to the southwest, while the Gulf of Mexico is to the southeast.

Maternal death the death of a woman while pregnant or within 42 days of termination of pregnancy

Maternal death or maternal mortality is defined by the World Health Organization (WHO) as "the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes."

Maternal Mortality and Morbidity Task Force long-term research team in Texas; part of Department of State Health Services

The Maternal Mortality and Morbidity Task Force was started by the Department of State in 2013 to help reduce maternal death in Texas. The task force and DSHS must submit a joint report on the findings of the task force and recommendations to the governor, lieutenant governor, speaker of the House of Representatives, and appropriate committees of the Texas Legislature by September 1 of each even-numbered year, beginning September 1, 2016. The maternal mortality ratio (MMR) for the state of Texas was concluded to be the highest in the developed world in 2016, with the maternal mortality rate (MMRate) of the state surging beyond the poor MMRate of 48 states of the US at 23.8% to a remarkably high 35.8%.

Family Planning Services

In the late 1900s, the importance of family planning services captured the attention of healthcare professionals and policy makers. The recognition that unintentional pregnancies had adverse health outcomes for mothers and increased costs of maternal and infant care coupled with ethical considerations led to the passage of Title X in 1970 and the creation of federal- and state-funded family planning programs. [6] [7] [8] Under Title X funding in Texas, family planning organizations participate in the 340B drug-pricing program, which reduces contraception costs by 50–80%. Under Title X regulations, clinics are also allowed to provide confidential family planning services to adolescents. [9]

The Title X Family Planning Program, officially known as Public Law 91-572 or "Population Research and Voluntary Family Planning Programs", was enacted under President Richard Nixon in 1970 as part of the Public Health Service Act. Title X is the only federal grant program dedicated solely to providing individuals with comprehensive family planning and related preventive health services. Title X is legally designed to prioritize the needs of low-income families or uninsured people who might not otherwise have access to these health care services. These services are provided to low-income and uninsured individuals at reduced or no cost. Its overall purpose is to promote positive birth outcomes and healthy families by allowing individuals to decide the number and spacing of their children.

The 340B Drug Discount Program is a US federal government program created in 1992 that requires drug manufacturers to provide outpatient drugs to eligible health care organizations and covered entities at significantly reduced prices. The intent of the program is to allow covered entities to "[s]tretch scarce federal resources as far as possible, reaching more eligible patients and providing more comprehensive services." Maintaining services and lowering medication costs for patients is consistent with the purpose of the program, which is named for the section authorizing it in the Public Health Service Act (PHSA) It was enacted by Congress as part of a larger bill signed into law by President George H. W. Bush.

Contraception and Screening

In 2007, the Health and Human Services Commission of Texas established the Women's Health Program (WHP), a Medicaid waiver program that received 90% of its funding from the federal level. [9] [10] The Program provided family planning services for women from the ages of 18–44 whose incomes were 185% below the federal poverty level. [9]

Medicaid United States social health care program for families and individuals with limited resources

Medicaid in the United States is a federal and state program that helps with medical costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, including nursing home care and personal care services. The Health Insurance Association of America describes Medicaid as "a government insurance program for persons of all ages whose income and resources are insufficient to pay for health care." Medicaid is the largest source of funding for medical and health-related services for people with low income in the United States, providing free health insurance to 74 million low-income and disabled people as of 2017. It is a means-tested program that is jointly funded by the state and federal governments and managed by the states, with each state currently having broad leeway to determine who is eligible for its implementation of the program. States are not required to participate in the program, although all have since 1982. Medicaid recipients must be U.S. citizens or qualified non-citizens, and may include low-income adults, their children, and people with certain disabilities. Poverty alone does not necessarily qualify someone for Medicaid.

Contraception methods Contraceptive Pills.jpg
Contraception methods

In September 2011, the program served ~119,000 low-income women. [9] In December 2011, the state of Texas established legislation that excluded family planning providers affiliated with abortion services, such as Planned Parenthood clinics, from the WHP. [9] [10] As a result, the federal government ruled this as a violation of federal law, and in March 2012, discontinued federal funding for the WHP. The WHP was then replaced with a program that was 100% funded by revenue from the state of Texas. [6] [9] [10]

Planned Parenthood a non-profit organization that provides reproductive health services in the United States and internationally

Planned Parenthood Federation of America, Inc. (PPFA), or Planned Parenthood, is a nonprofit organization that provides reproductive health care in the United States and globally. It is a tax-exempt corporation under Internal Revenue Code section 501(c)(3) and a member association of the International Planned Parenthood Federation (IPPF). PPFA has its roots in Brooklyn, New York, where Margaret Sanger opened the first birth control clinic in the U.S. in 1916. Sanger founded the American Birth Control League in 1921, which changed its name to Planned Parenthood in 1942.

The exclusion of Planned Parenthood clinics from the WHP was found to be associated with a reduced use of contraception by clients. [10] After the exclusion of Planned Parenthood clinics from the WHP, the claims in Planned Parenthood clinics for long-acting reversible contraception (LARC) reduced by 35.5% and the claims for injectable contraceptives reduced by 31.1%. [10] After the exclusion, there was also found to be an increase in childbirth covered under Medicaid from 7.0% to 8.4% in the counties with Planned Parenthood affiliates. [10]

Long-acting reversible contraceptives (LARC) are methods of birth control that provide effective contraception for an extended period without requiring user action. They include injections, intrauterine devices (IUDs) and subdermal contraceptive implants. They are the most effective reversible methods of contraception because they do not depend on patient compliance. So their 'typical use' failure rates, at less than 1% per year, are about the same as 'perfect use' failure rates.

In addition to the Women's Health Program, from September 2010 to August 2011, the Texas Department of State Health Services allocated $49.3 million in funding to private, public, and Planned Parenthood affiliated clinics through Title X, V, and XX funding to provide family planning services. [9]

In September 2011, preceding the exclusion of programs from WHP, the state of Texas reduced its family planning funding from $111.0 million to $37.9 million through the removal of Title V and Title XX block grants. [9] The funds were re-allocated away from family planning providers to other state and federal programs. With the remaining funding, family planning programs were organized into a 3-tiered system, with public agencies and federally funded health centers (tier 1) being prioritized over agencies that provided family planning services as a part of primary care (tier 2) and those that specialized in the provision of family planning services (tier 3). [6] [9] [10]

The reduction of the budget for family planning services and the creation of three-tiered program was associated with the closing of 82 family-planning clinics, with one third of the clinics being Planned Parenthood affiliates. [10] Without subsidized aid, fewer clinics were able to afford contraception, and as a result, reduced access to IUDs and implants for patients. [9] Clinics also began to reduce their service hours. With the loss of funding, clinics lost their participation in the 340B drug-pricing program, which had reduced contraception costs from 50 – 80%. [9] Clinics also lost their exemption status from a Texas law requiring parental consent for provision of family planning services to adolescents. Family planning organizations reported a 41–92% reduction in clients after the reduction and reallocation of family planning funding. [9]

The changes in family planning funding and exclusion of Planned Parenthood clinics from the WHP did not seem to affect screening and counseling services. Services such as cervical cancer screening, chlamydia and gonorrhea screening, and HIV testing continue to be offered at private and public clinics. [9]

Prenatal and Postpartum Care

Prenatal care is a form of preventative health care that aims to reduce the incidence of maternal morbidity and mortality and fetal defects and death. [1] [2] Women's access to prenatal care services is dependent on and can be limited by their socioeconomic status or region of residency. [1] One study conducted in 2010 through interviews of low-income women living in San Antonio, Texas, showed how those with limited education or in singly inhabited houses initiated prenatal care services later in their pregnancies. [11] The women reported "service-related" barriers as the number one reason for not initiating prenatal care services. [11]

Postpartum care is the provision of healthcare services upon delivery and mirrors prenatal care services. Postpartum care is offered both for the physical and mental repercussions that may result after delivery. The Pregnancy Risk Assessment Monitoring System is one way of gauging the mental health of women after delivery, and is used by hospitals in the state of Texas. [12] In 2003, Texas passed the Postpartum Depression to Pregnant Women Act, requiring healthcare professionals to equip women with information on accessing organizations that provide counseling and postpartum guidance. [13] This act also urged the consideration of insurance coverage and other economic factors in providing women with postpartum care.

Regarding one area of postpartum care, a study conducted in 2014 surveyed women living in Austin and El Paso, Texas on their preferred method of contraception six months after delivery and compared it with their current contraception use. [14] The surveys found that while women preferred to use LARC methods of contraception, they were unable to use or access them at the time. [14] Postpartum contraception has been deemed an integral part of the maternal healthcare system, especially because 61% of all unwanted pregnancies occur for women who have undergone delivery at least once. [15] [16]

Maternal Mortality

Maternal Mortality Rate by Race-Ethnicity, Texas 2007-2011 Maternal Mortality Rate by Race-Ethnicity, Texas 2007-2011.png
Maternal Mortality Rate by Race-Ethnicity, Texas 2007–2011

According to the World Health Organization, maternal mortality is defined as "the death of a woman while pregnant or within 42 days of termination of pregnancy." [17] The maternal mortality rates in Texas have been a source of concern as well as much discussion. From 2000 to 2010, the maternal mortality rate in Texas increased from 17.7 (for every 100,000 live births) to 18.6. [3] It must be noted that during this period, in 2006, Texas included the consideration of pregnancy on its death certificate. [3] However, this was not seen to visibly affect the maternal mortality rates in the ten-year time period. After 2010, the maternal mortality rate doubled, exceeding 35 between 2010 and 2014 and remaining higher than 30 in 2014. [3]

In the US, from 1987 to 2009, the leading causes of pregnancy-related deaths included hemorrhage, sepsis, and hyperintensive disorders. [18] From 2006 to 2009, these causes changed, with cardiovascular conditions accounting for more than a third of pregnancy-related deaths. [18]

While research is ongoing on the causes of maternal mortality in Texas, maternal mortality in the US has been linked to chronic health conditions in women. [19] [20] Cardiovascular conditions were shown to account for at least one third of pregnancy-related deaths. Behavioral factors, such as smoking, overdoses, and suicide have also shown to be present in a high frequency during the period of pregnancy and postpartum period. [19] [19] [21] Similarly, depression and anxiety have been prevalent in women during the postpartum period. [22] In Texas, African-American women are at the highest risk of maternal death. [19]

In 2013, the Senate Bill 495 passed, leading to the establishment of the Texas Maternal Mortality and Morbidity Task Force to assess the factors contributing to maternal death in the state and suggest measures to reducing its incidence. [23] [24] In the 2016 Biennial Report, the Task Force identified cardiac event, drug overdose, hypertension, hemorrhage, and sepsis as being the top five factors contributing to maternal death in Texas. [23] Since opioids are the most common method of drug abuse in Texas, the Task Force has initiated the Neonatal Abstinence Syndrome Prevention Pilot to reduce the incidence of this syndrome in newborns resulting from maternal opioid use. [23] [25] The Task Force is also working toward extending the number of days after delivery to which a woman in the Healthy Texas Women program can access health services. [24]

Other initiatives the Task Force has worked on include The Texas Collaborative for Healthy Mothers and Babies, which enables the delivery of postpartum health services to women while raising awareness of maternal and infant mortality. [24] Other programs such as Someday Starts Now and Preconception Peer Education, work to raise community awareness of maternal morbidity and mortality, and are specifically targeted to minority populations of childbearing age. [24] The Task Force is planning to allocate Title V funding to these programs and thus strengthen community health and awareness of maternal mortality and morbidity. [23]

See also

Related Research Articles

Postpartum period period beginning immediately after the birth of a child and extending for about six weeks

A postpartum period begins immediately after the birth of a child as the mother's body, including hormone levels and uterus size, returns to a non-pregnant state. The terms puerperium or puerperal period, or immediate postpartum period are commonly used to refer to the first six weeks following childbirth. The World Health Organization (WHO) describes the postnatal period as the most critical and yet the most neglected phase in the lives of mothers and babies; most maternal and newborn deaths occur during the postnatal period. In scientific literature, the term is commonly abbreviated to Px, where x is a number; for example, "day P5" should be read as "the fifth day after birth". This is not to be confused with the medical nomenclature that uses G P to stand for number and outcomes of pregnancy.

Reproductive health

Within the framework of the World Health Organization's (WHO) definition of health as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, reproductive health, or sexual health/hygiene, addresses the reproductive processes, functions and system at all stages of life. UN agencies claim sexual and reproductive health includes physical, as well as psychological well-being vis-a-vis sexuality.

Maternal health is the health of women during pregnancy, childbirth, and the postpartum period. It encompasses the health care dimensions of family planning, preconception, prenatal, and postnatal care in order to ensure a positive and fulfilling experience in most cases and reduce maternal morbidity and mortality in other cases.

Maternal–fetal medicine branch of medicine that focuses on managing health concerns of the mother and fetus prior to, during, and shortly after pregnancy

Maternal–fetal medicine (MFM) is a branch of medicine that focuses on managing health concerns of the mother and fetus prior to, during, and shortly after pregnancy.

Tropical diseases, especially malaria and tuberculosis, have long been a public health problem in Kenya. In recent years, infection with the human immunodeficiency virus (HIV), which causes acquired immune deficiency syndrome (AIDS), also has become a severe problem. Estimates of the incidence of infection differ widely.

The non-pneumatic anti-shock garment (NASG) is a low-technology first-aid device used to treat hypovolemic shock. Its efficacy for reducing maternal deaths due to obstetrical hemorrhage is being researched. Obstetrical hemorrhage is heavy bleeding of a woman during or shortly after a pregnancy. Current estimates suggest over 300,000 women die every year, of which 99% occurs in developing countries, most of which are preventable. Many women in resource-poor settings deliver far from health-care facilities. Once hemorrhage has been identified, many women die before reaching or receiving adequate treatment. The NASG can be used to keep women alive until they can get the treatment they need.

Unintended pregnancies are pregnancies that are mistimed, unplanned or unwanted at the time of conception. Unintended pregnancies may also result from rape or incest.

A puerperal disorder or postpartum disorder is a disorder which presents primarily during the puerperium, or postpartum period. The postpartum period can be divided into three distinct stages; the initial or acute phase, 6–12 hours after childbirth; subacute postpartum period, which lasts 2–6 weeks, and the delayed postpartum period, which can last up to six months. In the subacute postpartum period, 87% to 94% of women report at least one health problem. Long term health problems are reported by 31% of women.

Childbirth in Sri Lanka

Issues and practices related to childbirth in Sri Lanka are influenced by the sociocultural composition, political history and violence within the country.

Prenatal care in the United States is a health care preventive care protocol recommended to women with the goal to provide regular check-ups that allow obstetricians-gynecologists or midwives to detect, treat and prevent potential health problems throughout the course of pregnancy while promoting healthy lifestyles that benefit both mother and child. Patients are encouraged to attend monthly checkups during the first two trimesters and in the third trimester gradually increasing to weekly visits. Women who suspect they are pregnant can schedule pregnancy tests prior to 9 weeks gestation. Once pregnancy is confirmed an initial appointment is scheduled after 8 weeks gestation. Subsequent appointments consist of various tests ranging from blood pressure to glucose levels to check on the health of the mother and fetus. If not, appropriate treatment will then be provided to hinder any further complications.

Obstetric medicine, similar to maternal medicine, is a sub-specialty of general internal medicine and obstetrics that specializes in process of prevention, diagnosing, and treating medical disorders in with pregnant women. It is closely related to the specialty of maternal-fetal medicine, although obstetric medicine does not directly care for the fetus. The practice of obstetric medicine, or previously known as "obstetric intervention," primarily consisted of the extraction of the baby during instances of duress, such as obstructed labor or if the baby was positioned in breech.

Women's reproductive health in Russia refers to the set of physical, mental, and social health issues and services available to women in Russia. It includes the rights, laws, and problems experienced by women and their families regarding proper reproductive health. Women account for over half of the Russian population and are considered a vulnerable population due to political and social problems from inequalities in gender, age, socioeconomic status, and geographical location that affect access to comprehensive health care. As Russia struggles with a decreasing birthrate and increase in STIs, HIV, and poor reproductive health care, the need for government financed services and international programs is essential to successfully reach this vulnerable population. Currently, women in Russia access care through government funded free services, private insurance, and NGO programs.

The Texas Policy Evaluation Project, or TxPEP, began in the fall of 2011 with the purpose of documenting and evaluating the impact of reproductive health legislation passed by the 82nd Texas Legislature. Those measures included large cuts to state family planning funding programs in the 2012–2013 budget as well as changes in the eligibility of organizations to participate in those programs, and Texas House Bill 15, a law requiring that women undergo a mandatory sonogram at least 24 hours before an abortion. Their evaluation work continued after the 83rd Texas Legislature in 2013, when the legislature added funding streams for family planning to the 2014–15 budget and passed Texas House Bill 2, an omnibus bill restricting abortion care that was introduced in a special legislative session in summer 2013. HB 2 placed limits on medication abortion, banned abortion ≥20 weeks “post-fertilization,” and required abortion providers to have hospital admitting privileges and abortion facilities to meet the standards of ambulatory surgical centers (ASCs). In June 2016, the US Supreme Court struck down the admitting privileges and ASC requirements in HB 2, citing TxPEP research findings in its ruling.

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Childbirth practices in India are shaped by the prevalence of Hinduism and joint-family living, India's young average population, the lower national average age at marriage, and disparities in social status and literacy between men and women. Inadequate maternal health care services in India are a result of poor organization, the huge rural-urban divide, and large interstate disparities coupled with stringent social-economic and cultural constraints.

Maternal mortality in the United States

Maternal mortality refers to the death of a woman during her pregnancy or up to a year after her pregnancy has terminated; this only includes causes related to her pregnancy and does not include accidental causes. Some sources will define maternal mortality as the death of a woman up to 42 days after her pregnancy has ended, instead of one year. In 1986, the CDC began tracking pregnancy related deaths to gather information and determine what was causing these deaths by creating the Pregnancy-Related Mortality Surveillance System. Although the United States was spending more on healthcare than any other country in the world, more than two women died during childbirth every day, making maternal mortality in the United States the highest when compared to 49 other countries in the developed world. The CDC reported an increase in the maternal mortality ratio in the United States from 18.8 deaths per 100,000 births to 23.8 deaths per 100,000 births between 2000 and 2014, a 26.6% increase; It is estimated that 20-50% of these deaths are due to preventable causes, such as: hemorrhage, severe high blood pressure, and infection.


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