Overview of the State
Texas is a vast state, with regional differences in geography, population size, and demographic and socioeconomic characteristics. This section provides an overview of these variations and the existing challenges related to health care availability and access, as well as cultural literacy and effectiveness in meeting the health needs of Texas mothers, children, and their families.
Geography
Texas is the second largest state in the United States (behind Alaska) in terms of land. The Lone Star State encompasses approximately 262,000 square miles, and accounts for 7.4 percent of the total United States land area. The land area of Texas is equal to that of all six New England states and Ohio, New York, Pennsylvania, and North Carolina combined [[1]]. Texas has a larger land area than any single country completely contained in Europe including France and the Ukraine. Texas is slightly longer than it is wide, with the greatest straight-line distance from the northwest edge of the Panhandle to the southern tip of Texas below Brownsville on the Rio Grande spanning 801 miles [[2]]. The broadest expanse from east to west is 773 miles from the Sabine River in Newton County to the western bulge of the Rio Grande just above El Paso [2].
The geography of Texas is as varied as it is large. Texas includes 254 counties that are classified as either rural or urban (Figure 1), with 88.4 percent of the population residing in urban counties. The five largest metropolitan areas in Texas are located around the cities of Houston, San Antonio, Dallas, Austin, and Fort Worth, and these areas encompass multiple counties. Given the immense size of Texas, the distance that some individuals must travel to receive health care services can be a significant challenge to accessing and receiving those services, especially for those living in rural counties (Figure 1).
Figure 1. Rural and Urban County Designations in Texas, 2020.
For administrative purposes, each of the 254 Texas counties is assigned to one of 8 public health regions. Figure 2 outlines the eight public health regions and the city where each regional office is located. Regions 8, 9/10, and 11 contain border counties.
Figure 2. Texas Public Health Regions.
Population
Just as the Texas geography is varied, so is the distribution of its population (Figure 3). Differences in race/ethnic composition, along with the high percentage of foreign-born residents, present cultural literacy and effectiveness challenges when it comes to meeting maternal and child health (MCH) needs.
Figure 3. Texas Total Population by County, 2019.
Texas also has the second-largest population size in the United States (behind California), with an estimated population of over 29 million in 2019. According to United States Census annual estimates, Texas has been one of the fastest-growing states in the nation since 2010, with a 14.9 percent increase in the Texas population from 2010 to 2019. The Texas Demographic Center predicts that by 2050, the population in Texas will exceed 47 million people [[3]]. The majority of Texans live in the northeast, east, central, south, and gulf coast regions of the state (Figure 3).
Race/Ethnicity
The population of Texas is racially/ethnically diverse with 41.8 percent non-Hispanic White (hereafter referred to as White in the text and graphs), 39.3 percent is Hispanic, 11.8 percent is non-Hispanic Black (hereafter referred to as Black), 4.8 percent is non-Hispanic Asian (hereafter referred to as Asian), and 2.2 percent is non-Hispanic Other in 2019 (data not shown) [3]. Counties with the highest proportions of Hispanic populations are primarily located in the southern and western regions of Texas along the Texas-Mexico border. In 2019, three major cities in Texas (Brownsville, Laredo, and El Paso) were located in counties where over 75 percent of the population was Hispanic, and another three cities (San Antonio, Corpus Christi, and Odessa) were located in counties where over 50 percent of the population was Hispanic (Figure 4).
Figure 4. Percent of the Texas Population who are Hispanic or Latino by County, 2019.
The distribution of the Black population in Texas (Figure 5) differed from that of the Hispanic population. Based on 2019 Texas Demographic Center data, counties with the highest proportions of Black populations were largely concentrated in the northeastern, eastern, and north gulf-coast regions of the state. In contrast to the Hispanic population, the Black population along the Texas-Mexico border was low and estimated to be slightly above 38,000 in 2019.
Figure 5. Percent of the Texas Population who are Black by County, 2019.
Foreign-Born
Texas had a higher percentage of foreign-born residents (17.1 percent) compared to the nationwide average (13.7 percent) in 2019. In total, 60.4 percent of foreign-born residents in Texas were not United States citizens. Over 67.4 percent of foreign-born Texas residents were born in Latin American countries – more than 16 percentage points over the national average [[4], [5]]. Approximately 35.6 percent of Texans spoke a language other than English at home in 2019. Almost 30 percent of Texans spoke Spanish at home, compared with 13.5 percent of United States residents [[6]]. Texas border counties had high percentages of foreign-born residents in 2015-2019, as did several other counties in west and northwest Texas (Figure 6). Counties containing the non-border cities of Houston, Dallas, and Austin also had high concentrations of foreign-born residents. Given these demographic and social variations, the Texas Department of State Health Services’ (DSHS) Community Health Worker (CHW) program has increased the number of certified CHWs to address the need for cultural literacy and effectiveness [[7]].
Figure 6. Percent of the Texas Population who are Foreign Born by County, 2015-2019.
Age
According to 2019 American Community Survey 1-year estimates, Texas is the second youngest population in the United States, with a median age of 35.1 years, behind Utah (median age 31.2 years) [[8]].
In 2019, Texas had the second largest proportion of the population comprised of children younger than 18 years old (25.5 percent) in the nation [[9]]. About 6.8 percent of the Texas population were younger than five years old, 14.4 percent were five to 14 years old, and 4.3 percent were 15 to 17 years old. Texans younger than 22 years of age accounted for 31.2 percent of the total population in 2019. Border counties in South Texas had high percentages of individuals younger than 22 years old, as did several counties in the Texas Panhandle (Figure 7) [[10]].
Figure 7. Percent of the Texas Population Under 22 Years Old by County, 2019.
Women comprised half of the total population in Texas in 2019, and women of childbearing age comprise an important part of the population. Women between 18 and 44 years of age accounted for 18.7 percent of the total population of Texas [10]. For the most part, urban counties with large metropolitan areas (including counties containing the cities of Dallas-Fort Worth, Houston, San Antonio, Austin, and El Paso) had the highest proportions of women in their childbearing years (Figure 8).
Figure 8. Percent of the Texas Population Who Are 18-44 Years Old and Female by County, 2019.
Children with Special Health Care Needs
The 2019 National Survey of Children’s Health (NSCH) estimated that 15.8 percent of Texas children ages 0-17 had a special health care need. Of those Texas children identified as Children with Special Health Care Needs (CSHCN), 47.0 percent were White, 37.9 percent were Hispanic, and 8.7 percent were Black [[11]].
Socioeconomic Characteristics
Socioeconomic characteristics such as income and poverty, food security, education, unemployment, and crime rates are added challenges for meeting the health needs of mothers, children, and families in Texas. The presence of an increased number of risk factors of this nature in a community pose a danger to the health of the individuals within that community throughout the entire life course.
Income and Poverty
Income inequalities exist within different areas in Texas and largely reflect gender and race/ethnic differences. In 2019, the median household income in Texas was $61,874, which was slightly lower than the national median household income of $62,843 [8].
The Federal Poverty Level (FPL) is set by the United States Census Bureau based on income thresholds that vary by family size and composition. If a family’s total income is less than their determined income threshold, then that family and every individual in it is considered to be in poverty. These poverty thresholds are used throughout the mainland United States and do not vary geographically; however, they are updated each year to account for inflation. According to 2019 American Community Survey estimates, Texas had a higher proportion (13.6 percent) of people living below the FPL than the national average of 12.3 percent [8].
The proportion of adults living below the FPL varies geographically and by sex. Among the adult population aged 18 and older in Texas, counties with a large proportion of adults living below the FPL in 2015-2019 were concentrated in the Texas-Mexico border region. Several counties in east Texas, north central Texas, and the Texas Panhandle also had high rates of adults living below 200 percent FPL (Figure 9).
Figure 9. Percent of the Texas Adult Population Below 200 Percent Federal Poverty Level by County, 2015-2019.
It was estimated that about 15.0 percent of the female population lived below the FPL in Texas in 2019 [[12]]. Counties in the Texas-Mexico border region had high rates of women living below the FPL, as did several counties in rural East Texas, west of Fort Worth. The fastest growing major metropolitan areas – Austin, Houston, and San Antonio – had a relatively low proportion of women living below the FPL (Figure 10).
Figure 10. Estimated Percent of the Texas Adult Female Population Below 100 Percent Federal Poverty Level by County, 2015-2019.
Food Security
Food security refers to a household’s ability to provide enough food to keep each member of the family active and healthy. Along with negative health outcomes, food insecurity can make it difficult for children to learn and grow [[13]]. Overall, the food insecurity rate in the United States is an estimated 12.5 percent of the total population and 17.0 percent of children. As of 2018, 22.5 percent, nearly one in four children in Texas live in a food insecure household. There are eight counties in Texas where 30 percent or more children experience food insecurity (data not shown) [[14]].
Education
As higher educational attainment has been associated with positive health outcomes, it is crucial to understand education within the context of Texas [[15]]. Among those 25 years and older, a greater percentage of both men (15.9 percent) and women (14.8 percent) in Texas had less than a high school education in 2019, compared with men (12.1 percent) and women (10.8 percent) nationwide. About 25 percent of Texas residents aged 25 and older had a high school diploma or equivalent as their highest level of educational attainment, and 20 percent had a bachelor’s degree or higher [9].
Educational attainment levels are not evenly distributed throughout the state. There were four counties where the educational attainment of a bachelor’s degree or higher was greater than 45 percent among individuals 25 years of age and older: Denton and Collin counties outside of Dallas, Fort Bend county outside of Houston, and Travis county in central Texas (part of the Austin-Round Rock metropolitan area). Counties where less than 10 percent of the people aged 25 years and older had a bachelor’s degree or higher were largely clustered in south Texas, west Texas, and east Texas [8].
Unemployment
While Texas had a higher percentage of adults without a high school diploma compared to the nation, it had about the same rate of unemployment (4.4 percent) as seen nationwide (4.5 percent) in 2019 [8]. Even among persons aged 25-64 without a high school diploma, Texas had a lower rate of unemployment (4.4 percent) compared to the national average for this educational attainment group (6.7 percent). Consistent with nationwide trends, the Texas unemployment rate increased as education level decreased. The unemployment rate in Texas was as low as 2.5 percent among those with a bachelor’s degree or higher in 2019 [8].
Crime
Crime impacts the physical and behavioral health and wellbeing of mothers, children, and their families. Neighborhood crime can be detrimental to the safety of children by creating unstable living environments. By assessing communities where crimes occur more frequently, it is possible to identify areas where high risk populations reside and help prevent adverse consequences. In 2019, Texas’ Crime Rate was 2,779.3 crimes per 100,000 persons [[16]].
Texas index crime statistics include two major categories of crime: property crimes and violent crimes. Property crimes consist of burglary, larceny-theft, and motor vehicle theft. The 2019 property crime rate was 2,363.7 crimes per 100,000 Texans. The highest property crime rates in 2019 were primarily localized within larger Texas cities and their surrounding areas (Figure 11) [16].
Figure 11. Texas Property Crime Rate per 100,000 Residents by County, 2019.
Violent crimes recorded in the Uniform Crime Report index include murder, rape, robbery, and aggravated assault. The violent crime rate was 415.6 crimes per 100,000 Texans. The highest violent crime rates in 2019 were primarily concentrated near the larger cities of the panhandle: Odessa, Lubbock, and Amarillo (Figure 12). Houston, Dallas, San Antonio, Corpus Christi and surrounding areas also had a high concentration of violent crimes [16].
Figure 12. Texas Violent Crime Rate per 100,000 Residents by County, 2019.
Violence within Texas families has also been recognized as a growing threat to the safety of Texans. The Uniform Crime Report indicated 196,902 family violence incidents in Texas in 2019. Although the largest percentage of family violence was between other family members (56.5 percent), family violence also occurred among spouses/couples (27.3 percent) and within parent-child relationships (16.1 percent). Females were more likely to be victims in family violence. Of the victims whose gender was known, 28.7 percent were male, and 71.3 percent were female. The 25-29 age group had the highest number of victims in family violence [16].
Mobility/Migration
Moving or relocating is one of life’s most stressful events and can impact individual health and well-being. For example, results from the Texas School Survey of Substance Use show that this may influence risk behaviors in youth, as students in grades seven to 12 living in their current school district for three years or less are more likely to use illicit drugs than those living there more than three years [[17]]. Texas demographic data illustrates patterns of migration that include moving into the state from other states and countries and moving within the state between counties.
Out-of-State Mobility/Migration
Four Texas metropolitan areas (Houston, Dallas, Austin, and San Antonio) together added more people than any state in the country (except for Texas as a whole) between 2016 and 2017. The population in these four metropolitan areas increased by more than 350,000 people in a year. Among these four fastest-growing areas in Texas, between 2016 and 2017, two to three percent of the population consists of people who moved to the area from out of state (out-of-state migration). Some rural counties also had high levels of out-of-state migration in 2015-2019, particularly in the parts of the state bordering Oklahoma and the Panhandle, as well as in west Texas (Figure 13) [8]. The majority of Texas counties had little to no new residents from other states.
Figure 13. Percent of Resident Population that Moved from Another State to Texas by County, 2015-2019.
The oil and gas industry is concentrated in three areas of the state, west near Odessa, south between San Antonio and Corpus Christi, and west near Fort Worth (data not shown). In previous years, migration of people into these areas could be attributed to the jobs created by the oil and gas industry, but in recent years drilling permits have fallen from 10,533 approved drilling permits in 2018 to 9,616 in 2019 [[18],[19]]. Additionally, Texas is home to 13 United States military installations. A number of counties that saw a high level of out-of-state migration also have a United States military base nearby. In 2019, the military contributed to 226,555 direct jobs to the Texas economy [[20]].
In-State Mobility/Migration
Another aspect of mobility is the number of people who move within or between counties in Texas. While out-of-state migration may reflect job growth, mobility of populations within a county and between counties is more complicated.
Counties with universities and colleges in Texas were among the highest rates of within-county relocations over a one-year period [8]. College Station, Austin, Lubbock, and San Antonio are home to four of the ten largest universities in Texas, which can partially explain the high rates of within-county relocations in these areas. College students tend to move often within the same county to take advantage of lower rents.
Health Care Coverage and Access
Health insurance and access to health care are fundamental to the health of Texans. With 18.4 percent of the state’s population uninsured, Texas has the highest uninsured rate in the country [[21]]. Percent of the population that is uninsured is shown in Table 1. Region 11 has the highest uninsured rate and Region 7 has the lowest rate.
Table 1. Percent of Population that is Uninsured by State and Public Health Region
|
Region |
Percent Uninsured |
|
Texas |
18.4% |
|
Region 1 |
19.3% |
|
Region 2/3 |
19.1% |
|
Region 4/5N |
20.6% |
|
Region 6/5S |
20.4% |
|
Region 7 |
16.0% |
|
Region 8 |
18.1% |
|
Region 9/10 |
22.0% |
|
Region 11 |
28.2% |
|
Source: Small Area Health Insurance Estimates, 2018. Current Population Reports, United States Census Bureau, 2019. |
|
|
Prepared by: Maternal and Child Health Epidemiology Unit |
|
Health Insurance
Texas had the highest proportion of the population without health care coverage of any state in 2019, with 18.4 percent uninsured. The national average was 9.2 percent. Texas had higher proportions of uninsured children, uninsured women of childbearing age, and uninsured individuals living below 200 percent FPL than the corresponding uninsured percentages for these groups nationwide. In Texas, 10 percent of children younger than six years old were uninsured, and 28.2 percent of Texas women aged 19 to 44 were uninsured. Furthermore, 30.6 percent of Texans living below 100 percent FPL were uninsured [[22]]. In addition, 2018-2019 NSCH data showed that 10.6 percent of CSHCN ages 0-17 in Texas had no health insurance or had periods of no coverage during the year prior to the survey, higher than the nationwide average of 6.9 percent [[23]].
Counties with high proportions of uninsured children younger than six years of age were concentrated in west Texas between Odessa and San Antonio, and in the Panhandle (Figure 14). The Texas-Mexico border regions and several counties outside Lubbock and Waco had high proportions of women aged 19 to 44 without health insurance (Figure 15).
Figure 14. Percent of Texas Children Younger than Six Years Old Without Health Insurance by County, 2014-2018.
Figure 15. Percent of Texas Women (19-44 Years) Without Health Insurance by County, 2015-2019.
Access to Health Care
Given the large size of the state and the vast distances between points of care for health services in rural areas, access to care in the state of Texas can be a challenge. There was an increase in the number of primary care physicians in Texas from 18,834 (70.6 per 100,000 population) in 2013 to 22,610 (78 per 100,000 population) in 2019. However, 32 counties still had no primary care physicians in 2020 (Figure 16).
Figure 16. Number of 2020 Primary Health Care Physicians per 100,000 Texas Residents by County, 2019.
The total number of obstetricians (OB) and/or gynecologists (GYN) increased from 2,483 in 2013 to 2,678 in 2018. The density of OB/GYNs in Texas increased slightly from 18.5 OB/GYNs per 100,000 females in 2013 to 18.6 per 100,000 females in 2018. A total of 155 counties had no OB/GYN in 2017 [[24]].
The National Association for School Psychologists recommends a student-to-provider ratio of 1,000:1 [[25]]. In Texas, only 23 counties met this recommendation in 2019, including Travis and Bexar counties which respectively contain the cities of Austin and San Antonio (Figure 17).
Figure 17. Ratio of Texas Students to School Psychologists by County, 2020.
Psychiatrist shortage is also a concern. The HPSA cut-offs for designating an area with a mental health shortage is 30,000 people or residents to one psychiatrist, and 20,000 people/residents to one psychiatrist in areas with high needs [[26]]. One hundred and seventy-three counties do not have a psychiatrist, and many that do have at least one psychiatrist meet the HPSA criteria for the mental health shortage designation [[27]]. Several counties surrounding major cities, however, met one of the two HPSA cut-offs (Figure 18).
Figure 18. Ratio of 2020 Psychiatrists to Texas Residents by County, 2020
Additional challenges exist in identifying psychiatrists who specialize in child psychiatry. It is estimated that there are only about 8,300 practicing child and adolescent psychiatrists in the country [[28]]. There are almost no child and adolescent psychiatrists in the state practicing outside of major cities in Texas.
Emerging Issues
The 87th Texas Legislature, Regular Session convened on January 12, 2021 and adjourned May 31, 2021. DSHS tracked approximately 700 bills during that time, and of the 36 bills that were assigned to MCH, 7 of those bills passed and will impact MCHS. House Bill (HB) 4 relating to the provision and delivery of health care services under Medicaid and other public benefits programs using telecommunications or information technology and to reimbursement for some of those services; HB 1164 relates to patient safety practices regarding placenta accreta spectrum disorder; HB 1967 relates to a database of information about women with uterine fibroids and to uterine fibroid education and research; HB 2831 relates to the confinement in county jail of persons with intellectual or developmental disabilities; Senate Bill (SB) 970 relates to the repeal of certain provisions related to health and human services; SB 1578 relates to the use of opinions from medical professionals in making certain determinations relating to the abuse or neglect of a child; and SB 1941 relates to the creation of a hyperemesis strategic plan. Lastly, per an exceptional item submitted by the DSHS, the appropriations bill, Senate Bill 1, now includes a rider that allows for greater flexibility with funding for maternal mortality programming.
The positioning of DSHS’ Maternal and Child Health Section (MCHS) program staff at both the state and regional levels allows a broad and local approach in addressing current and emerging issues, including novel coronavirus (COVID-19), lung injuries associated with vaping, and maternal mortality and severe morbidity in Texas.
Addressing COVID-19
In 2019, a novel coronavirus emerged causing a respiratory disease known as COVID-19 and leading to a pandemic which is ongoing as of August 2021. The disease was first reported in the United States in late January 2020 [[29]]. Texas reported its first case in early March 2020. As of March 16, 2021, Texas had over 2,351,382 confirmed cases and 45,700 fatalities, with 4,279 new cases and 69 fatalities on March 16, 2021. All 254 Texas counties have reported cases, indicating widespread community transmission [[30]].
As of August 2021, the Food and Drug Administration issued Emergency Use Authorization to Moderna, Pfizer-BioNTech, and Janssen (Johnson and Johnson) for their COVID-19 vaccines. Distribution of COVID-19 vaccinations have been underway in Texas since December 2020. As of March 20, 2021, a total of 9,204,921 doses of the COVID-19 vaccination have been administered in Texas, with 3,148,130 individuals being fully vaccinated [[31]]. In May, 2021, vaccine eligibility opened up to all individuals in Texas over the age of 12.
Implications for the maternal and child population
Although implications of this virus are still being studied, pregnant women may be at increased risk for severe symptoms and there is a potential for negative effects on birth outcomes when exposed, so pregnant women are encouraged to take precautions to protect themselves from the risk of infection [[32]]. DSHS is assisting TexasAIM hospitals for readiness and response to COVID-19 by providing information and resources, as it relates to key practices in obstetric care, including through an online resource, newsletter, and discussion platform and, previously, a series of webinars. Through TexasAIM, hospitals triaged and cared for obstetric patients during the pandemic.
The risks associated with COVID-19 to pregnancy outcomes, to infants born to infected mothers, and for breastfeeding infants are still under investigation [6].
Although children infected with COVID-19 typically experience mild symptoms, some children do experience severe illness when infected with COVID-19 [[33]]. Multisystem inflammatory syndrome in children (MIS-C) has occurred in children who had or were exposed to COVID-19. MIS-C causes inflammation of heart, kidneys, lungs, brain, skin, eyes, and gastrointestinal organs. Most children with MIS-C need to be treated in the hospital or Intensive Care Unit [[34]]. As of March 15, 2021, there were 97 reported cases of MIS-C in Texas, with nearly half (45 cases) occurring in Public Health Region 4/5S [[35]].
Beyond the effects of the infection and complications from the infection, there were concerns over the impacts of closing schools (e.g., related to the health and wellbeing of children who depend on school meal programs living in food insecure situations) [[36]]. Measures to contain the spread of the virus, like social distancing and stay-at-home orders, may increase domestic abuse and child abuse and neglect due to the situational stress, social isolation, and reduced interactions with teachers who often report abuse [[37], [38]]. The impacts of COVID-19 on maternal and child health are not yet fully known, but the need to monitor the health and wellbeing of this population is evident.
DSHS Response
The DSHS commissioner, Dr. John Hellerstedt, declared a public health disaster on March 19, 2020. Governor Greg Abbott began issuing executives orders on April 17, 2020 to reopen the state of Texas in phases with regards to the continually-evolving situation while taking health safety precautions. He issued an executive order on July 20, 2020 requiring face covering over the nose and mouth in public places. On March 10, 2021, the governor lifted the executive order requiring face coverings and fully reopened the state of Texas. DSHS continues to work with the CDC to closely monitor the situation and disseminate the most updated information and resources on a DSHS webpage dedicated to the coronavirus. DSHS launched a COVID-19 case dashboard which is updated daily with the preliminary number of cases by county and include basic demographic information [[39]]. DSHS has also launched a COVID-19 vaccination dashboard which is updated daily with number of vaccinations administered by county [33].
Lung Injury Associated with Vaping
In 2018, DSHS announced vaping usage had reached epidemic levels. Vapes or electronic cigarettes are tobacco products that contain a battery which heat a cartridge containing nicotine, tetrahydrocannabinol (THC) and/or cannabinoid (CBD) oil, along with flavoring. The heat creates an aerosol that is then inhaled into the lungs [[40]]. These products have been on the market since 2007, but have recently experienced a rise in popularity, particularly among youth. As of 2014, these products have become the most commonly used tobacco product for youth [14]. Vaping is associated with a number of dangers including electronic devices catching on fire, nicotine use harming adolescent brain development, and poisoning from swallowing the vaping liquid. Particular attention has been drawn to the negative health outcome of bronchiolitis obliterans, a lung injury associated with vaping causing scaring of air sacs within the lungs, leading to narrowing of air ways. As the airways narrow, patients experience shortness of breath and wheezing [14].
As of February 2020, in the United States there have been about 2,800 hospitalized cases of lung injury associated with vaping. Of those cases, there were 250 cases of lung injury and four deaths associated with vaping in Texas [[41]].
DSHS Response
In response to the vaping epidemic, DSHS has utilized both existing tobacco programing, as well as developed novel vaping specific programs. Some of the existing programming include the Texas tobacco phone quitting line called ‘Yes Quit.’ This program includes both online and telephone resources for individuals quitting tobacco use. Other existing tobacco programming includes the ‘Students and Youth Working Hard Against Tobacco!’ or the ‘Say What!’ program which is a youth tobacco prevention collation program working to reduce youth tobacco usage.
While many of the existing tobacco initiatives have adapted to also address electronic cigarettes, more specific vaping programming has been developed. Within the DSHS Tobacco Prevention and Control Program website, there is now a specific vaping section which houses resources and information related to vaping. The tobacco unit has also developed a general presentation that can be tailored to a variety of different audiences, highlighting vaping information, health risks, and prevention strategies.
Addressing Maternal Mortality and Severe Morbidity
In April 2017, the DSHS’ MCHS staff attended the National Alliance for Innovation on Maternal Health (AIM) meeting in Baltimore, MD. Key partners were identified, and the staff learned about effective and efficient strategies for implementing the Council on Patient Safety in Women’s Health Care AIM-supported maternal patient safety bundles in Texas. In August 2017, the 85th Texas Legislature passed Senate Bill 17 which required the state to implement Maternal Health and Safety Initiatives. In December 2017, DSHS applied for and was selected as the lead coordinating agency to implement the AIM maternal safety bundles, starting with Obstetric Hemorrhage (launched November/December 2018), Hypertension (launched Winter 2020 due to COVID-19), and Obstetric Care for Women with Opioid Use Disorder (pilot currently being conducted).
In January 2018, DSHS created the AIM Implementation Advisory Workgroup. This group includes representatives from Texas’ Perinatal Advisory Committee, the American College of Obstetrics and Gynecologists, the Consortium of Texas Certified Nurse Midwives, the Texas Hospital Association, the Texas Medical Association, the Texas Collaborative for Healthy Mothers and Babies, and the Texas Nursing Association. DSHS held webinars and sent a letter to all Texas birthing hospitals to recruit hospitals to participate. DSHS hosted the TexasAIM Leadership Summit and Orientation on June 4, 2018, which was the kickoff meeting for TexasAIM. There were over 330 attendees present at the Summit, which included at least one representative from over 150 participating hospitals. In December 2020, a “Leadership Summit and Kickoff Meeting" was held to highlight the successes of the TexasAIM OBH Program and to mark the launch of the AIM Plus Sever Hypertensions in Pregnancy (HTN) Learning Collaborative. There were over 590 attendees present at this virtual meeting. As of September 2020, 219 of Texas’ 223 hospitals with obstetric lines of service were enrolled in TexasAIM and participate in the TexasAIM Obstetric Hemorrhage Bundle. These hospitals represent 98 percent of all the birthing hospitals in Texas and provide care for approximately 99 percent of the births in Texas and approximately 9.9 percent of the births in the nation [[42]]. Regarding TexasAIM HTN, there are 197 hospitals enrolled as of March 2021 representing 88% of Texas birthing hospitals and learning sessions for these participating hospitals began in April 2021. Additionally, a harvest meeting was planned for the Spring but has been replaced with a series of structured interviews with improvement team members from high performing hospitals participating in the TexasAIM Plus Obstetric Hemorrhage Learning Collaborative.
The TexasAIM Faculty Chair approached MCHS staff to disseminate information around COVID-19 to hospitals given that 98 percent of the birthing hospitals participate in TexasAIM. Weekly webinars on COVID-19 and the impact on labor and delivery practice have been discussed as it relates to readiness, recognition, response, and reporting and systems learning. Some discussions have been related to the guidelines and protocols hospitals are using for the prevention of anemia and how they are conserving blood products, transport protocols and how a rural hospital was approaching their COVID-19 response.
Additionally, MCHS has been collaborating with staff from the Substance Use Disorder Unit at the Texas Health and Human Services Commission and the Texas Targeted Opioid Response Initiative to improve the quality of care for women with substance use disorders and children with Neonatal Abstinence Syndrome. In June 2018, DSHS recruited ten hospitals to begin independently testing implementation of the newly released AIM Obstetric Care for Women with Opioid Use Disorder (OB-OUD) Bundle components and assessing the operational considerations and feasibility of implementation. Participating hospitals partook in a series of collaborative calls to share lessons learned to-date regarding implementation of the OB-OUD bundle components and to discuss barriers of implementation. A series of structured qualitative interviews with the hospitals’ improvement teams began in the Summer of 2020 and concluded in the Fall of 2020. Lessons learned from these activities will inform development of programming and an approach to customize the bundle for implementation of a TexasAIM Plus OB-OUD Learning Collaborative.
DSHS is responsible for overseeing the maternal levels of care designation process for Texas. The maternal levels of care designation rule became effective on March 1, 2018 and the designation for maternal level of care is an eligibility requirement for Medicaid reimbursement beginning September 1, 2021.
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[36] Feeding America: Map the Meal Gap (2020). No one should go hungry during the COVID-19 pandemic. Retrieved from https://www.feedingamerica.org/take-action/coronavirus?s_onsite_promo=lightbox
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