“If they were white and insured, would they have died?”: Contextualizing the 2022 Texas Maternal Mortality and Morbidity Report

Udodiri R. Okwandu

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In December 2022 – a few days shy of the new year – the Texas Maternal Mortality and Morbidity Review Committee (MMMRC) and Department of State Health Services released a joint Biennial Report on maternal mortality and morbidity rates in the state. They use term “maternal mortality” to describe the death of a childbearing person while pregnant or in the year following the end of a pregnancy from any cause related to or aggravated by the pregnancy.^[1] Meanwhile, “maternal morbidity” refers to any health condition attributed to and/or exacerbated by pregnancy and childbirth that negatively impacts the childbearing person’s well-being.^[2]

This report, long overdue, revealed what many had long known: that negative maternal health outcomes were on the rise, with Black parents experiencing disproportionately high levels of harm and death.

The MMMRC was established in 2013 by Senate Bill 495, 83rd Legislature, Regular Session to address a longstanding problem in the state of Texas: disproportionately high rates of pregnancy- and childbirth-related illness and death and racial disparities in maternal mortality and morbidity. In the year that the committee was formed, Black women constituted 31% of maternal deaths even though they made up only 11% of those giving birth.^[3] The Texas Health and Safety Code, Section 34.015 required that the MMMRC and the Department of State Health Services submit a joint report on the findings by September 1st of each even-numbered year.^[4] As a result, the MMMRC had a legal obligation to publish a report before or by September 1, 2022.

Yet in the months leading up to the overdue 2022 release, the report elicited significant controversy. After the Committee failed to release the report by the September 1, 2022 deadline, The Society for Maternal-Fetal Medicine – a non-profit organization dedicated to improving maternal and child outcomes – threatened to sue the state for refusing to release vital information to the public that could address Texas’ longstanding maternal mortality crisis.^[5] Two months later, the Committee’s pre-release warning that the report would reveal disturbing racial and class disparities elicited additional outrage given the state’s present assault on abortion rights, which has already proven to disproportionately impact low-income women of color.^[6]

Unfortunately, these concerns did not prove to be unfounded. The report’s results were startling: of the 118 pregnancy-associated deaths reviewed by the MMMRC, 40% were pregnancy-related (i.e., the deaths were explicitly tied to complications arising from pregnancy itself) and 36% were pregnancy-associated.^[7] In fact, 90% of pregnancy-related deaths were found to be preventable. This means that “there was at least some chance of averting the death by one or more feasible changes to the circumstances of the patient, provider, facility, systems, or community factors contributing to the death.” ^[8] Further, Black childbearing people and individuals who lacked private insurance disproportionately died from or experienced severe complications during pregnancy. ^[9] According to the MMMRC, these deaths result in 6,162 years of potential life lost and have left approximately 184 children affected by their mothers’ deaths. ^[10]

As a historian of race and medicine, I was disturbed but – unfortunately – not surprised. An honest examination of the historical record shows how rampant disparities and inequities in maternal health outcomes are due to systemic racism and classism. Systemic racism and classism refer to the complex interactions of large-scale systems, practices, and beliefs that systematically disadvantage racial and ethnic minorities and members of the working class. In the U.S., systemic racism and classism have been critical to the historical formation of not only obstetrics but also American medicine and the healthcare system more broadly. For example, the belief that Black people have inferior, different bodies, and psyches – which emerged in the 18^th and 19^th centuries – was a foundational, widely-held belief held by members of the white professional medical academy.^[11] While this belief has been challenged, it continues to persist, manifesting as rampant racial bias and discrimination amongst providers that, ultimately, impacts the provision of care. In addition, a capitalistic-driven healthcare system continues to drive unequal access to healthcare, particularly among the working class.

Systemic racism and classism explain why the U.S. continues to have the highest maternal death rate among developed nations.^[12] And since Texas accounts for 10% of all births in the U.S., the results of the MMMRC’s reports are particularly damning.^[13] Yet some have argued that the abysmally high rates of maternal mortality are due to a “statistical mirage.” In 2006, Texas added a checkbox to death certificates that asked if the deceased person was pregnant or had been pregnant in the last year of their life. While some of these deaths could have been mistakenly linked to pregnancy, the reality is that systemic racism and classism historically have shaped maternal healthcare policy in Texas.^[14] For example, in 2011, as part of its assault on reproductive autonomy, Texas reduced its family-planning budget by two-thirds in order to defund Planned Parenthood, a domestic and global nonprofit organization that provides reproductive and sexual healthcare and education. This action, however, ignored the fact that Planned Parenthood and its affiliated clinics were the largest providers of pregnancy-related healthcare for low-income women – many of whom were racial and ethnic minorities.^[15]

In addition, it is critical to note that Texas has the largest uninsured rate in the U.S. – 18% compared to the national average of 8.6%.^[16] This is, in part, due to two key developments. In 2012, the state legislature blocked billions of dollars in federal aid to expand Medicaid under the Affordable Care Act. Further, in 2021, the legislature refused to pass any broad expansion of state and federal healthcare coverage for Texans without insurance.^[17] Given that access to health coverage is directly correlated with better health outcomes, these policy decisions continue to put childbearing people – particularly Black and working-class ones – at undue risk of maternal death.

The consequences of these developments are reflected in the report’s findings. The MMMRC found that six underlying conditions (obstetric hemorrhage, mental health conditions, non-cerebral thrombotic embolism, injury, cardiovascular conditions, and infection) accounted for 79% of all pregnancy-related deaths. Many of the factors that contributed to the onset of these conditions were social and environmental determinants of health that occurred over the course of the women’s lifespans. Limited access to financial resources, poor health literacy, and limited access to continuous care were all prominent factors. However – and this is significant – many of these conditions arose due to the failures of the providers, facilities, and healthcare systems meant to serve these women. Discrimination from providers and the healthcare system accounted for 12% of patient deaths. Providers’ poor clinical skill and care, failure to conduct adequate assessments for risk, delay in referring to or accessing treatment, and a lack of standardized policies and procedures at health facilities and within healthcare systems also played key roles. Black women, who already have the highest maternal mortality rate in the U.S., were disproportionately impacted.

The MMMRC noted that the following question guided their research: “If she had not been pregnant, would she have died?” I contend, however, that this question is both evasive and misguided. Instead, the MMMRC should have asked the following: if she were white or insured, would she have died? The results of the MMMRC’s report tell us the following: probably not. Indeed, as a historian of race of medicine, I believe that the results of the MMMRC’s report are entirely predictable. Yet, as a young, Black woman with aspirations to one day embark on my own personal journey with pregnancy and parenthood, I am terrified – and I know that I am not alone.

Yes, I can “quell my fears” and “protect and empower my future self” by learning how to navigate a medical system that is – both consciously and unconsciously – hostile to people like me. I can read the countless guides – in print and online – intended to instruct me on how to “advocate for myself” if faced with medical paternalism or discrimination. I can “find the right provider,” learn how to ask the “right questions,” or even “bring a companion” to my appointments to support me.

But a critical question remains. As a patient, why should I be responsible for ensuring that I receive the care that I deserve? Concerted and intentional action – such as introducing universal health care, investing in and partnering with communities, and changing the culture of medicine by foregrounding and addressing how race and racism structures medical education and practice – is long overdue. The lives of childbearing people, particularly Black and working-class ones, depend on it.

1. “What Are Maternal Morbidity and Mortality?,” National Institutes of Health (U.S. Department of Health and Human Services), accessed January 27, 2023, https://orwh.od.nih.gov/mmm-portal/what-mmm. ↑
2. What Are Maternal Morbidity and Mortality?,” National Institutes of Health (U.S. Department of Health and Human Services), accessed January 27, 2023, https://orwh.od.nih.gov/mmm-portal/what-mmm. ↑
3. Eleanor Klibanoff, “Delayed Texas Maternal Mortality Report to be Released Next Week, State Says,” The Texas Tribune, accessed February 27, 2023, December 9, 2023, https://www.texastribune.org/2022/12/09/texas-maternal-mortality-report/ ↑
4. Texas Maternal Mortality and Morbidity Review Committee and Department of State Health Services Joint Biennial Report 2022, Texas Department of State Health Services, December 2022. ↑
5. Mary Tuma, “’It’s Easy to Dismiss Black Women’s Lives’: Texas Drags Feet on Maternal Mortality Crisis,” The Guardian (Guardian News and Media, May 30, 2021), https://www.theguardian.com/us-news/2021/may/30/texas-maternal-mortality-crisis-black-women-medicaid. ↑
6. Kennedy Sessions, “Texas Doctors Issue Dire Warning Ahead of State Maternal Death Report,” Chron (Houston Chronicle, December 10, 2022), https://www.chron.com/politics/texas/article/texas-pregnant-mortality-rate-17643565.php. ↑
7. Texas Maternal Mortality and Morbidity Review Committee and Department of State Health Services Joint Biennial Report 2022, Texas Department of State Health Services, December 2022. ↑
8. Texas Maternal Mortality and Morbidity Review Committee and Department of State Health Services Joint Biennial Report 2022, Texas Department of State Health Services, December 2022. ↑
9. Texas Maternal Mortality and Morbidity Review Committee and Department of State Health Services Joint Biennial Report 2022, Texas Department of State Health Services, December 2022. ↑
10. Texas Maternal Mortality and Morbidity Review Committee and Department of State Health Services Joint Biennial Report 2022, Texas Department of State Health Services, December 2022. ↑
11. Jennifer Lyle Morgan, Laboring Women: Reproduction and Gender in New World Slavery (Philadelphia: University of Pennsylvania Press, 2004). ↑
12. “Severe Maternal Morbidity in Communities across Texas,” University of Texas System, August 31, 2020, https://utsystem.edu/offices/population-health/overview/severe-maternal-morbidity-texas. ↑
13. Mary Tuma, “’It’s Easy to Dismiss Black Women’s Lives’: Texas Drags Feet on Maternal Mortality Crisis,” The Guardian (Guardian News and Media, May 30, 2021), https://www.theguardian.com/us-news/2021/may/30/texas-maternal-mortality-crisis-black-women-medicaid. ↑
14. Robin Fields, “Maternal Death Rates are Increasing in Texas, but Probably Not as Much as Officials Thought,” The Texas Tribune, January 4, 2018. https://www.texastribune.org/2018/01/04/maternal-deaths-are-increasing-texas-probably-not-much-officials-thoug/ ↑
15. Katha Pollott, “The Story Behind the Maternal Mortality Rate in Texas is Even Sader Than We Realize,” The Nation, September 8, 2016, https://www.thenation.com/article/archive/the-story-behind-the-maternal-mortality-rate-in-texas-is-even-sadder-than-we-realize/ ↑
16. Boram Kim, “Texas Maintains Highest Uninsured Rate for Children and Adults in the Country at 18% in 2021,” State of Reform, September 20, 2022, https://stateofreform.com/featured/2022/09/texas-maintains-highest-uninsured-rate-for-children-and-adults-in-the-country-at-18-in-2021/. ↑
17. Karen Brooks Harper, “Texas House Votes down Budget Amendment Aimed at Giving Health Coverage to More Uninsured Texans,” The Texas Tribune (The Texas Tribune, April 22, 2021), https://www.texastribune.org/2021/04/22/texas-house-medicaid-expansion-uninsured/. ↑

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