Healthy Texas Mothers and Babies (HTMB) Data Book

The HTMB Data Book provides an overview of maternal and infant health in Texas. In 2020, MCH Epidemiology (MCHE) expanded the HTMB Data Book to include a new maternal mental health section and made substantial revisions to the Perinatal Periods of Risk (PPOR) analysis, maternal mortality, and severe maternal morbidity sections. The HTMB Data Book highlights infant and maternal health outcome trends and disparities and is widely used by other state agencies, programs, and policymakers to make data-driven decisions to improve Texas maternal and infant health outcomes. The Maternal and Child Health Section (MCHS) uses these statistics for various need assessments. The 2022 HTMB Data Book is projected to be published Summer 2023.

Pregnancy Risk Assessment Monitoring System (PRAMS)

 Texas PRAMS data collection for the 2022 birth year began in April 2022. The current Texas PRAMS survey includes questions on maternal attitudes and experiences before, during, and shortly after pregnancy developed by CDC in 2016 plus three supplemental questions on prescription drug use started in 2017 and expiring in May 2023. Texas implementation of the Phase 9 PRAMS Questionnaire begins in June 2023. CDC, with the support of the Texas PRAMS Steering Committee, developed the phase 9 questionnaire that includes supplemental questions emphasizing social determinants of health.

The current available data is from the 2020 birth year and 2021 data will released in Summer 2023. Texas Department of State Health Services (DSHS), other state agencies, and stakeholders continue to use Texas PRAMS data to inform, develop, and drive policies and programs to improve the health of mothers and babies and to understand their emerging health needs. Starting with Texas’ 2019 PRAMS data, an overview of major findings disseminated via the PRAMS Dashboard. Published in August 2021, The Texas PRAMS Dashboard currently contains data from 2012-2019 with the addition of 2020 data in Summer 2023. Ad hoc data analysis requests for single year and multiple years of PRAMS survey data are routinely fulfilled. 

Birth Defects Surveillance

In 2022, the DSHS Birth Defects Epidemiology and Surveillance Branch (BDES) entered over 23,000 birth defect cases (i.e., individuals affected by one or more birth defects) into the web-based abstraction system. By the end of state fiscal year 2022 (8/31/2022), delivery year 2019 was estimated to be 88% complete statewide and more than 95% complete by the start of calendar year 2023. By the end of FY 2022 (8/31/2022), delivery year 2020 was estimated to be 61% complete statewide. Data are used for cluster investigations, looking at the occurrence and patterns of birth defects, prevention and family outreach, studies of access/proximity to services, studies of mortality and survival, causes of birth defect studies, and understanding changes over time. By the end of 2022, more than 450 peer-reviewed publications have used TBDR data.  Noteworthy activities/projects in 2022 include continued work on a new CDC-funded grant (cooperative agreement) to improve the population-based surveillance of birth defects with a focus on increased data quality and automation.

 BDES receives $300,000 per year over 5 years to fund two new staff and a contract with UT School of Public Health.  BDES also submitted a grant application in response to the CDC funding opportunity “Birth Defects Study To Evaluate Pregnancy exposures (BD-STEPS)” RFA-DD-23-001 and is awaiting application funding notification.  

BDES continued sharing information about high-dose folic acid to reduce neural tube defects (NTD) risks through the NTD recurrence prevention mailout initiative. In 2022, BDES identified 170 women from the Texas Birth Defects Registry who had a recent NTD-affected pregnancy. BDES mailed these women information packets to inform them about their increased risk for having another NTD-affected pregnancy and the importance of speaking with their healthcare provider about high-dose folic acid.

BDES has historically referred children 9-18 months old with select birth defects to DSHS social workers for assistance accessing health and social services programs. In 2022, BDES conducted a pilot project with Regional and Local Health Operations (RLHO) social workers in Region 6/5 (Houston area) to connect 3-year-old children with critical congenital heart defects to RLHO social workers. In 2022, BDES referred a total of 170 3-year-old children to RLHO social workers. This pilot demonstrated a need for referral services among older children with birth defects which led to program expansion to include older children over the age of 18 months. In 2022, BDES continued their partnership RLHO social workers to connect children from the Texas Birth Defects Registry to health and social service programs as well as case management. BDES referred a total of 540 children ranging in age from 9 months to 4 old to RLHO social workers in 2022.

Children and Youth with Special Health Care Needs (CSHCN) Data Analysis & Surveillance

In fiscal year 22, MCHS analyzed the data results from the 2020 CSHCN Outreach Survey for Young Adults and Families. The Outreach Survey asks questions of young adults with special health care needs and families of CSHCN related to transition, care coordination, community inclusion, respite care, and emergency preparedness. MCHS distributed English and Spanish versions by mail and online and tracked responses by zip code to confirm Texas CSHCN subset population representation. MCHS uses survey data to develop programming to improve Texas CSHCN wellbeing in Texas across the six core system outcomes.

MCHS contractors also conduct a continuous Family Satisfaction Survey. These surveys are distributed to families who participate in Title V-funded community-based initiatives to determine whether the services provided were accessible, family-centered, continuous, comprehensive, coordinated, compassionate, culturally effective, and assess overall family satisfaction.  In FY23, MCHS is developing an updated CSHCN Outreach Survey that will be distributed and utilized in the same manner. MCHS will deploy the survey in Summer 2023.

Maternal Mortality and Morbidity Data Analysis & Surveillance

In early 2021, the Texas Maternal Mortality and Morbidity Review Committee (MMMRC) began review of the 2019 pregnancy-associated cohort (deaths confirmed to have occurred during pregnancy or within 365 days postpartum using vital statistics data matching). MCHS renewed the contract with the University of North Texas to provide medical records redaction and case synthesis support. DSHS MMMRC recommendations were reported in the 2022 Joint Biennial Report for the Texas Legislature published in December 2022.

MCHE conducted aggregate analyses of disparities in maternal mortality and severe maternal morbidity using statewide vital event, hospital discharge, Texas Medicaid, and census data over the past year. These analyses were designed to be integrated into reports used by the MMMRC during case review and by abstractors preparing these reports. Additionally, through a Memorandum of Understanding with the Texas Health and Human Services Commission, Center for Analytics and Decision Support (CADS), the custodians of Medicaid/CHIP administrative data, MCHE receives periodic data to supplement records ascertainment, and to analyze state Medicaid program enrollment at times of delivery and death. Medicaid/CHIP information is used in case coversheets that list all claims, encounters, and prescriptions within a period of two years prior to the woman’s death.

MCHE continued the successful enhanced method for identifying maternal deaths for years beyond 2012. MCHE staff completed the enhanced method for 2018, 2019, and 2020 cohorts and are currently working on 2021. In 2021, MCHE staff also linked vital event data and Texas Health Care Information Collection (THCIC) data to identify 2018-2021 confirmed and unconfirmed maternal deaths and enhanced reviews are currently underway for these years. Unconfirmed maternal deaths are defined as female Texas resident deaths which did not link to an existing live birth of fetal death yet are indicated to be maternal by a positive pregnancy checkbox value on the death certificate, an ICD-10 obstetric code for underlying cause of death, or both. MCH epidemiologists request relevant records to either support or disprove the indicated maternal status of these deaths.

MCHE continues to work with the MMMRC around health disparity efforts. In July 2021, MCHS kicked off the Discrimination Assessment and Social Determinants of Health (DASH) Facilitated Discussion Tool Pilot Study. Findings will be used to enhance the structure, process, and tool utilization for future MMMRC use in other states and jurisdictions.

MCHS is working with hospitals and other partners to implement national AIM patient safety bundles/toolkits for obstetric hemorrhage, substance use disorder, and severe hypertension in pregnancy. The TexasAIM Obstetric Hemorrhage Bundle concluded in December 2020 and is currently in a maintenance phase. Regarding the TexasAIM Hypertension bundle, 210 hospitals enrolled as of July 2022 representing 93% of Texas birthing hospitals. Due to COVID-19 and the impact the pandemic had on hospitals, the TexasAIM Hypertension bundle was paused to focus on TexasAIM obstetric care and COVID-19 educational needs. A relaunch for the Hypertension bundle is scheduled for Fall 2023. The decision to utilize these evidence-based, standardized care toolkits was informed by MCHE conducted analyses.

Newborn Screening

The Texas Newborn Screening (NBS) Program conducts mandated genetic screening for all Texas newborns.  The Texas NBS Program screens for more than 50 disorders using bloodspot samples taken from the newborn’s heel. The Texas NBS Laboratory tests nearly 800,000 specimens each year. Two samples are collected to maximize detection rates: the first at 24 to 48 hours of age and the second between one and two weeks of age.  The NBS, Clinical Care Coordination team follows up on infants who test positive for a disorder or medical condition. The goal of the Texas NBS Program is to identify infants who have these rare conditions before symptoms arise.  Early detection and treatment can prevent serious complications and even death. Based on provisional data as of June 2022, there are currently 1,017 confirmed cases diagnosed through the NBS program in 2022. On June 1, 2021, Texas began screening for Spinal Muscular Atrophy (SMA), a condition which is among the leading genetic causes of death in infants and toddlers. The program is preparing to add four additional disorders in 2024: Pompe disease, Mucopolysaccharidosis (MPS) type I and II, and Guanidinoacetate methyltransferase (GAMT) deficiency.

Oral Health Needs Assessment & Surveillance

The Oral Health Improvement Program (OHIP) promotes oral health through public health practice leadership, policy development, education, and population-based preventive services. MCHE continues to support OHIP surveillance activities. Every five years, MCHE provides required epidemiological surveillance and analysis for the Basic Screening Surveys (BSS). This surveillance includes providing a list of a representative sample of schools and conducting final weighting and analysis for the 3rd grade and Kindergarten. The 2022-2023 BSS cycle is currently underway.

In 2020, MCHE made updates to the electronic data collection system to accommodate continued data quality improvements for tracking preventive dental service and surveillance. MCHE provided technical support for several requests and action items including a standard operating procedure for data quality management revealed during an internal HHS OHSP audit. MCHE provided several reports/briefs for OHIP including documents utilizing data from the 2017-2018 3rd grade BSS, 2018-2019 kindergarten BSS, 2012-2020 Behavioral Risk Factor Surveillance Survey (BRFSS), 206-2020 National Survey of Children’s Health (NSCH) and School Physical Activity and Nutrition (SPAN) surveys.

MCHE provided analysis and coauthored Oral Health in Texas: A Comparison of Kindergarten and Third Grade Children, a manuscript published in the September 2020 edition of the Texas Dental Journal. MCHE also provided data analysis for oral health projects including the Smiles for Moms and Babies program, a report for the State Board of Dental Examiners, and Human Papilloma Virus (HPV) vaccination data. MCHE collaborated with OHIP to create two oral health posters for the Virtual 2020 CityMatCH Leadership and MCH Epidemiology Conference entitled Teeth Cleaning During Pregnancy in Texas: PRAMS 2012-2016 and Dental outcomes of school children living in border and non-border counties of Texas. MCHE provided analysis and coauthored "Collaborating to Expand Dental Services for Individuals with Special Health Care Needs", a poster presentation for the AMCHP 2022 Annual Conference. MCHE provided analysis and coauthored Oral Health of Texas Children: National Survey of Children’s Health, 2019, a poster presentation for the National Oral Health Conference. MCHE continues to work closely with OHIP to enhance oral health questions for future surveys including SPAN, Youth Risk Behavior Survey (YRBS), and the BRFSS.  

Child Fatality Review Team (CFRT)

To better understand and prevent child fatalities, multidisciplinary teams review a sample of child deaths at the Texas local level per state law.  DSHS analyzes Child Fatality Review Team (CFRT) data in addition to death certificate data.  CFRT collected data augments Texas death certificate data and provide further insight into the causes and circumstances surrounding Texas child fatalities. From 2020-2021, local teams reviewed 2,811 (25%) of the 11,195 child deaths that occurred from 2017-2019. The State Child Fatality Review Team Biennial report published data trends for child deaths occurring from 2017-2019 along with child fatality prevention recommendations based on the leading causes of preventable child deaths including motor vehicle crashes and drowning.