Maternal & Child Health

Pregnant women and children in Houston’s three-county region have poorer health outcomes compared to national averages, jeopardizing the future well-being of mothers and their children

Overall infant and child mortality rates in the region are down, but we’ve seen declines in health and well-being in pregnant women, infant vaccinations and child nutrition over the last decade. Racial disparities have either widened or remained flat — the result of variation in underlying chronic conditions, inequitable access to quality health care, and implicit bias in our health care system.

The data

Disparities in maternal and child health outcomes across racial/ethnic groups are deep and pervasive

Racial/ethnic disparities in maternal, infant and child mortality and health have been evident for many years.⁶ Women of color, particularly Black women, consistently have the highest maternal mortality rates. Multiple factors contribute to these disparities, such as variation in underlying chronic conditions, access to quality health care, implicit bias and structural racism.

For a variety of environmental and social reasons, Black women are more likely to have pre-existing conditions such as obesity, heart disease, and diabetes prior to being pregnant, which increases pregnancy risks and the likelihood of complications.⁷ Further, the health care they receive is typically of lower quality — not only because of lower-quality health care establishments and caregivers⁸ but also because of implicit racial bias embedded in the health care system. For example, health concerns and reported pain from Black patients are more likely to be dismissed than those from white people.⁹ The Listening to Mothers Survey III found that one in five Black and Hispanic women reported poor treatment from hospital staff — citing factors such as race, ethnicity, cultural background or language — compared with 8% of white mothers.¹⁰

National data show that Black women are more likely to receive delayed prenatal care (after the first trimester) or none at all.¹¹ While Medicaid covers women who are pregnant, women must first learn they are with child, apply for coverage, and wait to be approved before they are able to seek care. By the time this happens, it could be after the first trimester of gestation.

Black women are also more likely to receive poor follow-up care after the baby’s birth or none at all.¹² Nearly 71% of women who died from pregnancy-related causes in Texas in 2013 died within one year after the baby was born, according to a 2020 report from the Texas Maternal Mortality and Morbidity Review Committee.

Black women have higher maternal mortality rates than white women even when income and education are controlled.¹³ This phenomenon led some researchers to theorize that extreme emotional and psychological stress can produce a sufficient physiological reaction, called “weathering,” that harms, or ages, the body and could lead to negative health outcomes, including maternal and infant mortality rates.¹⁴ Meaning, the compounding trauma and stress simply from being both Black and a woman could contribute to racial disparities and negative outcomes in maternal and child health. This could also explain why the mortality rate for Black mothers over 40 is nearly triple that for white mothers in the same age group.^15,16,17

The national maternal mortality rate jumped 37% between 2018 and 2020

One of the more troubling trends in health is the increasing number of women who die from pregnancy-related complications. The World Health Organization defines a pregnancy-related death as the death of a woman while pregnant or within 42 days of the end of pregnancy from any cause related to or aggravated by the pregnancy.

The leading causes of pregnancy-related death in Texas include cardiovascular-related issues, mental disorders, hemorrhaging, and preeclampsia, characterized by extremely high blood pressure.The Texas Department of State Health Services estimates 89% of these deaths in 2013 could have been prevented.

Between 1987 and 2018, maternal mortality in the United States soared 140%. (Because of changes in methodology, data prior to 2018 cannot be compared with data for 2018 and after.)

In 2020, 861 women died of maternal causes (i.e., women who die from pregnancy-related complications while pregnant or within 42 days of giving birth) in the U.S., an increase from 754 in 2019. The maternal mortality rate in 2020 was 23.8 deaths per 100,000 live births, up from 20.1 in 2019, and higher still from the 2018 rate of 17.4 — a 37% increase.

Other wealthy nations are not experiencing the high rates of maternal mortality found in the U.S. In Canada, the maternal mortality rate is about 10 per 100,000 live births, while in the U.K. it is 7. The U.S. trend is also at odds with several less developed countries, where maternal mortality has declined.

The maternal mortality rate in Texas in 2018 was 18.5 per 100,000 live births, above the U.S. average of 17.4. When data between 2018 and 2020 are combined, the maternal mortality rate in Texas is 22.9 — still higher compared to 20.4 overall in the U.S. Among the 30 states for which a rate was calculated, Texas ranks in the middle, with the highest rate in Arkansas (40.4) and the lowest rate in California (10.2).

Maternal mortality rates vary drastically by both race/ethnicity and age. In 2020, the maternal mortality rate for Black women was 55.3 deaths per 100,000 live births. This is not only nearly three times the rate for white women (19.1), but it is also 1.5 times the rate from two years earlier in 2018 (37.3 deaths per 100,000 live births).

Typically, the younger the woman’s age, the lower the mortality rate. The maternal mortality rate per 100,000 live births was 13.8 for all women under 25 years of age, 22.8 for women between 26 and 39, and 107.9 for women 40 and older. However, Black women under 25 are still 1.5 times more likely to die than white women between 25 and 39 years of age.

Women over 40 face a much higher rate of maternal mortality than women under 40. Black women across all ages experience higher rates of maternal mortality. In 2020, Black women over the age of 40 had a maternal mortality rate of 263.1 per 100,000 live births, nearly triple the rate for white women in the same age group (96.8).

Maternal Morbidity

Maternal mortality can be too small (statistically) to see meaningful trends at smaller geographies, so researchers often cite severe maternal morbidity. Severe maternal morbidity can be considered “a near miss” for maternal mortality and refers to unexpected outcomes of labor and delivery resulting in significant short- or long-term consequences to a woman’s health.¹⁸

Between 2008 and 2015, Harris County’s incidence of maternal morbidity increased 53%, compared to a 15% percent increase for Texas overall. In order to address this rise in Texas, in 2021 lawmakers passed a bill expanding postpartum Medicaid coverage from two months to six months, but many advocates hoped for a full year of health coverage to reflect the long-term impact of giving birth on a woman’s body. Similar to maternal mortality, maternal morbidity in Texas has significant variation in rates across racial/ethnic groups.¹⁹

Pregnant women in Fort Bend and Harris counties access prenatal care in their first trimester at lower rates than the state and nation

Early prenatal care is defined as pregnancy-related care beginning in the first trimester (1-3 months). It has been viewed as a strategy to improve pregnancy outcomes for more than a century.

Nationally, less than 2% of pregnant women received no prenatal care during their pregnancy in 2020. In Texas, the rate was double at 4%. In the three-county area, the rate of no prenatal care ranged from 5.6% in Harris County to 3.2% in Fort Bend and 1.5% in Montgomery in 2020.

While none of the three counties is considered maternity care deserts, a lack of health insurance is the largest contributor to women delaying or not accessing prenatal care.²⁰ While Medicaid covers women who are pregnant, women must first learn they are with child, apply for coverage, and wait to be approved before they are able to seek care. By the time this happens, it could be after the first trimester of gestation. In an analysis of national data, researchers found women with Medicaid were less likely to begin prenatal care in the first trimester and were less likely to receive adequate prenatal care compared to privately insured women.²¹

More than 77% of pregnant women in the U.S. received prenatal care in the first trimester in 2020, unchanged since 2016. While early prenatal care has slightly increased recently in Texas to nearly 70% in 2020 from 67% in 2016, it remains below the national rate. In fact, Texas was ranked last in the country for early prenatal care in 2016, according to the most recent report on the topic from National Center for Health Statistics.

Regionally, pregnant women in Montgomery County receive early prenatal care at higher rates, 73% compared to 60% in Fort Bend and Harris counties. The rate of early prenatal care in Harris County has not improved since 2016, and the rate in Fort Bend has declined by more than 10 percentage points from 2019 to 2020.

Overall infant mortality in the Houston-area has ticked down in the last decade, though racial disparities have widened

Infant mortality is defined as the death of a baby before their first birthday, and it is regarded as a strong indicator of the overall health of a population. The five leading causes of infant death are congenital malformations, low birth weight, maternal complications, sudden infant death syndrome (SIDS), and unintentional injuries. The health of the mother, level of prenatal and postnatal care, and access to health care also influence infant mortality.²²

Infant mortality rates are highest among infants born to teenage moms and women over 40. Babies born to mothers with obesity or mothers who smoke or consume alcohol during pregnancy also have a greater risk of infant mortality, particularly during the first 28 days after birth.^23,24,25

The infant mortality rate in the United States was 5.6 deaths per 1,000 live births in 2019. Despite the progress made to reduce infant mortality in the past decades, the national rate is still higher than that of other developed countries. Data from Organization for Economic Co-operation and Development (OECD) shows the 2021 infant mortality rate in the U.S. is higher compared to several nations, including Russia, Canada, the Netherlands, France, Poland, United Kingdom, South Korea, and Estonia.

Infant mortality in Texas was 5.6 per 1,000 live births in 2017–19, slightly lower than the national average. Locally, the highest infant mortality rate is in Harris County, and the lowest rate is in Fort Bend County. While infant mortality rates over the past decade have dipped in Texas, they have remained relatively flat in Harris County. Wide disparities exist among racial groups, for many of the same reasons described above.

In Harris County, the infant mortality rate for babies born to Black mothers is three times that for babies born to white women. While the infant mortality rate in Harris County for white women has remained relatively flat, it has worsened for Black women — up 26% between 2011 and 2018. The racial disparity in infant mortality rates in Harris County is nearly 1.5 times the gap at the state and national level.

Among the three regional counties, the mortality rate in 2018 for babies born to Black mothers was highest in Harris County (11.19 per 1,000 live births) compared to the nation (10.6) and Texas (9.9). This is different from what we see among white mothers. The mortality rate in 2018 for babies born to white mothers was lowest in Harris County (3.7 per 1,000 live births) compared to Texas (4.5) and the nation (4.5).

Babies born to mothers in Fort Bend and Harris counties tend to have the lowest birth weights in the region

Newborns weighing less than 2,500 grams, or 5.5 pounds, are considered low birth weight. In addition to the high risk of infant mortality, infants with low birth weight also face short- and long-term health conditions that can permanently affect their quality of life, such as intestinal disorders, learning and behavioral problems, and type 2 diabetes.^26,27

The most common causes of low birth weight are premature birth (birth prior to 37 weeks gestation) and restricted fetal growth (when a fetus is smaller than expected for its gestational age). Environmental risk factors contribute to fetus development — exposure to air pollution (both indoor and outdoor) and drinking water contaminated with lead are also found associated with low birth weight.²⁸ This has significant implications since communities of color and low-income communities are more likely to be exposed to contaminated air and water. Additional risk factors such as smoking or drinking alcohol during pregnancy may also lead to slower fetus development even if the baby was born full-term.

Nationally, the percentage of infants born with low birth weight has ticked up slightly to 8.24% in 2020 from 8.15% in 2010. Regionally, 8.26% of babies in Fort Bend County, 8.72% in Harris County, and 6.79% in Montgomery County were born with low birth weight in 2020. Low birth weight is more prevalent among babies born to Black women than those born to Hispanic or white women, even when controlling for education, according to a national analysis.²⁹ Again, this can be attributed to many of the same aforementioned reasons.

Vaccination rates in Houston and Texas have fallen while they have risen nationally

Immunization is a safe and cost-effective means of preventing illness in young children and interrupting disease transmission within the community.

The seven-vaccine series provides immunization against diphtheria, pertussis, tetanus, poliovirus, measles, mumps, rubella, hepatitis b, hemophilus influenza b, chicken pox, and pneumococcal infections. The seven-vaccine series indicator measures overall compliance with the recommendations of the Advisory Committee on Immunization Practices (ACIP) for young children.

For children born in 2017 and 2018, the seven-vaccine coverage rate by age 24 months was 70.5% in the U.S. In Texas, the rate was lower at 65.9%, and in the city of Houston, the rate was 65.2%.

Coverage by age 2 was lower for most vaccines among children who did not have private health insurance. Coverage was lower for both Black and Hispanic children compared with white children for most vaccines. The lowest coverage was for the influenza vaccine (60.6%).³⁰ Research suggests racial disparities in vaccine uptake could be due to overall lower insurance rates, apprehensions or distrust of the health care system, or misconceptions about vaccine efficacy.³¹

Child mortality rates are highest in Harris County and lowest in Fort Bend

Because of advances in medicine over the last half of the 20^th century, child mortality has declined so much that even though youth comprise a quarter of the U.S. population, they represent less than 2% of all deaths.³² The leading causes of death among children and adolescents include accidents, assaults, suicide, and cancer.³³

In Texas, 48.6 per 100,000 children die before their 18th birthday. Within Houston’s three-county region, child mortality rates are highest in Harris County (51.4 per 100,000) and lowest in Fort Bend (31.6).

Child mortality rates for Black youth are consistently the highest compared to other race/ethnicity groups. Mortality rates in Harris County among Black children are the highest (96.5 per 100,000) — nearly 2.5 times that of white children. Even with the overall decline in child mortality in the U.S., racial disparities continue and are greatest for certain medical conditions that are sensitive to delays in medical care, suggesting poor access to health care.³⁴

Nearly 232,000 Houston-area children do not have health insurance

Children may receive health insurance coverage from a variety of sources, including private insurance or public programs such as Medicaid and the Children’s Health Insurance Program (CHIP). However, some have no insurance at all. In 2020, 4.3 million American children under the age of 19 did not have access to health insurance coverage.

Nearly one million children in Texas do not have any form of health insurance coverage — about one in eight. Nearly 232,000, or 23%, of Texas’s uninsured children reside in Houston’s three-county region. The level of uninsured children in the Houston area (13.6%) is slightly higher than in Texas (12.8%), which is double that of the nation overall (5.7%). Fifteen percent of children in Harris County do not have insurance — the highest rate in the region — compared with 9.1% of children in Fort Bend and Montgomery counties.

Consistent with coverage trends among adults, Hispanic children in the Houston region have the highest uninsured rates. One out of five Hispanic children in Harris County does not have health insurance compared to one out of 15 white children. One out of eight Black children in Montgomery County does not have health insurance.

Children from low-income families may be able to get access to health insurance coverage through Medicaid and CHIP.

On average in 2020, 3.2 million children in Texas were enrolled in Children’s Medicaid and CHIP. The COVID-19 pandemic caused an increase in Medicaid/CHIP enrollment across the country. Texas saw a 23% increase in Medicaid/CHIP enrollment from February 2020 to September 2021. In State Fiscal Year 2020,³⁵ nearly 633,000 children enrolled in Medicaid, and 80,000 children enrolled in CHIP each month in the three-county region.

Food insecurity among children was in decline prior to the pandemic

The U.S. Department of Agriculture (USDA) defines food insecurity as a lack of consistent access to adequate food for a healthy life. Children who do not have enough to eat tend to experience lifelong health problems. Food insecurity has been found to not only have clear and consistent harmful impacts on children’s general health, chronic health, and acute health,³⁶ but also on their physical, behavioral and brain development.³⁷

Feeding America provides estimates for food insecurity at different community levels. Using the relationship between food insecurity and its closely linked indicators (poverty, unemployment, homeownership, disability prevalence, etc.) an estimated food insecurity rate is generated.

In 2020, 11.7 million (16%) children in the U.S. were food insecure, a rate higher than the general population (11.8%).³⁸

According to Feeding America, the child food insecurity rate fell across the Houston region from 2017 to 2019. However, the effects of COVID-19 were estimated to have led to an increase in food insecurity in 2020, which remained elevated in 2021. Feeding America estimates one in four children in Harris County are food insecure — about a quarter of a million children.

More than a third of City of Houston and Texas high school students are overweight or have obesity

Even when children have enough to eat, they may have poorer nutrition or eat lower-quality food as budget constraints may prompt families to purchase cheaper, more energy-dense foods.³⁹ Childhood obesity is defined as having a body mass index (BMI) at or above the 95th percentile for their gender, according to the CDC sex-specific BMI-for-age growth charts. About 18.5% or 13.7 million children and adolescents in the United States have obesity, putting them at higher risk for poor health.⁴⁰

In 2018, the obesity rate in Texas for children who are 2-4 years old and are enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) was 15.9%. While this is one percentage point lower than the 2010 rate, it remained above the national level of 14.4%.

The percentage of American high school students who are overweight ticked up from 15.2% in 2011 to 16.1% in 2019. In Texas, that rate increased nearly two percentage points to 17.8% during the same period. About 18.8% of high school students who live within the city of Houston are classified as overweight. Obesity rates in Houston grew faster than the rate of those who are overweight — an additional 19.5% of high school students have obesity, an increase of six percentage points since 2011. Combined, 38.3% of high school students in Houston are either overweight or have obesity compared to 34.7% in Texas and 31.6% nationally.