UPDATE (June 24, 2022, 12:32 p.m.): On Friday, the Supreme Court overturned Roe v. Wade, which established the constitutional right to abortion in 1973, with five of the six Republican-appointed justices arguing that there was no basis for the constitutional right to abortion.

In an article we published earlier this year, we examined why overturning Roe could make maternal mortality even worse in the U.S. The U.S. has one of the highest maternal mortality rates in the developed world with 861 women dying from causes related to pregnancy and birth in 2020. You can read more about what we found below.

Giving birth in the U.S. is already far more dangerous than in other wealthy countries. Ending the protections of Roe v. Wade — the 1973 decision that established the constitutional right to abortion — could make it even more so.

Multiple studies have found that the states that already have the tightest restrictions on abortion also have the highest rates of maternal and infant mortality. And that correlation stubbornly persists even after researchers account for some of the other differences between states, like racial demographics and health care policy. Some researchers think that abortion restrictions are part of the reason why pregnancy and childbirth are so much more dangerous in the U.S. — even for people who never wanted an abortion to begin with.

This data could just be a statistical red herring. But there are ways abortion restrictions could kill people, both directly and indirectly. And scientists say these correlations point toward dangerous disparities in health care access in the U.S. — not just in terms of who can get an abortion, but also in terms of who can get preventative care while pregnant, or even before.

The U.S. is a uniquely dangerous place to have a child

Carrying an unplanned pregnancy involves shouldering increased risks of depression, preterm birth, lower birth weight and other complications. That was definitely true for Brittany Mostiller. In the summer of 2006, this Chicago mom of two young children found herself pregnant, and every circumstance in her life felt like it was conspiring to make raising a third child impossible. Mostiller had recently lost her job and was sharing a two-bedroom apartment with her sister and niece. She was overwhelmed and wanted an abortion, but the cost of the procedure put it out of reach. 

So she stayed pregnant. And as the pregnancy progressed, she became more and more unhappy. “I was just severely depressed, and I wasn’t caring for myself,” she said. Her body seemed to rebel against her; she was fending off infection after infection, she said. And then her water broke when she was 32 weeks pregnant — two months before the baby was supposed to be born.

Mostiller’s story illustrates how easily a pregnancy you didn’t plan for can go awry. She and her baby — now a healthy teenager — came out of the experience okay. But not everyone does. Unplanned pregnancies are already more likely to end in the death of the mother. But the truth is that all pregnancies are more dangerous in the U.S. than they are in comparable countries, and those dangers are particularly acute for Black people, like Mostiller. 

Recently released government data shows that 861 women died from causes related to pregnancy and birth in 2020, up from 754 the year before. In population-level terms, the maternal mortality rate in 2020 was 23.8 deaths per 100,000 live births in the U.S., compared with 3.2 deaths per 100,000 live births in Germany in 2019 and 7.9 deaths per 100,000 live births in France in 2015. (The maternal mortality rate calculated by the CDC includes deaths from abortion-related complications, but the organization also calculates that subset separately. In 2019, the death rate from abortion in the United States was minuscule: 0.41 deaths per 100,000 legal abortions between 2013 and 2018.) Infants are also at higher risk of dying in the U.S. than in other wealthy countries. In 2020, the infant mortality rate in the U.S. was 5.4 deaths per 1,000 live births, compared with 1.9 infant deaths per 1,000 live births in Finland and 2.7 infant deaths per 1,000 live births in Spain.

Black Americans are nearly three times more likely than their white counterparts to die as a result of maternal complications, and the risk to Black babies is much higher as well. These disparities are so large that the states with the highest maternal mortality rates are also often states with large Black populations, and researchers have concluded that social factors like inequality and structural racism are playing a huge role in why pregnancy complications kill Americans. 

But some researchers think that attempts to restrict abortion access are playing a part too. In a 2021 study, Tulane University researchers categorized states based on the presence or absence of specific types of abortion restrictions and found that total maternal mortality was 51 percent higher in states where only licensed physicians are permitted to perform abortions, and total maternal mortality was 29 percent higher in states with Medicaid restrictions on abortion.

Another set of researchers looked at changes in maternal mortality from 1995 to 2017, and similar to the others, they found that states with abortion restrictions had higher rates of maternal mortality than states that were either neutral toward abortion or protected abortion rights.

A third study found that infants living in states with more abortion restrictions were more likely to die — which wasn’t really surprising, given the close link between the health of mothers and infants.

Of course, a pattern is not an explanation. It’s impossible to demonstrate conclusively that tightening abortion restrictions causes an increase in maternal or infant deaths, researchers told us. That’s because the way science establishes causality is through experiments that simply can’t happen in real life. “That would be the gold standard of a randomized, controlled trial,” said Summer Hawkins, a professor of social epidemiology at Boston College. “You’d randomize states to implement certain policies or to close Planned Parenthood clinics … and of course that’s never going to happen.” 

And there are plenty of reasons why maternal mortality might be higher in those states that aren’t specifically connected to abortion policy. For one thing, many states with strong abortion restrictions didn’t expand Medicaid, which experts told us can lead to generally worse health outcomes because many direct causes of maternal mortality begin as long-term chronic health problems that go untreated or undiagnosed for years. Poverty is also high in many of those states, which experts said can have a similar impact. Stacie Geller, a professor of obstetrics and gynecology at the University of Illinois College of Medicine who studies maternal death, pointed out that health care providers can address only some of the factors that lead to maternal mortality — and their ability to help is often limited to pregnancy. “​​You can’t take a woman with a lifetime of poor health, poor social surroundings, and get her healthy in nine months of pregnancy,” she said. “It’s just not possible.”

But researchers have accounted for some of those differences in their studies — and the associations between abortion restriction and maternal mortality remain. Hawkins’s research, for example, statistically controlled for whether states expanded Medicaid. The study found that reducing Planned Parenthood clinics by 20 percent was associated with a maternal mortality increase of 8 percent, while states that implemented abortion restrictions based on gestational age saw a 38 percent increase in maternal mortality. Likewise, the study that tracked changes in maternal mortality across states between 1995 and 2017 got around the problem of distinguishing correlation from causation by focusing on changes in maternal mortality that happened after restrictive abortion policies were implemented. During that same time period, obesity and poverty rates didn’t change significantly, said Mark Hoofnagle, a surgeon at Washington University in St. Louis and a co-author of the study.

All told, you end up with a collection of evidence that points toward the conclusion that abortion restrictions and maternal mortality are somehow linked. And that makes sense because we already knew that social forces could affect maternal mortality. But what’s behind that link — specifically, how abortion restrictions could cause more women to die — is harder to pin down. 

How could abortion restrictions lead to higher maternal mortality?

Amanda Stevenson, a professor of sociology at the University of Colorado Boulder, estimated late last year that a total ban on abortion would result in a 7 percent increase in pregnancy-related deaths in first year of the ban and a 21 percent increase in pregnancy-related deaths in the years that followed. Those estimates are probably high, she told us, because overturning Roe wouldn’t result in a nationwide ban — but she thinks more maternal deaths are still likely to occur. 

But supporters of abortion restrictions frame the laws as life-saving measures. Monique Wubbenhorst, a senior researcher and policy fellow at Notre Dame University’s de Nicola Center for Ethics and Culture who is anti-abortion, said she saw no clear mechanism for how diminished access to abortion could cause an increase in deaths. Instead, she suspected that the correlations were statistical ghosts — perhaps hinting at some third factor connected to both. That’s certainly a possibility. Maternal deaths, despite being more common in the U.S. than in other wealthy nations, are still very rare. And that small sample size means that researchers who try to draw broader conclusions using the data can run into problems — it’s hard to look at what’s going on within demographic subgroups, for instance, or examine what’s happening within specific states.

Other researchers do see potential mechanisms, though. The simplest explanation is just that giving birth is statistically more dangerous than having an abortion. If the states with the highest mortality rates are the also the ones banning abortion that means more births — and also more deaths.  

Deaths could also increase because doctors in states that ban abortion may be unsure about when they can legally end a pregnancy in a person who is miscarrying. For example, in 2012, doctors in Ireland refused an abortion to Savita Halappanavar because the baby she was miscarrying still had a fetal heartbeat. In the time it took for cardiac activity in the fetus to stop — and the doctors to then be confident an abortion would conform with the country’s laws — Halappanavar developed the infection that killed her. The case ultimately led to the repeal of many abortion restrictions in Ireland.  

In a similar way, abortion restrictions could lead to more infants dying in birth or immediately afterward, said Maeve Wallace, a professor of reproductive epidemiology at Tulane University. She is part of a team that found a correlation between the implementation of gestational age restrictions on abortion and an increase in infant mortality due to congenital abnormalities. During a pregnancy, doctors run tests to spot such abnormalities, but some tests can’t be performed until the middle of the second trimester, which is very close to when abortion becomes illegal in some restrictive states. “You’re getting these test results and you’re beyond your gestational age limit to abort this fetus that might not even live an hour outside the womb because of some severe anomaly,” Wallace said. 

But the connection between abortion restrictions and death could also be more complicated than these examples — tied to how additional support for mothers and families isn’t usually addressed in step with the passage of new restrictions. In fact, efforts to reduce abortion access have often resulted in the closure of clinics like Planned Parenthood that offer a range of non-abortion-related services. Losing access to preventative health care puts people at a higher risk for all kinds of illnesses that can later cause pregnancy complications. And this effect means the impacts of abortion restriction can overlap and build on the social inequalities that are already harming Black people and babies.

For example, states like Georgia and Louisiana, which have consistently high rates of maternal mortality, also have disproportionately high numbers of those deaths happening in Black people. The deaths often come from conditions like chronic hypertension, preeclampsia and hemorrhage.

Black Americans have a harder time accessing health care that could prevent or treat those conditions, and they have a harder time getting proper treatment even when they can access it. “​​Just in my own social circles and network, I can throw a rock and hit somebody who also had a traumatic birth experience, who also experienced a loss or a morbidity,” said Nakeenya Wilson, a community advocate on the Texas’s Maternal Mortality and Morbidity Review Committee.

Black people, and especially those who have low incomes and live in rural areas, have precious little access to health care before, during or after they become pregnant, said Madeline Sutton, a professor of obstetrics and gynecology at Morehouse College whose work focuses on health care inequalities for women. When people go without checkups and prenatal care because they can’t afford it, can’t take time off work or live hours from the nearest clinic, their risks go up. 

Abortion restrictions aren’t the only thing making it hard for pregnant people in states like Georgia to get preventative care — hospital closures in rural areas have been a huge factor, Sutton said — but reducing access to clinics like Planned Parenthood is just pulling one more brick out of an a wall that was already listing. What’s more, while anti-abortion Sen. Bill Cassidy of Louisiana has co-sponsored federal bills aimed at studying racial disparities in health care and promoting remote monitoring of pregnant Medicaid patients’ blood pressure and other health metrics, state legislatures that remove the supports offered by abortion clinics have not generally made an effort to shore up the wall in other ways. 

“It’s almost like the abortion hostility is a signal for a general hostility towards interventions on women’s health and prenatal care,” Hoofnagle said. All the states in his study of maternal mortality had similarly low rates of maternal mortality in the 1990s. And all saw an increase in deaths over the next 20 years because the way maternal mortality is measured improved during that time, he said. But some states chose to put a legislative priority on preventing future deaths. California, for example, took steps to standardize blood-transfusion protocols statewide, ensuring that even small hospitals would have skills and tools to deal with hemorrhage in childbirth, and that obstetricians were following the latest, evidence-based guidelines for how transfusions should be done. The efforts reduced severe maternal morbidity in patients with hemorrhages by nearly 29 percent. 

All of the experts we spoke with believe maternal mortality rates are a huge problem, and each stressed the need to improve maternal health care. Part of the challenge, though, is that abortion is such a fraught issue and it’s hard to get people on the same page about what the data is saying. Researchers who are very concerned about threats to abortion rights will probably be more inclined to see a connection between abortion restrictions and maternal deaths than researchers who oppose abortion rights, like Wubbenhorst. She, for instance, questioned whether legislators were best suited to help reduce maternal deaths, as opposed to hospitals. Meanwhile, other experts, like Geller, expressed anger that anti-abortion lawmakers were focusing so much on restrictions and so little on the pregnancies that the restrictions would cause. 

Most experts we spoke with, though, said there needs to be more attention on the health of women who want abortions and won’t be able to get them. Wilson, the maternal-health advocate in Texas, said that she tries to stay out of the abortion debate in general, but she’s worried that, as lawmakers race to ban abortion, those women and their babies are being left out of the conversation. “​​No [woman] should ever have to face death in order to bring life into this world,” Wilson said. “If, in fact, we’ve taken the position as a country, as a state, that we are going to protect the unborn baby, where is the pipeline and the follow-through … to ensure that that child and family unit has the resources that they need in order to not just survive, but to thrive?”

Additional reporting by Katie Kindelan and Mary Kekatos. Additional statistical analysis by Jeffrey Howard, a professor of public health at University of Texas at San Antonio.