In the last year, Houston and Harris County’s infant mortality and preterm birth rates have taken a turn for the worse.
In Texas, 11 percent of births occur before 37 weeks of gestation, according to the March of Dimes 2020 Report Card. For every 1,000 babies born in the state, 5.5 die at birth.
In Houston and Harris County, the share of preterm births are slightly higher — and growing, earning both the city and county an F on this year’s report card. In Houston, the rate increased from 11.2 percent at the time of last year’s report card to 11.9 percent this year; for Harris County, the share grew from 11.1 percent to 11.6 percent.
Preterm births, which have been increasing for five years, and their complications are the second largest factor in infant death in the United States.
“We’re at a crisis level,” said Stacey Stewart, president and CEO of March of Dimes, an organization focused on improving the country’s infant mortality rate. “Maternal mortality has doubled in the past 25 years. Every other large, highly industrial country’s rates have declined, and ours has increased. We have a lot of work to do.”
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The mother’s health, and access to equitable health care, must be factored into the conversation surrounding infant mortality and preterm births, said Dr. Sean Blackwell, an OBGYN and professor at UTHealth’s McGovern Medical School.
There are definite racial disparities related to preterm birth, maternal morbidity (medical problems related to pregnancy) and mortality, Blackwell said. Poverty, adequacy of prenatal care and access to coverage and transportation all contribute to the rising numbers.
Black women die at a rate 2.3 times higher than white women in Texas, according to Improving Maternal Health Houston, a locally funded initiative working to increase maternal survival and improve women’s wellness pre- and postpartum.
Between 2008 and 2015, the share of Harris County women with severe maternal morbidities increased by 53 percent, as the state increased by 15 percent, according to IMHH. A woman’s separate health conditions during the birth — such as any heart problems, renal failure or aneurysms — factor into the severe maternal morbidity rate.
The group has found that the health of women before pregnancy is compromised by multiple unmanaged or untreated issues that eventually become “the source of severe complications at childbirth or after delivery.”
There is a strong relationship between maternal morbidities and premature births related to those issues, said Blackwell, who is the co-chair of IMHH’s steering committee. If a woman has diabetes, high blood pressure or lupus, there is not only a risk for the conditions worsening during her pregnancy, but she’s at a high risk of delivering early.
Forty percent of preterm births are related to medical problems, he said.
“We’re in a severe health crisis related to underserved patients — long before COVID, but COVID has really made it a lot worse and harder,” Blackwell said. “All the things the pandemic has made harder for us in our lives has really affected a woman’s ability to get to health care providers, and it has disproportionately affected our disadvantaged women.”
In partnership with March of Dimes and other agencies, the U.S. Department of Health and Human Services released an action plan last week to reduce maternal deaths and disparities that put women at risk before, during and after pregnancy.
The initiative is focused on limiting disparities between women of color and white women, Stewart said. The agencies involved will work with hospitals and all health care providers who care for pregnant women before, during or after the birth of their child, she said.
The partnership’s five-year goals include reducing maternal mortality by 50 percent, lowering the number of low-risk cesarean section births by 25 percent and achieving blood pressure control in 80 percent of women who are of reproductive age and have hypertension, Stewart said.
The country’s poor numbers reflect a general lack of access to health care for Black women, Native American women and other women of color, Stewart said.
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“This country has never done a good job of extending adequate high quality of care to all people, especially if the people are people of color,” Stewart said. “Most of the way our health is really determined is in how we live and whether we have access to safe and affordable housing, access to insurance coverage, access to good-paying jobs that allow us to make ends meet and live a decent lifestyle, and access to educational opportunities that allow us to grow and achieve.”
While the March of Dimes’ work is largely focused on reducing preterm births and infant mortality, Stewart said it has always worked to improve maternal health. If a mother’s health is declining, it is potentially putting the baby’s health at risk, she said.
“If we just try to impact premature births during the time of pregnancy, we are too late in many cases. We need to move more upstream,” Stewart said. “We expanded the scope of our work to take in maternal health outcomes.”
Anahi Espinoza’s second child came along about 13 years after her first; age aside, the native Houstonian said it was an entirely new experience from pregnancy to delivery to now.
Espinoza, who is 32, is grateful neither her 15-year-old son nor her 15-month-old daughter were born with any complications and both were near-full term. But her health had changed in the years between both pregnancies.
The first thing she noticed was her mood. She was depressed and anxious, but she didn’t realize that wasn’t normal until she saw her gynecologist at the HOPE Clinic, a federally qualified health clinic. A former health care worker for the clinic, Espinoza decided it was the best and most affordable place to go when she became pregnant.
Asthmatic flare-ups were also a bigger problem during her second pregnancy, as well as intense migraines. Her primary doctor referred her to specialists outside of the clinic; she felt safe going because her doctor had made the recommendation, she said.
“When my baby was born, I already had everything ready. I already knew which pediatrician to bring her to, and I was comfortable with everyone in the front desk and in the back,” said Espinoza. “It made the process so much easier.”
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HOPE Clinic provides continuity of care after pregnancy, part of the HHS Action Plan to reduce maternal deaths and disparities.
During prenatal visits, doctors found that Espinoza’s baby was bigger than expected at 37 weeks. She was induced two weeks before her due date.
“When I was working at the clinic, I would see patients who came in and were ready to deliver tomorrow, but they had never been seen by a doctor,” Espinoza said. “If I hadn’t known she was a bigger baby, there could have been complications or I may have needed a C-section. Just being able to go to the clinic made such a big difference.”
Maternal deaths are not only counted during delivery, Stewart said. The maternal mortality rate takes also factors in deaths in the first year after childbirth, which accounts for one-third of maternal deaths.
The American College of Obstetricians and Gynecologists and other agencies encourage health care providers to consider a fourth trimester, which is the first year after a child is born, to continue giving coverage and support.
Forty percent of all U.S. births are covered by Medicaid, Stewart said. And March of Dimes has advocated for expanding Medicaid coverage to postpartum women to a full year after giving birth. In Texas, a woman is eligible for Medicaid during pregnancy, but can be dropped 60 days after she gives birth.
“Especially if she had surgery or has a history of chronic health conditions, like hypertension or diabetes, those women need to be seen by a doctor for followup visits,” Stewart said.