Maternal Mortality Increase in Texas - People Factor vs Clinical Intervention Influence

As an advocate it is tempting to look for "evidence" that supports your "side." An example is maternal morbidity in Texas. Advocates are happy with articles that link poor maternal outcomes to declines in reproductive funding. They are claiming the clinical intervention card. The same advocates would likely be the ones that identify disparities as a problem. This is a people factor claim. Which influence dominates? 

Is it People Factor Influence or is it Clinical Intervention Influence?

It is not acceptable to play the people factor/social determinant card for some studies and claim clinical intervention as a major influence at other times. You may or may not be an advocate for reproductive services in Texas. You may want to believe that cuts in funding for clinical services directly impacted maternal mortality, but this disregards the disparities that often tend to shape outcomes to a much greater degree. 

People factors should consistently be dominant as health outcomes influences, as much as 60 - 70% of outcomes. Clinical interventions should remain a a minor player at 10% - 15% of influence. 

Clinical Intervention Equals Distraction from Better Outcomes

Over forty years of clinical intervention focus has resulted in minimal impact on health outcomes. The quality intervention focus 1999 to the present has made matters worse with substantially higher administrative and other costs - returning clinical intervention focus to highest distorting influence. Meanwhile the important people factors that can change outcomes remain minimized.

After decades there is finally some recognition that Maximizing clinical interventions is what deprives us of the funding needed to address people factors.

People Factor Influence for Health Outcomes Improvements

Behavior changes can have substantial influence. Some behavioral changes (education changes, situation changes, smoking, substance abuse, obesity) can impact outcomes in a relatively few years.  Applied over decades for populations, behavioral changes can substantially prevent the need for clinical intervention (smoking). Minimized people factor focus is the rule rather than the exception. Even in the clinical arena, the cognitive services are paid least, keeping primary care and mental health care from influencing people factors.

There are a number of alternative hypotheses to explore in studies about health outcomes. Texas may be one of the only states with declines in maternal mortality this year, but declines have been seen across states with more disadvantaged populations for a number of years. Texas is not alone in poor outcomes and may just be behind others in timing. 

Texas and People Factors

Texas shows up poorly in a number of studies across health, education, and other outcomes - which indicates the populations that are concentrated in Texas. The people factors drive outcomes - situations, social determinants, behaviors, attitudes. The outcomes of these women have been shaped over the last 15 - 25 years and may also represent 2 or 3 generations of influence. Poor outcomes are common to hundreds of counties where lower cost of living concentrates populations with many different people factor issues.


Beginning a New Era of People Factor Focus - Closing Clinical Focus

It is really sad to see short term influences given blame or credit for changes in outcomes. Recent political changes are too soon for much of anything other than distraction from action.

• Medicaid expansion has at best an indirect impact tied to other changes. 
• ACA did not suddenly improve Kentucky or make Texas worse. 
• Primary Care Medical Home fails for influence but you can compare different populations of patients and have differences.  
• Resident work hours limitations in teaching hospitals cannot change patient outcomes because the populations are the same before and after
• Physician vs nurse practitioner studies should indicate the same "quality" as noted in JAMA if the patient populations are the same or similar.

What is consistent in studies of quality is lower outcomes for populations more closely associated with disadvantage (Pay for Performance via Hong in JAMA, Urban vs rural hospitals, Readmission penalties higher for underserved counties). This is why quality measurement, pay for performance, readmission penalty, and other manipulations fail most where care is most needed.

There are 2621 counties where 40% of the US population is clustered around lower cost of housing/living with lowest concentrations of physicians, physician assistants, and nurse practitioners due to insufficient Medicaid, Medicare, and other lowest paying plans. These are populations left behind by federal, state, corporate, association, and other designers. They are the most complex populations with the least resources and the worst outcomes across health, education, economics, and more. They existed before ACA, before Red vs Blue, before Medicaid expansion, etc. Improvements in their outcomes requires investments in these people and the people that can best invest time and effort addressing behaviors, situations, environments, and other people factors. We have tolerated distraction from real interventions to change outcomes far too long and especially 1999 (To Err is Human) to ACA to the present. 

We must stop the focus on clinical interventions and focus resources
on people factor influences.

Advocates for populations left behind should not play the clinical intervention card and contribute to more decades of populations behind by design.

Thinking Through Insufficient Studies

In the case of obvious bias as in my people factor bias above, there is another consideration. Cuts in reproductive funding could impair the team members to deliver behavioral and other people factor interventions. The real problem is that studies rarely consider people factors. It is much easier to do simple studies. It is also much easier to get published if your study is a nice fit with current controversies.

Of course there is a people factor explanation for worsening maternal morbidity.

This brings up the real debates that we should be having. How do we best support people factor change

• Directly within practices reaching out to people 
• Directly within communities on people factors
• Or both

Prying dollars away from disease focus will be most difficult in any case.


The plot thickens. Turns out Texas has not been alone in mortality rates, with a little research. Texas went from 18 to 37 per 100,000 in Texas in recent years. For some perspective:

• Washington Post Why Pregnant Women in Mississippi Keep Dying 2015 "The problem is particularly acute in the South. For instance, Mississippi’s maternal mortality rate, one of the highest in the country, has been climbing for more than a decade. From 2010 to 2012, the last measure, an average of nearly 40 women died for every 100,000 births. Risk varied drastically by race: The rate for black women, 54.7, was much higher than the rate for white women, 29.3."  Turns out the US nearly tripled maternal mortality from 7.2% to 18.5% across 1987 to 2013. Women enter pregnancy with higher rates of obesity and other problems. 
• For fun, review this article and see how it struggles with the people factors vs the clinical interventions. This one mentions race/civil rights issues, Medicaid coverage, too few doctors, poor nutrition, lack of regular check ups, and doctors not listening to women.
• Washington DC had 38.2 maternal deaths per 100,000 in 2001 to 2006   This place had a 30 to 1 income quintile ratio or $210,000 for the top income quintile compared to $7000 for the bottom income quintile. Disparities are substantial. Are maternal mortality rates subject to the same increases as seen in infant mortality increases and longevity declines?
• US News and World Report noted changes in reporting methods as a reason for an increase in a 2015 media piece. This one promoted insurance access, best practices, and better 24 hour access.

Scientific American also indicated the problems with different data collection: 

• The addition of this question means that the apparent increase in maternal mortality in the U.S. “is almost certainly not a real increase. It’s better detection from the new certificates,” says Robert Anderson, chief of the Mortality Statistics Branch with the CDC’s National Center for Health Statistics. “The numbers are going up but it’s most likely not because women are more likely to die,” he contends. (Anderson’s branch of CDC counts maternal mortality as death during pregnancy or in the following 42 days; some other researchers look at the whole year after giving birth.) States have been slow to switch over to the new form and even now two states—Alabama and West Virginia—still have not adopted it. But “as the certificate with the check box is being implemented over time, we are detecting more maternal deaths,” Anderson says. Another administrative change in how deaths were classified and coded internationally, called the International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10), is also widely believed to be a contributing factor to the uptick in death numbers.

So why not check as to when Texas implemented changes in the forms... 

ACOG had an interesting slideshow indicating a decline in the rates from nearly 1000 in 1920 to less than 10 in 1990 before beginning to rise again. Note the disease focus and lack of people factor focus

1. Better ascertainment – still underestimated
2. Delayed childbearing
3. Obesity
4. Rising C/Section Rate
5. Cardiomyopathy
6. Multiparity
7. Immigration
8. Death Certificate change
9. In Vitro and other technology

More clinical interventions were proposed by ACOG ...

Recent Posts and References 

Solving Mental Health Takes More than Race and Place

Health Access Professional Training Should Avoid Medical Schools

Why Not a Behavior Change Moonshot?

Burying More Americans By Health Design

The Mystique of Medicaid Expansion

A Few Hundred Million More is 8 Billion Less for Primary Care

More Geriatricians Will Not Solve the Geriatric Care Crisis

Prevent MACRA to Do No Harm

Poor Payment Dictates Poor Training Outcomes in Primary Care

No Positive Spin for the Innovator Tailspin - more claims for innovation successes are apparently attempts to hide failure

Stop the Promotion To Restore Mental Health Access - claims of mental health care reforms or improvements are a stark contrast from the reality of lowest payment, highest complexity of care, unreliable payment, and poor support other than lots of rhetoric

The Federal Cause of Shortage Areas and Access Barriers - The Federal Design for payment shapes the breadth, depth, and locations of shortage areas due to lowest payments for Medicaid and Medicare and other plan designs that pay least 

Primary care can be recovered and should be recovered, 

but cannot be recovered when moving the wrong directions

Robert C. Bowman, M.D.        Robert.Bowman@DignityHealth.org

The blogs represent the opinion of the blogger alone.

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