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On 20 August 2016, the UK newspaper The Guardian (among others) published an article about a September 2016 study suggesting that the maternal mortality rate in Texas had doubled in recent years (outstripping that of countries with overall poorer health outcomes): The article noted that reproductive health advocates placed the blame squarely on Texas' unique targeting of reproductive health centers and practices, citing budget cuts, atypically strict reproductive health laws and efforts to defund Planned Parenthood, along with the vast size of the state (which made it difficult for many women to cross state lines to obtain gynecological care unavailable in Texas): Not everyone was convinced the ostensible cause and effect was so clear cut, as noted in a Townhall piece holding that conclusions about Texas' legislative efforts were politically motivated and contradicted by data: Both items cited the study, titled Recent Increases in the U.S. Maternal Mortality Rate published [PDF] in the September issue of the journal Obstetrics and Gynecology. Both the study's title and its objective described a nationwide focus on maternal mortality: Similarly, its conclusion singled out no state by name and made no specific reference to Texas: Texas' second namecheck in the study was benign, noting that the overall rate of maternal mortality was so low that only California and Texas served as sources of by-state data — due not to their specific outcomes, but to the size of their populations: But the Results portion of the introductory page noted that California's and Texas' statistics trended differently and provided a primary finding that colored media coverage of the findings: Much of the research hinged on pinpointing and adjusting for what was described as the pregnancy question (which was added to the 2003 revision of the U.S. standard death certificate), defined by the World Health Organization as death certificate language recording The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. The WHO also provided for late maternal deaths via a separate but similar checkbox: The death of a woman from direct or indirect obstetric causes more than 42 days but less than 1 year after termination of pregnancy. Although the phrasing termination of pregnancy typically is understood to mean an abortion in layman's speech, the researchers and WHO used it to mean the end of a pregnancy via live birth, stillbirth, miscarriage, or abortion. Researchers noted that state-by-state adoption of the pregnancy question vis a vis death records led to findings that required some adjustment to reach conclusions. While some states immediately adopted the guideline in 2003, others waited years. By January 2014, 44 states and the District of Columbia included the question on their death certificates; that incongruous state-by-state data pool led to efforts on the researchers' parts to calibrate the data and parse it. The study noted that Texas (which adopted the question in 2006) demonstrated results that led to uncertainty in the final report: In that section, researchers described Texas' atypical spike in maternal mortality and noted that the laws in question were not likely sufficient to account for the spike (referencing a future study to obtain more information on Texas): The study's introduction cited [e]arlier studies [which] identified significant underreporting of maternal deaths in the National Vital Statistics System, reiterating in its Discussion section that variations by state impeded the research: The study noted that Texas demonstrated what appeared to be a spike in maternal mortality between 2011 and 2014, but researchers weren't yet confident that slashed funding for women's healthcare was primarily responsible for the change. Moreover, researchers mentioned widespread underreporting of maternal mortality across all states, positing it was an international embarrassment that the United States, since 2007, has not been able to provide a national maternal mortality rate to international data repositories such as those run by the Organization for Economic Cooperation and Development. Study author Christine Morton told a reporter that the Texas-specific findings remained an unsolved puzzle: As the Townhall columnist pointed out, Texas did demonstrate upticks in maternal mortality antedating 2011 clinic funding provisions. State data from 1970 to 2014 evidenced the 2011 to 2014 spike in maternal mortality but exhibited a maternal death rate (a number unaffected by the raw number of deaths or births in any given year) that didn't appear to correlate directly with changes in state laws. In 1970, the maternal death rate hovered at 0.3 per 1,000 live births, dropping to 0.1 in 1977 and remaining virtually static until it rose to 0.2 in 2003. That figure remained fairly constant until 2009, when it reached 0.3 at 116 deaths; 2011 saw identical numbers. In 2012, 2013, and 2014 respectively that rate was 0.3 (121 deaths), 0.4 (153 deaths), and 0.3 (139 deaths): So the September 2016 study on the United States' maternal mortality rate published in the journal Obstetrics and Gynecology identified a steady increase in maternal deaths in Texas and cited state laws and funding as a potential (not proven) factor in that post-2011 uptick. But study authors bemoaned a lack of comprehensive record-keeping nationwide that impeded research, and the first year maternal deaths began increasing in Texas was 2003 (before clinics were affected by legislative efforts to reduce abortion).
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