Moments after her second child was born, Nakeenya Wilson almost bled to death. The Austin mom had already spent that day in 2016 enduring one problem after another at the hospital, from a long wait for a scheduled induction—a simple and common procedure to start labor—to a nurse who kept getting her name wrong. “I felt like I was being punked,” Wilson recalled. “It was kooky from the beginning.”
But things got serious when she started to hemorrhage. The bleeding was later chalked up to several risk factors Wilson had throughout her pregnancy, along with the unusual position of her son during delivery. But during her care, she said she received almost no communication about what was going on. “I didn’t even know that I was hemorrhaging,” Wilson said. Her nurse administered a drug to stop the bleeding without telling Wilson what she was doing, she said, and it ended up causing a dangerous spike to her blood pressure, which had already been high throughout her pregnancy. Wilson’s doctor subsequently told her she should never have been given the medication. “I was a near miss,” Wilson said.
That experience inspired Wilson to apply to be a community advocate on Texas’s Maternal Mortality and Morbidity Review Committee. The committee—whose seventeen members include maternal health-care experts, nurses, psychiatrists, and state-appointed physicians—studies cases of pregnancy-related death and illness and makes recommendations to the state for improving health outcomes for mothers. “I had a bad experience with this nurse, but she isn’t the whole problem,” Wilson said. “It’s the system that trained her, the hospital policies . . . those things can be changed.”
It’s also Texas law that needs changing in this year’s legislative session, say Wilson and her MMMRC colleagues—including the state’s limited Medicaid coverage for new moms. And with the state’s near-total ban on abortion in effect after last summer’s U.S. Supreme Court decision overturning Roe v. Wade, the need for more coverage has only become more urgent.
National data show that states that have implemented complete abortion bans, or bans after the first trimester, see higher death rates and more pregnancy-related illnesses. Dr. Carla Ortique, an ob-gyn at Texas Children’s Hospital in Houston who chairs the MMMRC, said she believes that more women in Texas will suffer health consequences—such as gestational diabetes or eclampsia—because of the ban. “You can look to the past and what happened to women then,” Ortique said, referring to the pre-Roe era.
According to Ortique, the abortion ban not only means that many Texans will be required to carry high-risk pregnancies to term and face postpartum complications, but also that they may be unable to receive some emergency services for miscarriages due to concerns that doctors may be criminally liable for providing care. Although the law in Texas does make an exception for abortions that would save the life or seriously impact the health of the mother, hospitals have been erring on the side of caution to protect doctors, which can mean that by the time the best course of action is determined, it’s too late. “This is unprecedented,” Ortique said. “We’ve never been in a situation in which a doctor is unable to do what is evidence-based for fear of criminal liability.”
As the Legislature meets for the first time since the abortion ban, two bills on the docket could minimize the potentially adverse impact of those restrictive laws on maternal health. House Bill 663 would speed up access to state data on maternal deaths and serious illnesses, giving the MMMRC a better opportunity to improve health outcomes for moms. Senate Bill 73 would expand Medicaid coverage for Texas women from eight weeks to twelve months after giving birth. That would be no small thing: Around half of all babies in Texas are born to mothers on Medicaid.
Last session, the state House voted to increase Medicaid coverage for new mothers from eight weeks to a full year, as SB 73 calls for, but the Senate reduced that coverage period to six months. The law never went into effect, however: last August, the Texas Health and Human Services Commission revealed that the federal government had not granted approval, which is necessary because the bill focused on federally funded Medicaid. The legislation still remains under review by the Centers for Medicare and Medicaid Services. (CMS did not respond to a question about why the review process was taking so long.)
Under the American Rescue Plan Act, states had been given the option to extend Medicaid coverage to twelve months after birth without a lengthy application and approval process, but when the state Senate cut the extension to six months, they were signing up for a more complicated road to enacting the law. Some legislators who support the Medicaid expansion said the feds’ slow review of the legislation may also be linked to the Senate’s exclusion of people who’d recently had abortions from coverage. But now that abortion is illegal in Texas, such specifications are not included in the new bill, which has already been filed in both the House and Senate.
“The fact that we have reprehensibly abolished abortion rights should have the somewhat beneficial effect of removing obstacles to enacting Medicaid expansion,” said state senator Nathan Johnson, a Democrat from Dallas and the sponsor of SB 73. Johnson is optimistic that his bill will not only make it through the Senate, but also be approved by the federal government; it should be a “huge priority” this session, he said. Boosting its chances, Republican House Speaker Dade Phelan echoed Johnson in a statement to Texas Monthly: “a priority for the Texas House this year is to further improve care for mothers and children in our state, which will include legislation that extends critical postpartum coverage for moms to a full year,” he said. (The speaker backed the previous bill in 2021.)
Health-care experts say that twelve months of postpartum coverage is essential—and far preferable to the six months the Senate approved last session. “Pregnancy is a crucible: it uncovers problems that may come up in the future,” Ortique, the MMMRC chair, said. “You may have been diagnosed with pregnancy-associated diabetes, but it’s not until twelve weeks or so after delivery that we might realize you have chronic diabetes now—but by then you’re close to losing coverage.”
Ortique’s committee helps legislators come up with policies like SB 73—but it’s hampered by onerous regulations such as redaction requirements. HB 663, with its focus on data gathering, aims to change that. The MMMRC releases a report every two years with findings and recommendations drawn from data on how many Texans die or develop health problems related to pregnancy and childbirth. But those reports are always outdated; this year’s, released in December, is based on 2019 data, meaning that information about how the pandemic and the abortion ban have affected maternal health has still not been studied. “We have this antiquated way of combing through records,” said Democratic state representative Shawn Thierry of Houston, who filed HB 663. “The data almost becomes moot because it’s so old.”
The biggest hindrance is the time-consuming process of acquiring maternal health data in Texas.
There is no continuous data reporting from hospitals across Texas; instead, the Department of State Health Services periodically requests data on maternal death and illness from individual hospitals around the state. Once DSHS receives hospital records—which can be thousands of pages long—those records have to be redacted to remove details identifying hospitals and particular nurses and doctors. That’s because of the Texas Nurse Protection Act, which requires nurses to report hospitals and providers to the state if they observe subpar care. Under that law, nurses who sit on the MMMRC, or who work at DSHS, would be required to report if they read hospital records that indicate poor care, which would take a lot of time and potentially make hospitals skittish about recording thorough data.
The redaction process often takes months. Once it’s done, the data are passed off to the University of North Texas, which creates a case summary of the records, condensing the salient information into something the committee can review. Finally, the committee receives the data and can begin its work. The committee members argue that this cumbersome process is unnecessary. Ortique noted that every member of the committee is vetted by DSHS and required to sign a nondisclosure agreement. And it’s unusual, she said, for nurses who participate in peer-review activity to be required to report to the state.
Thierry’s bill would streamline the process by creating a statewide database for maternal mortality and morbidity data, and eliminating the reporting requirement for nurses on the committee. The time-eating redactions would no longer be necessary. Thierry said she has strong bipartisan support for her bill. But this is the third session in which she has filed similar legislation, and the bills have yet to make it to the House floor. In 2021, Thierry’s bill was voted out of committee and placed on the House calendar late in the session, but amid the flurry of last-minute legislation that characterizes the Lege, it didn’t reach the floor in time. “Had we had fifteen more minutes last session, we would have had a vote on that bill,” Thierry said.
Until the system is reformed, delays in data access will continue to impact policy decisions. Usually, the biennial report comes out in September—well ahead of both the November elections and the upcoming Lege—but this year, the report (on 2019 data, no less) was late. In September, the Texas Department of State Health Services announced that the report would be delayed until June, after the legislative session ends, contending that the committee hadn’t reviewed enough data to publish its findings. Members of the committee pushed back, arguing that the remaining data was minimal and would not impact their recommendations. “Suppressing and withholding data that does not make us look good is dishonestly burying those women [who have died],” Wilson said at a December 9 committee meeting.
Shortly after, interim DSHS commissioner Dr. Jennifer Shuford announced the report would be released ahead of the legislative session; it came out on December 15. The report found, as it had in previous years, that nearly all of the pregnancy-related deaths in the state were preventable. But for the first time, the committee flagged racial discrimination as a cause of maternal death and illness—particularly when it comes to hemorrhage.
In previous reports, the committee had detailed new protocols to safely treat hemorrhaging, which persists as the leading cause of maternal death in the state. Ninety-seven percent of hospitals statewide had implemented the protocols by 2019, the committee found, reducing maternal mortality—with one exception. For Black women, the rate of hemorrhaging after childbirth actually went up. “It’s discouraging, and it’s telling us that we need to look somewhere else,” Wilson said. The protocol “is working for everyone else, but not Black women? So, what is happening?” About 63 percent of Black women in Texas are on Medicaid when they give birth, which is more than double the percentage of white women who rely on Medicaid coverage during and after pregnancy. (Wilson had private insurance when she gave birth in 2016, but with her other two pregnancies she was on Medicaid.)
At a December 9 committee meeting, Wilson spoke frankly about her fears if she were to become pregnant again. She’s aware that her risks of serious complications or death from pregnancy are significantly higher as a Black woman in Texas. But now she no longer has any real say over whether or not she continues a pregnancy. “The walls are closing in on us,” she said. “We are staring down the barrel of a gun.”