Maternal Mortality and Postpartum Depression

By Katelyn Kenney

It has come to light in recent years that Texas has a problem with women’s healthcare, especially in regards to maternal mortality rates.

The Texas Maternal Mortality and Morbidity Task Force, in conjunction with the Texas Department of State Health Services, addressed the issue of usually high maternal mortality rates in their 2016 biennial report. They analyzed data from 2011-2012 to conclude four points: black women are at the greatest risk of maternal death, cardiac events, drug overdose, and hypertensive disorders are the leading causes of death, majority of obstetric deaths occur after the 42-day window as defined by the World Health Organization, and data quality issues related to death certificates make it difficult to identify maternal or obstetric deaths.

Row Labels Sum of White Number Sum of Black Number Sum of Hispanic Number
All Other Direct Obstetric Causes (O10, O12, O21-O43, O47-O66, O68-O71,
O73-O75)
26 12 26
Eclampsia and Pre-Eclampsia (O11, O13-O16) 3 3 1
Hemorrhage of Pregnancy and Childbirth and Placenta Previs (O20, O44-O46,
O67, O72)
1 0 4
Indirect Obstetric Deaths (O98-O99) 20 10 7
Obstetric Death of Unspecified Cause (O95) 1 0 1
Obstetric Embolism (O88) 2 1 1
Other Complications Predominately Related to the Puerperium (O85-O87,
O89-O92)
0 1 4
Other Deaths Related to Pregnancy, Childbirth and the Puerperium (O96-O97) 1 5 5
Total for Selection 54 32 49

Because the number of maternal deaths is so low, rates could not be calculated for every cause. Overall, the maternal mortality rate for white women was 1.1, the rate for black women was 2, and 0.9 for Hispanic women. These statistics are consistent with the assertion that black women are at the greatest risk. The task force found that difference between the maternal mortality rate of black women and the rate of live births by black women in the time period during which this study was conducted was significantly larger than the other races.

In terms of overall trends of maternal mortality rates in Texas, the task force acknowledges that there is no definitive answer because different methodologies produce varied results. The rate has seen a decrease between 2013 and 2014, but the rate is nearly double what it was in 2010, jumping to 31.5 deaths per 100,000 live births from 18.7 according to the Texas Department of State Health Services.

The same task force report also found the mental health is a factor in the maternal mortality discussion. I became particularly interested in this notion and decided to focus my attention on possible links between postpartum depression and access to healthcare.

To begin, I wanted to see if there were certain demographics of women that are more likely to get a postpartum checkup than others. While the differences are not huge, there are some clear indicators of the kind of woman who might not get a postpartum checkup where, among other things, she could get screened for postpartum depression.

According to this graphic derived from the CDC PRAM Surveillance report in 2013, a higher percentage of women who participate in programs like Medicaid and WIC that are linked to low income are more likely to not have a postpartum checkup. Without a checkup, it is more probable that these women have an undiagnosed mental condition. This assumption is supported by the Texas Health and Human Services Commission and Texas Department of State Health Services 2016 report’s claim that women with incomes lower than $15,000 had nearly twice the rate of postpartum depression than women with incomes above $50,000.

Medicaid covers mental health screenings for pregnant and postpartum women, but according to HHS/DSHS report, covering patients with postpartum depression is costlier in southeast Texas; costs to Medicaid are a little more than $600 while other regions are closer to $300. Perhaps coincidentally, that same region reported the highest maternal mortality rate in 2014 with 0.7 deaths per 1,000 live births. The state average was 0.3 deaths per 1,000 live births.

County Live Births Maternal Deaths Maternal Death Rate
TEXAS 399,482 139 0.3
REGION 1 – High Plains 12,640 6 0.5
REGION 2 – Northwest Texas 7,145 4 0.6
REGION 3 – Metroplex 103,739 36 0.3
REGION 4 – Upper East Texas 14,647 5 0.3
REGION 5 – Southeast Texas 9,974 7 0.7
REGION 6 – Gulf Coast 101,249 29 0.3
REGION 7 – Central Texas 45,389 19 0.4
REGION 8 – Upper South Texas 40,389 18 0.4
REGION 9 – West Texas 10,596 3 0.3
REGION 10 – Upper Rio Grande 13,895 1 0.1
REGION 11 – Lower South Texas 39,819 11 0.3

It might not come as a surprise, then, to find out that the counties of this southeast region have total per capita personal incomes that are on the lower end of the spectrum. Note the counties on the eastern border above the Gulf Coast region.

amCharts

It’s plausible that relatively lower incomes and high costs to Medicaid for coverage could limit access to postpartum care and, more specifically, postpartum mental health screenings. While postpartum depression is directly linked to a small portion of maternal deaths—according to the task force report, suicide accounted for 5.3% of maternal deaths from 2011 to 2012—depression can exacerbate existing conditions that could lead to death. Lower income women and women of color are at a higher risk of pregnancy-related death, but paying more attention to the mental health of these women could make a difference.

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