Maternal & Child Health

Pregnant women and children in Houston’s three-county region have worse outcomes on about half of health indicators compared to the nation, jeopardizing their well-being

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. Disparities have either widened or remained flat — the result of variation in underlying chronic conditions and disproportionate access to quality health care.

The data

The national maternal mortality rate decreased 44% between 2021 and 2023

One of the more troubling trends in health is the increasing number of women who die while pregnant or from pregnancy-related complications. Maternal deaths can be measured in two ways: the Maternal Mortality Rate (MMR) include deaths that occur during pregnancy or within 42 days of the end of pregnancy (excluding deaths due to accidental causes); and the pregnancy-related mortality ratio (PRMR), which measures the death of a woman during pregnancy or within one year of the end of pregnancy from a pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy. Each of these are measured as a ratio of the number of deaths per 1000,000 live births. Essentially, the key differences between the two measures are the time period and the range of causes of deaths, with Maternal Mortality representing a more narrow view and PRMR representing a broader view.

Between 1987 and 2023, the pregnancy-related mortality ratio (PRMR) in the United States more than doubled. The PRMR increased significantly during the COVID-19 pandemic, peaking in 2021 when over 1,200 women died from pregnancy-related causes within one year of giving birth, resulting in a PRMR of 33.2 per 100,000 live births. For comparison, in 2019, roughly 660 women died from pregnancy-related complications—a rate of 17.6 per 100,000 live births.

Pregnancy-related deaths have decreased significantly with about 670 women, or 18.7 per 100,000 live births, dying from pregnancy-related causes in 2023—a 44% decrease from the peak in 2021. However, this is still significantly higher compared to nearly four decades ago when, in 1987, the PRMR was 7.2 per 100,000 live births.

The maternal mortality ratio (MMR) — the number of women who die from pregnancy-related causes while pregnant or within 42 days of the end of pregnancy per 100,000 live births — in the United States increased from 17.4 per 100,000 live births in 2018 to a five-year peak of 32.9 in 2021 before declining to 18.6 in 2023, according to the CDC.

To place these figures in a global context, other wealthy nations do not experience the high rates of maternal deaths found in the U.S. The World Bank finds that the U.S. MMR is 17 per 100,000 live births in 2023 compared to 12 per 100,000 live births in Canada, 8 in the U.K., 4 in Germany, and 3 in Japan. The U.S. trend is also at odds with several less developed countries, where maternal mortality has declined.

Texas’ maternal mortality rate has risen in recent years

Texas uses an enhanced method to measure maternal mortality that involves matching death certificates with birth or fetal death certificate and a review of medical records for deaths with pregnancy indicates on the death certificate. Since Texas utilizes a method different from other states, it cannot be compared with other maternal mortality ratios (MMR).

The enhanced MMR (death during pregnancy or within 42 days of giving birth) in Texas between 2013 and 2017 remained relatively stable at around 20 deaths per 100,000 live births, before dipping in 2018 and 2019 to 17 per 100,000. After 2019, during the height of COVID-19, the MMR increased significantly, reaching a peak of 37.7 deaths per 100,000 live births in 2021.

Texas state law requires a biennial report from the Maternal Mortality and Morbidity Review Committee to study and review cases of pregnancy-related deaths and make recommendations to reduce deaths. Their 2024 report found that the leading causes of pregnancy-related death in Texas in 2020 included infections, cardiovascular-related issues, hemorrhaging, embolisms, and mental health conditions. The Texas Department of State Health Services estimates 80% of these deaths in 2020 could have been prevented.

Because the Texas method to calculate MMR is unique, we can see how the state compares to others and the nation using a different data set that combines data from 2018 through 2022. This data set finds that the MMR in Texas was 28.2 —higher than the nation at 23.2. Among the 39 states for which a rate was calculated, Texas ranks 27th, with the highest rate in Tennessee (41.1) and the lowest rate in California (10.5)

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

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, including variation in underlying chronic conditions and lower access to quality health care.

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 maternal and child health issues.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 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

While the national pregnancy-related mortality ratio (PRMR) — death during or within 1 year of the end of pregnancy — trend over time is similar amongst different racial/ethnic groups, significant disparities exist and have widened over time. Pregnancy-related mortality rates for Black, Hispanic, and white women peaked in 2021 and then decreased the following year. However, between 2018 and 2023, the difference in PRMR between Black and white women increased with the rate for Black women being 2.5 times higher than for white women in 2018 (37.3 vs 14.9) and widening to over 3 times higher in 2023 (49.4 vs 14.9).

When the Texas Health and Human Services Maternal Mortality and Morbidity Review Committee determines if the death of a recently pregnant person was pregnancy-related, they ask themselves, “If she had not been pregnant, would she have died?” According to a 2024 report prepared by this committee, the pregnancy-related mortality ratio (PRMR), which measures the number of deaths during or within 1 year of the end of pregnancy per 100,000 live births, increased for Hispanic women between 2019 and 2020 from 13.4 to 22.2 as well as Black women from 27.9 to 39.0. For white women during the same time, this rate decreased from 18.8 in 2019 to 16.1 in 2020. In 2020, the PRMR for Black women was about 2.5 times greater than that for white women.

Maternal mortality also varies by age, with younger women typically experiencing lower mortality rates.

 In 2023 maternal mortality rates (MMR) (pregnancy-related complications while pregnant or within 42 days of giving birth per 100,000 live births) varied by age: 12.5 for all women under 25 years of age, 18.1 for ages 25 and 39, and 59.8 for women 40 and older. Black women experience the highest rates of maternal mortality across all ages.

Women over 40 face a much higher rate of maternal mortality than women under 40. Women 40 and older saw encouraging progress from 2018-2023, with overall MMR declining 27% (from 81.9 to 59.8). This improvement varied by race: Black women 40+ experienced a 45% decrease, white women 21%, and Hispanic women 7%. Despite this progress, younger Black women showed alarming increases during this period. For Black women under 25, MMR increased by 83% while white women saw a 20% decrease. For Black women ages 25-39, rates increased by 40% while white women’s rates remained unchanged. As a result, Black women ages 25-39 remain twice as likely to die from pregnancy-related causes as white women in the same age group.

Pregnant women in Texas access prenatal care in their first trimester at lower rates than the 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. According to the CDC, nationally, 2% of pregnant women received no prenatal care during their pregnancy in 2023. In Texas, the rate was double at 4%. In the three-county area, the rate of no prenatal care ranged from 4.8% in Harris County to 2.6% in Montgomery County and 2.2% in Fort Bend County.

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.¹⁸ 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.¹⁹

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.

Around 3 out of every 4 (76%) pregnant women in the U.S. received prenatal care in the first trimester in 2023, mostly unchanged since 2010 when the rate was 73%. While early prenatal care access in Texas has increased from 62% in 2010 to 67% in 2023, it remains below the national rate. In fact, in 2023 amongst all states and the District of Columbia, Texas had the third lowest rate of pregnant women who accessed early prenatal care (67%) just ahead of Hawaii and Florida at 66%.

Regionally, pregnant women in Montgomery County receive early prenatal care at higher rates, 67% compared to 64% in Fort Bend County and 60% Harris County.

Overall infant mortality in the Houston area has ticked down in the last decade (except in Fort Bend County), while racial disparities have persisted

Infant mortality, defined as the death of a baby before their first birthday and measured by the number of deaths per 1,000 live births, 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.²⁰

The national infant mortality rate has been in a steady decline from 7.6 deaths per 1,000 live births in 1996 to 5.6 in 2022. In 2022, infant mortality rates were highest among infants born to Black women (10.9) and teenagers younger than 15 (14.3). Babies born to mothers with obesity, who smoke, or consume alcohol during pregnancy also have a greater risk of infant mortality, particularly during the first 28 days after birth.^21,22,23,

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 2023 infant mortality rate in the U.S. is higher compared to several nations, including Russia, Canada, the Netherlands, France, and Poland.

Infant mortality in Texas was 5.6 per 1,000 live births in 2021-23, the same as the national average. Locally, the highest infant mortality rate is in Harris County and the lowest is in Montgomery County. Between 2009-11 and 2021-23, infant mortality rates decreased across Texas and in Harris and Montgomery counties while they increased in Fort Bend County.

Across the U.S., Texas, and in Harris County, the infant mortality rate for babies born to Black mothers is two times that for babies born to white women and has not improved since 2011. Nationally, the infant mortality rate between 2011 and 2023 declined for both Black and white women while it was mostly flat in Texas during this period. In Harris County over the same time, the infant mortality rate increased by 22% among white women and increased 11% among Black women.

The mortality rate in 2023 for babies born to Black mothers was lower in Harris County (9.87 per 1,000 live births) compared to the nation (10.25) and Texas (10.93). This is similar to rates among white mothers. The mortality rate in 2023 for babies born to white mothers was lower in Harris County (4.45 per 1,000 live births) than in Texas (4.89) and the nation overall (4.48).

Continue reading about disparities in life expectancy in Texas and how it varies across neighborhoods in Houston’s three-county region. 

Babies in Fort Bend and Harris counties 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.^24,25

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.²⁶  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.

Continue reading about water and air pollution in Houston.

Nationally, the percentage of infants born with low birth weight has ticked up slightly to nearly 9% in 2020 from 8% in 2010. Regionally, 9% of babies in Fort Bend and in Harris counties, and 8% in Montgomery County were born with low birth weight in 2023. Between 2016 and 2023, the low birth rate has remained relatively flat for most racial and ethnic groups except for infants born to Black mothers. The percentage of infants with a low birth weight born to Black mothers increased by 3 points in Montgomery County and 2 points in Fort Bend County. 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.²⁷ Again, this can be attributed to many of the same aforementioned reasons.

Vaccination rates have fallen in Houston

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, Haemophilus influenza b, chicken pox, and pneumococcal infections. The seven-vaccines series indicator measures overall compliance with the recommendations of the Advisory Committee on Immunization Practices (ACIP) for young children younger than 24 months.

For children born in 2019 and 2020, the seven-vaccine coverage rate by age 24 months was 69% in the U.S. In Texas, the rate was lower at 67%, and in the city of Houston, the rate was 68%.

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 for all groups was for the influenza vaccine (63%). 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.²⁸

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

Because of advances in medicine, child mortality (a person who dies before their 20th birthday) has declined so significantly that even though youth comprise a quarter of the U.S. population, they represent less than 2% of all deaths.²⁹ The leading causes of death in 2023 among children and adolescents 5 to 19 years old include accidents, assaults, suicide, and cancer.³⁰

In Texas, 53 per 100,000 children die before their 20th birthday. Within Houston’s three-county region, child mortality rates are highest in Harris County (54 per 100,000) and lowest in Fort Bend (39).

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 (101 per 100,000) — nearly 2 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 and mental health care in the Houston area.³¹

Nearly 236,000 Houston-area children do not have health insurance

Goals for maternal and child health don’t end after the postnatal period. While maternal and child health is focused on the health of mothers during pregnancy, childbirth and the postnatal period (defined as up to one year after birth), the field of study also covers a child’s health during these stages and the first five years of life — the most important time of early childhood development.

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 2023, nearly 4.2 million American children under the age of 19 did not have access to health insurance coverage.

Over 900,000 children in Texas do not have any form of health insurance coverage — about one in eight. Nearly 236,000, or 25%, of Texas’s uninsured children reside in Houston’s three-county region. The level of uninsured children in the Houston area (13.5%) is slightly higher than in Texas (12%), which is double that of the nation overall (5%). Fifteen percent of children in Harris County do not have insurance — the highest rate in the region — compared with 9% of children in Fort Bend and 12.5% Montgomery.

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 and Montgomery counties does not have health insurance compared to one out of 15 white children. One out of five 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 2024, 3.3 million children in Texas were enrolled in Children’s Medicaid and CHIP. In State Fiscal Year 2024,³² nearly 710,000 children enrolled in Medicaid, and 32,000 children enrolled in CHIP each month in the three-county region.

Food insecurity among children has increased since 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,³³ but also on their physical, behavioral and brain development.³⁴

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 2023, 13.8 million (19%) children in the U.S. were food insecure, a rate higher than the general population (14%).

According to Feeding America, child food insecurity in the Houston area fell from 2017 to 2019. However, the effects of COVID-19 were estimated to have led to an increase in food insecurity in 2020. Rates declined in 2021 but then rebounded in 2022, likely due to the expiration of many expanded COVID-era public benefits and the sharp rise in inflation. As of 2023, food insecurity rates have remained the same. Feeding America estimates one in four children in Harris County are food insecure — about 300,000 children.

Nearly two in five City of Houston 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.³⁵ Childhood obesity is defined as having a body mass index (BMI) at or above the 95th percentile for their gender and age, according to the CDC sex-specific BMI-for-age growth charts. About 21% of children and adolescents in the United States have obesity, putting them at higher risk for poor health.

In 2020, 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 16%. While this is one percentage point lower than the 2010 rate, it remained above the national level of 14.5%.

The percentage of American high school students who are overweight ticked down slightly from 15.2% in 2011 to 14.7% in 2023. In Texas, that rate also fell from 16% to 15% during the same period. The rate of high school students considered overweight increased during this time with 18% classified as overweight in 2023. Obesity rates in Houston grew faster than the rate of those who are overweight increasing by 7 percentage points from 14% in 2011 to 21% in 2023. Combined, 39% of high school students in Houston are either overweight or have obesity compared to 34% in Texas and 31% nationally.

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