Because Texas is the worst state to have a baby

Texas ranks last in the country in caring for expectant and new mothers. The high cost of care in North Texas, the worst health insurance rate in the nation, and a high infant mortality rate make the Lone Star State 50th in access to quality prenatal and maternal care.

The ValuePenguin study analyzed data from the Bureau of Labor Statistics, the Centers for Disease Control and Prevention, the Centers for Medicare and Medicaid Services, and other data to determine its most recent rankings. The key metrics were women aged 18-44 with health insurance and access to a health professional, the number of maternal care providers per capita, and the proportion of live births with access to adequate prenatal care. Each state received an Access Score and a Quality Score which were averaged to create a final ranking.

Texas finished with the lowest overall score despite having midway quality of care. The state’s suppliers have talent, but many Texans don’t have access to those suppliers. Texas was last in the percentage of women of childbearing potential who have health insurance and a primary care provider. It also has one of the highest infant mortality rates in the country, with 5.5 deaths per 1,000 live births. Texas has a relatively high birth rate and the fifth highest C-section rate.

New England states had the highest score in the league table, with New Hampshire in first place. Rhode Island, Vermont, Massachusetts and Connecticut rounded out the top five. Texas was joined by Nevada, Wyoming, Georgia and Tennessee at the bottom. The study found that only 73.6 percent of women aged 18 to 44 had access to health insurance in Texas and only 57 percent had a primary care provider. Only 70.2% of births had access to adequate prenatal care. Texas ranked well in the number of providers per capita, with 40.6 maternal care providers per 10,000 residents.

Texas is one of the last 12 states still to expand Medicaid, despite conservative neighbors like Arkansas, Oklahoma and Louisiana having done so in the past two years. For many conservative lawmakers in the capital, expanding Medicaid is not a starting point, despite evidence that it would improve access and save the state money it spends caring for the indigent and uninsured. Expanding Medicaid would provide insurance and improve access for an estimated one million Texans, yet more than 18% of Texans are uninsured (the national average is 9%). About 4 million uninsured Texans would remain uninsured regardless of Medicaid expansion.

Texas has long struggled with maternal death, especially for black women. A 2016 CMS study overestimated the number of maternal deaths, leading to panic and some unfortunate headlines. The number was eventually reduced, but Texas still has one of the highest maternal mortality rates in the country. Black women in Texas die at three times the rate of white women in childbirth.

“We wanted to know what was happening in Texas and the causes of maternal mortality,” says Marjorie Quint-Bouzid, senior vice president of women’s and children’s health at Parkland Health. “For Texas, it was about hypertensive disorders of pregnancy, behavioral health, and substance use.”

These problems are not easily fixed. Dallas has one of the worst uninsured rates of any major city in the country. It is often left at the County Safety Net Hospital to make sure uninsured and indigent patients get the care they need for their chronic and acute conditions. Lack of insurance is only part of the problem. Due to Dallas’ severe segregation, many of Parkland’s patients face other obstacles to quality care and good outcomes such as transportation, food deserts, education deficits and poverty, which often push women to make difficult choices.

“There are material needs that people have where they’re just trying to survive,” says Quint-Bouzid. “Women make a decision between an expensive drug that the doctors have told them they need and paying for daycare or paying for a doctor’s appointment.”

Texas passed legislation in 2021 that increases Medicaid coverage from 60 days to six months for mothers after the birth of a child, but advocates are pushing to extend that coverage to twelve months. Pregnancy can be a dangerous time for a mother, and pregnancy-related complications account for 45 percent of maternal morbidity in the year following birth, Quint-Bouzid says.

Parkland uses all the tools at its disposal to make sure women who want to give birth are connected to quality care. Parkland hospital delivers 12,000 babies a year, one of the highest rates in the country, and many of its patients are uninsured. Despite the obstacles, 97 percent of patients who give birth in Parkland receive prenatal care, Quint-Bouzid says. The Health System’s 11 Women’s Health Centers and Comprehensive Care provide care to those who need it most.

Parkland health care workers meet with patients to try to get them some form of insurance, including the Parkland Community Health Plan. This is particularly useful because many pregnant patients suffer from other chronic diseases such as diabetes and hypertension. They often did not receive treatment due to a lack of insurance and primary care providers.

“These are unresolved issues that either weren’t addressed during pregnancy or didn’t have appropriate follow-up after delivery,” she says. “High blood pressure, cardiomyopathy, anxiety and depression have not been addressed and can continue to cause serious illness and death as early as one year postpartum.”

Parkland also uses technology to address disparities. The hospital has partnered with the Parkland Center for Clinical Innovation to enroll at-risk pregnant women to be reminded of their appointments and medications in the months leading up to pregnancy. Parkland also has an extensive maternal care program that takes a detailed inventory of a patient’s health and social determinants of health and follows women one year after birth. Healthcare providers try to address issues like healthy eating deficits, access to mental health and substance abuse resources, and even WiFi access (often partnering with a public library for a mobile hotspot) to make sure these women have access to more convenient remote care.

The impact of case management can be stark. Quint Bouzid recalled a recent patient who had abused her blood pressure cuff and reported inaccurate readings during her remote visits. When the nurse called to check on her, they realized she wasn’t using the machine properly and discovered that her high blood pressure was causing headaches. The uninsured patient was six weeks postpartum and she most likely would not have gone to the doctor herself without that remote care appointment. “I shudder to think what would have happened to her,” Quint-Bouzid says. “By being able to connect via television, we saw a huge difference.”

In addition to the loss of life for mothers and babies, there are financial benefits to providing quality maternal and prenatal care. Avoiding premature births, complicated pregnancies, lost time at work, and more expensive downstream treatments are also the result of increased front-end care. If a woman comes for her antenatal visit and develops hypertension early, this can mean significant savings for the health care system in the future.

While Parkland is doing a lot to address the barriers to care many of its patients face, it’s not trying to meet every need. Instead, she seeks to partner in the community with other organizations that can improve outcomes. “We’re finding local resources and community partners and providing connections,” says Quint-Bouzid. “Normally, our moms don’t have the social capital to navigate some of our systems, so we’re building these partnerships so they can stay in their community.”


Will Maddox

Will is the managing editor of CEO D magazine and editor of D CEO Healthcare. You wrote about health…

Because Texas is the worst state to have a baby

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