There’s no doubt that the United States maternal health crisis is severe. The U.S. has the highest maternal mortality rate among high-income nations, and the Centers for Disease Control and Prevention (CDC) estimates that over 80% of pregnancy-related deaths are preventable. The situation is even worse when you account for severe maternal morbidity, which is defined as unintended, life-threatening outcomes of labor and delivery, such as sepsis, hemorrhage, and eclampsia. For every maternal death, there are 70-80 identified cases of severe maternal morbidity at birth.
Maternal mortality and morbidity are also serious and, in the case of maternal morbidity, worsening problems in Texas. Texas has had consistently higher maternal mortality rates compared to the national average. From 2019 to 2023, the state experienced 29.3 maternal deaths per 100,000 live births, as opposed to 23.5 nationally. For both Texas and the United States, rates of severe maternal morbidity have increased from 2016 to 2023, with Black women experiencing disproportionately high rates.
Severe obstetric complications threaten lives, substantially increase health care costs, and have long-term health consequences for mothers and infants. Imagine an expecting mother who experiences preeclampsia, as 3-8% of birthing women do. This significantly increases the chances of delivering early, which may lead to a NICU stay for her baby. But it also places her at risk of life-threatening complications like eclampsia, organ damage, and stroke, which mean intensive and costly hospital stays. Furthermore, preeclampsia during pregnancy increases lifelong susceptibility to hypertension and chronic kidney disease for both mother and child.
Milliman, an actuarial and consulting firm that partners with state agencies and foundations to analyze health care claims data, released a report last month detailing the prevalence of and health care costs associated with severe obstetric complications (SOCs)1 among Texas Medicaid STAR beneficiaries. The study was commissioned by Texas organizations Episcopal Health Foundation and the Michael & Susan Dell Foundation to support existing work in Texas to reduce SOCs and incentivize improvements in maternal health.
The results have implications not only for Texas Medicaid but also any state interested in improving its own maternal health outcomes and reducing unnecessary costs, which is especially important as H.R. 1 changes make it more difficult for states to finance their Medicaid programs.
Findings show that SOCs are not just devastating for the families who endure them; they also cost Texas Medicaid an estimated $136.4 million annually. Obstetric complications were relatively common, occurring in 1 in 8 deliveries (12.6%) among Texas women covered by Medicaid studied in this report. Average delivery costs for mothers with at least one studied complication were approximately 1.6 times higher than for uncomplicated deliveries. In deliveries with more than one complication, the cost was around 2.7 times higher.
Newborn costs were also over twice as high when mothers experienced SOCs, a consequence of prematurity and NICU use that often accompany birth complications.
The study projects that reducing SOCs by 20% on average statewide over three years could save Texas Medicaid $95.5 million dollars, in addition to improving health outcomes for mothers and infants. This is significant because Medicaid covers 45% of Texas births as of 2024, with around a third of those pregnancies classified as high risk. As H.R. 1 cuts threaten states’ ability to maintain strong funding for Medicaid, maternal mortality and morbidity may worsen, even in non-expansion states like Texas. H.R. 1 changes to state Medicaid financing, including provider tax rules and state-directed payments, may lead to drastic program cuts that threaten the ability of hospitals to provide labor and delivery services—or stay open at all—which will make it much harder for birthing people to receive care. Already, over half of Texas counties lack an obstetric hospital or provider. This problem is especially pronounced in rural areas—over 60% of rural hospitals in Texas did not offer obstetric services in 2024.
The Rural Health Transformation Fund attempts to fill this gap with a $50 billion infusion to states for programs aimed at improving rural health care. At $281 million, Texas received the largest single RHTF allocation for 2026, but this falls short of making up for the $4 billion decline in federal Medicaid spending in the state’s rural areas alone over the next decade.
Adopting Medicaid expansion would allow many more people of reproductive age to receive consistent health care. Texas has the highest uninsurance rate for women of childbearing age in the nation, with more than 1 in 5 uninsured. If Texas adopted Medicaid expansion, over 1.1 million more people could receive coverage.
While the Milliman study provides insight into the overall prevalence and estimated costs of obstetric complications, there are gaps in the data that would help the state, health providers, and stakeholders better understand the experiences of specific populations and the impacts of recent maternal health policies.
Neither the Milliman report nor the Texas Medicaid Quality Performance dashboard disaggregate maternal health outcomes for Medicaid beneficiaries by race and ethnicity. These data are necessary because Texas has some of the worst racial disparities in maternal health outcomes in the nation, with Black women in the state 2.5 times as likely as white women to experience a pregnancy-related death as of 2020.
The Texas Maternal Mortality and Morbidity Review Committee has also delayed releasing its biennial maternal mortality report from September 1 to December 1, 2026. Even once released, the report is expected to forgo the customary comprehensive review of maternal deaths for 2022 and 2023. This threatens the ability of state leaders, health professionals, and stakeholders to understand the impacts of significant maternal health policies in Texas, including the postpartum Medicaid extension and abortion bans.
Reducing SOCs is the first step to improving maternal morbidity outcomes and reducing health care costs in Texas Medicaid. Detailed data on maternal mortality and morbidity trends can help inform policy, care, and prevention efforts, and they help hold our health care system accountable to the people it serves.
- Severe obstetric complications are serious clinical events that occur during delivery or the postpartum period and may result in significant maternal harm. They include measures typically counted under severe maternal mortality metrics, alongside behavioral health and personal safety. The study also examined severe preeclampsia and hypertensive readmissions. ↩︎