By Abigail Abrams
TIME, September 22, 2021
Texas’ controversial six-week abortion ban has been in effect just 21 days, and physicians and researchers are already warning that the impact could be dire: if the law remains in effect, Texas could see a significant increase in maternal mortality.
A new analysis from Dr. David Eisenberg, a board certified obstetrician-gynecologist who provides abortions in Missouri and Illinois, estimates that with the new law in effect, the state could see increases in maternal mortality of up to 15% overall, and up to 33% for Black women next year. The estimate is based on previous research that has established a clear link between abortion restrictions and maternal mortality. Black patients are often disproportionately impacted by abortion restrictions, and they are far more likely to die in to pregnancy-related deaths than white or Hispanic women.
“When you eliminate the ability for people who become pregnant to decide what’s best for them and their health and their family, it has a negative impact on the health of themselves, as well as their families and the communities they come from,” says Eisenberg, the former medical director of Planned Parenthood of the St. Louis Region and Southwest Missouri.
The Texas law, known as Senate Bill 8, prohibits abortion once an ultrasound detects cardiac activity. In practice, that means that no one in the state can provide an abortion after roughly six weeks into a pregnancy, which is before many people discover they are pregnant. In addition to the law’s impact on patients, its extreme limit could also cause many abortion clinics to close their doors, which would further reduce access to care for state residents.
While the Texas law is unprecedented in its private enforcement mechanism, many other states have passed limits on abortion in recent years, and researchers have shown that these are associated with negative health outcomes. In a study published in March in the journal Contraception, Eisenberg and his co-authors found that from 1995 to 2017, the maternal mortality rate increased most significantly in states that enacted the most restrictive abortion laws. In 2017, states that restricted abortion had a maternal death rate (28.5 maternal deaths per 100,000 live births) that was nearly double (15.7 maternal deaths per 100,000 live births) those that had passed laws protecting access to abortion.
In another study, published in the American Journal of Preventive Medicine in 2019, researchers looked at maternal mortality data from 38 states and Washington, D.C. and found that gestational limits on abortion and Planned Parenthood clinic closures each significantly increased maternal mortality. They found that laws restricting abortion based on gestational age increased maternal mortality by 38% and that a 20% reduction in Planned Parenthood clinics increased a state’s maternal mortality rate by 8%.
Since the study was based on statistical analyses of state-level data, researchers could not look at complicating factors for each individual patient. But Summer Sherburne Hawkins, the study’s lead author and an associate professor at Boston College’s School of Social Work, says the analysis shows the direct impact of abortion restrictions like the one in Texas.
“Based on our research, restricting abortion based on gestational age, as has been done in Texas, will likely have detrimental effects on women’s health,” she says. “It could have increases in maternal mortality.”
Eisenberg’s new analysis builds on this idea and pulls from his previous research published in Contraception. He found the Global Health Data Exchange showed a 6% increase in maternal mortality in states that restricted abortion access relative to neutral states. The CDC WONDER database showed a 24% increase in states that restricted abortion access relative to neutral states. The median increase, 15%, is what he predicts could take place in Texas if its current abortion law remains in place.
Abortion providers in the state are already seeing patients who they fear could end up in dangerous circumstances. Dr. Bhavik Kumar, a staff physician at Planned Parenthood Center for Choice in Houston, says the law has forced him to turn away patients who will likely not be in a place to have a healthy pregnancy. Planned Parenthood has become a “traffic control” center with care coordinators helping people find resources to travel out of state for care or explore other options, he says. But not all patients can travel long distances to receive care.
Kumar says he saw a patient last week who is navigating a meth addiction and is homeless, who he doubts will be able to travel out of state to get an abortion. Another of his patients already has seven children, one of whom is in the hospital with a terminal illness. She likely will not be able to leave the state—and her children—to get an abortion either, but she also knows she will struggle to take care of another child, Kumar says.
The Texas law means these patients must make incredibly difficult choices as they seek care. If they cannot obtain abortions, they may be forced to deal with the mental and physical stress of carrying unwanted pregnancies to term.
“There’s also consequences with morbidity, meaning people having more complicated pregnancies that take a toll on their health, having more complications, and having a lower quality of life,” Kumar says. “And that’s not just for them. It’s also for their families and the children that they are forced to have.”
The U.S. faces a crisis of maternal mortality
The new Texas law is the latest in a wave of restrictions on abortion nationwide. For more than a decade, largely conservative states like Texas that have steadily implemented a series of laws and regulations making it more logistically and financially difficult for women to access all kinds of reproductive health care. Even amid this trend, Texas stands out as one of the most challenging places to obtain an abortion and to give birth to a child.
The U.S. has faced a crisis of maternal mortality for years. It has the highest rate of maternal mortality in the developed world, and the country’s numbers have worsened significantly over the last 30 years, according to a new report the U.S. Commission on Civil Rights released Sept. 15. This is in large part due to growing disparities in access to quality care for women of color. “As an individual, as a Texan, I’m appalled that, at a time where we need stronger hospitals and a higher quality of hospital care for Texans, we’re going in the wrong direction,” Norma Cantú, chair of the Commission on Civil Rights, said in response to a question from TIME last week.
The maternal mortality rate in Texas is already higher than the U.S. average, and Black women bear the brunt of this tragedy: they account for just 11% of live births, but make up 31% of maternal deaths in the state. In 2013, Texas created an expert committee to examine this issue. It found that many of the maternal deaths in Texas are preventable and recommended that the state extend health insurance coverage for poor mothers to one year after they have a baby. But lawmakers have not done that. Instead, in May the state passed a law extending Medicaid coverage for six months after childbirth.
Texas has the highest rate of uninsured residents in the country, the highest rate of uninsured women of childbearing age, and its leaders have refused to expand Medicaid under the Affordable Care Act, which would have allowed more low-income Texans to access the public health insurance program. Texas also has the strictest income limit for Medicaid eligibility in the country: a single Texan parent with three children must earn $277 or less a month to be eligible. During pregnancy, that cap increases to $4,373.
The new Texas abortion law is being challenged in court. The Department of Justice has asked a federal judge in the Western District of Texas to block the law while it sues Texas, and the next hearing is set for Oct. 1. But even if the law is temporarily blocked, it is written in a way that could make it difficult for abortion providers to resume their regular work until they have a final verdict.
The effects of even a temporary ban are likely to reverberate. When Texas enacted a law in 2013 that required abortion clinics to obtain admitting privileges at local hospitals and imposed other restrictions, half the clinics in the state closed. Even after the Supreme Court ruled that law unconstitutional in 2016, few clinics returned. As a result, huge swaths of the state became abortion deserts. Under the new law, the average Texan must drive 14 times farther than they had to previously to access an abortion.
In recent weeks, lawmakers from other conservative states have said they see Texas as a model and hope to pass similar legislation, and in December, the conservative Supreme Court is scheduled to hear a case about an abortion restriction in Mississippi. While those who oppose abortion are celebrating what they see as a win for their movement, physicians and researchers like Eisenberg—as well as residents in conservative states—say they are bracing for a coming wave of maternal deaths.