When a group of state health officials and members of Texas’ maternal mortality committee gathered to review applications for new members, they easily agreed on who should fill five positions reserved for medical professionals.
But the two spots for community members were more difficult to fill, records show.
For the rural community member position, the committee did not choose a candidate, instead advancing the top two choices. The candidate who scored highest on the application rubric was an obstetrics nurse and nursing professor from the Rio Grande Valley; the next highest was Dr. Ingrid Skop, a prominent anti-abortion OB-GYN in San Antonio.
Department of State Health Services deputy commissioner Kirk Cole broke the stalemate, writing in a memo that “although the applicant did not have the highest score, I recommend selecting Dr. Ingrid Skop.”
Cole wrote that Skop’s application “indicates previous practice in rural areas” and noted her involvement in community organizations that serve rural interests. Her resume, however, shows a career spent entirely in San Antonio, and volunteer work primarily at anti-abortion organizations based in cities.
For the other community member position, reserved for someone from one of the state’s urban centers, the application review committee recommended Queen Esther Egbe, a Black woman who had personally experienced maternal health complications. Egbe runs a nonprofit that helps Black women advocate for themselves during childbirth, and serves on the Tarrant County infant mortality review committee.
Cole nixed that recommendation, however, instead advancing Dr. Meenakshi Awasthi, a Houston pediatric emergency fellow who scored higher on the application rubric.
The two spots reserved for community members are now both filled by doctors, and more than 90% of the members have a doctoral degree. Committee chair Dr. Carla Ortique said at the June meeting this was “cause for concern.”
“It is rarely possible for those who sit in positions of privilege to truly be the voice of at-risk communities,” she said. “We can and should at all times be voices that support and attempt to foster positive change. We can be trusted allies. However, we cannot truly be their voice.”
State Rep. Shawn Thierry, an outgoing Houston Democrat who authored the legislation that increased the number of community members from one to two, said it was never the intention to have those spots filled by more doctors.
“The goal was quite simple, just to add an additional voice so that the existing community member would not be the sole voice for the community on the panel,” Thierry said. “Two voices was better than one.”
Now, there are none.
Recruiting community voices
Texas’ maternal mortality and morbidity review committee was created in 2013 to track and study maternal deaths and near-misses. At the start, it had 15 members, a mix of obstetricians, midwives, psychiatrists, nurses and researchers. One spot was reserved for a community advocate.
Nakeenya Wilson, an Austin-area maternal health advocate and community organizer, served in that role starting in 2021. As a Black woman who nearly lost her life during childbirth, Wilson has been outspoken about the importance of having voices like hers in the room while the committee reviews what led to maternal deaths.
Thierry’s 2023 legislation grew the committee to 23 members. In addition to new spots for a cardiologist, an oncologist and other medical providers, it also doubled the number of community positions, allocating one for an urban representative and one for rural. But the job description changed too, from a community advocate to “community members with experience in a relevant health care field, including a field involving the analysis of health care data.”
Thierry said this wasn’t intended to exclude people with lived experience, and said Wilson, or someone with similar health care advocacy experience, would still qualify for the position.
The bill was signed by the governor on June 12, 2023. Less than two weeks later, months before the bill went into effect or the committee began soliciting applications, DSHS received two letters recommending Skop be appointed.
One was from state Rep. Stephanie Klick, an anti-abortion Republican from Fort Worth, who wrote that Skop’s “education, experience and especially her understanding of women’s needs and health issues” made her a good candidate for the “next open, appropriate position.”
The other letter came from Tara Sander Lee, vice-president at the Charlotte Lozier Institute, a national anti-abortion research group where Skop serves as medical director. Sander Lee wrote that Skop “cares deeply for the health of the two patients she serves — mom and baby — and is motivated to identify contributing risk factors of maternal mortality and morbidity.” Sander Lee also sent the letter to Gov. Greg Abbott.
Skop said in a statement that she has applied to join the committee several times in recent years.
Rural community member
In September 2023, the state health department solicited applications for the new positions. Six people applied for the rural community member position, including Skop, who also applied for the urban community member and emergency medicine positions.
Skop is not just any anti-abortion doctor. She is the face of a small but powerful medical lobby that has helped restrict abortion access across the country. Skop has testified to state legislatures and before Congress, and been called as an expert witness in court cases. She is one of the doctors who sued to have mifepristone, a common abortion-inducing drug, moved off the market, a case that ultimately failed at the U.S. Supreme Court.
Skop has worked as an obstetrician in San Antonio since 1998. In April 2022, she joined the Charlotte Lozier Institute, where she is now vice president of medical affairs. Her resume lists her address as Arlington, Virginia, where the institute is based.
Skop wrote in her application that she had cared for two women who experienced maternal mortality, and was “intrigued by the multitudes of data deficiencies plaguing collection and evaluation of maternal mortality and severe maternal morbidity.”
In a statement to The Texas Tribune, Skop said she has often cared for women from rural areas who had to travel to San Antonio for prenatal care or were transferred there during obstetric emergencies.
“I hope to contribute my expertise to identifying and resolving gaps in health care that lead to tragic outcomes,” she said. “The heartbreaking loss of any mother in relation to childbirth harms all of society, and regardless of political differences, we should all work together to address the root causes.”
Vanessa Hale also applied for the rural position. Hale has worked as a labor and delivery nurse in the Rio Grande Valley since 2012 and a clinical assistant professor of nursing at the University of Texas Rio Grande Valley since 2023.
Hale, a Brownsville native of Mexican descent, has spent her whole career in triage, antepartum, labor and delivery, operating rooms and postpartum units on the U.S.-Mexico border, she said in her application. She represented the Rio Grande Valley with the Texas Collaborative for Healthy Mothers and Babies Maternal Committee, and helped bring a maternal risk assessment training course to the region.
Hale disclosed in her application that she was reprimanded by the Board of Nursing in 2014 for documentation-related errors. She told The Texas Tribune in an interview that this experience gave her an appreciation for the exacting standards required to work in medicine, and led her to become certified in obstetric and neonatal quality and safety.
Hale declined to comment on Skop or the committee’s decision, except to say that she remained a supporter of the group’s “extremely important” work. She said she applied for the committee because rural Hispanic women are underrepresented in maternal health advocacy work, and she wants to help raise awareness about how these issues impact her community.
While Hispanic women are less likely to die during childbirth than some other groups, they are at a higher risk for “near miss” severe morbidity events, especially compared to white women.
“Those morbidity rates are affecting our families, and our mothers, in the long run,” she said. “We’re not dying in large numbers, but we are sick … and more needs to be done for the women in our community.”
Each of the seven reviewers scored the applicants on a series of questions including knowledge about maternal mortality, relevant experience and personal and professional achievement, as well as whether they work in or represent diverse communities that are impacted by maternal mortality.
Each reviewer then said whether they recommended the candidate, recommended them with qualifications or reservations, or did not recommend. They could recommend multiple candidates.
Hale received glowing marks from the application review committee, with two of the seven reviewers giving her 29 points out of a possible 30. She received a total score of 175, the highest of the six candidates. Skop received the second most points with 157.
But no candidate received a plurality of recommendations, with or without qualifications. Three members of the committee recommended Hale; four recommended Skop. The most recommended candidate was Kathryn Jacob, president and CEO of Safe Haven Tarrant County, the state’s largest domestic violence shelter.
DSHS redacted comments from the review committee members indicating why they recommended certain candidates over others.
In the end, the committee could not reach a consensus, instead sending Hale and Skop, the two top-scoring applicants, to Cole to decide. He chose Skop.
Through a spokesperson, Cole declined to comment on his decision-making beyond what was in the records.
Urban community member
Three times as many people applied for the urban position than the rural one. Most of the applicants had a medical background, as either a doctor, nurse, or midwife.
Two of the candidates, however, were Black moms who had turned negative experiences with the maternal health care system into the basis of their own advocacy work. Wilson, who’d previously been on the committee, reapplied, and Egbe applied for the first time.
In her application, Egbe wrote about the experience of delivering her son in 2021, and feeling “overwhelmed by the feeling of helplessness hanging over me like a cloudy sky,” one of many Black mothers who felt silenced and ignored during the childbirth process, even as they raised concerns about the standard of care they were receiving.
Motivated by her own experience, Egbe helped found the Angel With Big Wings Foundation, dedicated to celebrating motherhood and helping Black women access pre- and postpartum health care.
More than 10 years after Texas created this committee to research maternal deaths, the state still has above average maternal mortality rates. And the disparities haven’t budged either — Black women are far more likely to die in childbirth than any other group.
The committee strongly endorsed both Egbe and Wilson for the role, with six of the seven reviewers recommending both of them. Egbe received the second-highest score on the matrix, next to Dr. Meenakshi Awasthi, a pediatric emergency specialist from Houston.
The committee put forward Egbe as their official recommendation, but noted that both she and Awasthi were highly qualified.
Cole overruled the Egbe endorsement, saying that “considering the nature of the reviews that occur,” Awasthi was a better fit.
Egbe told the Tribune that she was disappointed by the decision, and the missed opportunity to have a member of the most impacted community serving alongside the doctors and nurses.
“Being a community advocate comes not from what you studied, not what someone else is telling you, but from personal experience, which cannot lie,” she said. “With doctors and nurses, at some point, it becomes routine ... But as a community advocate, you see yourself in the people. They're not numbers to you. They are people you communicate with, people you live with, people you love and care for.”
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