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After the Supreme Court overturned the constitutional right to abortion in 2022, President Joe Biden issued an executive order tasking the federal government with assessing the “devastating implications for women’s health“ of new state abortion bans.
Experts were warning that these bans would interfere with critical medical care and lead to preventable deaths. And the states that passed the laws had little incentive to track their consequences.
Biden directed the secretary of Health and Human Services to make sure federal agencies were “accurately measuring the effect of access to reproductive healthcare on maternal health outcomes.” He called on the National Institutes of Health and the Centers for Disease Control and Prevention to drive targeted research and data-collection efforts.
But the Biden administration has missed a critical opportunity to illuminate how abortion bans are interfering with maternal health care, leading to deaths and irreversible injuries: The CDC has not pushed state committees that review maternal deaths to examine the role these new laws have played.
The CDC leads the nation’s work to track and reduce maternal mortality, spending nearly $90 million over the last five years to fund state panels made up of health experts who analyze fatalities to spot trends and recommend reforms. While it cannot require states to collect or report certain data, the CDC gives committees detailed guidance for assessing whether deaths were preventable and which factors contributed to them.
Following this guidance, committees consider factors including obesity, mental health issues, substance use, homicide and suicide. In 2020, the CDC added a checkbox to its model case review form for committees to indicate whether discrimination played a role.
Yet the agency has issued no guidance to address the recent rollback of reproductive rights or to direct committees to consider how abortion bans factor into deaths. Some state officials point to this silence as a reason their committees haven’t made any changes to their process. “The committee must follow national guidelines in maternal mortality review committee death investigations,” said a spokesperson for Oklahoma’s health department, which oversees the committee in the state.
Researchers say that this can obscure the impact of abortion bans.
“It’s pushing it under the rug in a way — like we don’t want to count it, we don’t want to know what’s happening,” said Maeve Wallace, an epidemiologist at the University of Arizona who has published studies on the intersection of intimate partner violence and maternal deaths, including one that found a rise in maternal homicides in places with increased abortion restrictions.
When asked about this, the CDC said the information submitted by states is sufficient to understand any effects from abortion bans.
“Maternal mortality review committees already comprehensively review all deaths that occur during pregnancy and through the year after the end of pregnancy, including abortion-related deaths,” said David Goodman, lead health scientist with the CDC’s Maternal Mortality Prevention Team. “The current process includes documenting and understanding contributing factors.”
But experts said that the CDC’s current guidance gives committees no standard way to consider the role abortion bans played in maternal deaths, which makes it harder to study deaths related to the restrictions and create an evidence base to inform recommendations.
Georgia’s maternal mortality review committee blamed the state’s abortion ban as a factor in one of the deaths examined by ProPublica, that of Candi Miller. The 41-year-old mother of three ordered abortion medication online and suffered complications, but did not visit a doctor “due to the current legislation,” her family told the coroner, who documented the statement. Committee members told ProPublica that the explicit mention in the records indicated the law created a barrier to care.
Candi Miller and her family
(Courtesy of Turiya Tomlin-Randall)
The case of Amber Thurman wasn’t as clear-cut; she had taken abortion medication at home and she sought care in a Georgia hospital for complications similar to Miller’s. Records showed doctors discussed, but did not provide, a dilation and curettage procedure to clear her uterus of infected tissue as she suffered for 20 hours with sepsis. Any impact the law may have had on the doctors’ decisionmaking was not noted in records the committee reviewed.
The committee concluded that one of the factors in her preventable death was the delay in care. And while members were able to check a “discrimination” box for Thurman’s case, they did not have any method to flag that she experienced a delay in receiving a procedure that is commonly used in both abortions and miscarriages and that had recently been criminalized.
If such a category were created by the CDC, it would allow researchers to see if there have been increased delays in care after abortion was banned, maternal health researchers said.
Experts told ProPublica this categorization would likely have covered the three other deaths ProPublica reported on, of Texas women who had not considered ending their pregnancies but who needed the same kind of procedure to manage their miscarriages. In those cases and that of Thurman, doctors diverged from the standard of care in ways that raise serious questions about how criminal abortion bans are affecting care for pregnancy loss, ProPublica’s reporting found.
“CDC public data shows an alarming increase in maternal mortality in states that ban abortion,” said Nancy L. Cohen, president of Gender Equity Policy Institute, a nonpartisan research organization. “Our analysis of the evidence and other factors strongly indicates that the bans are driving this increase, but there is no way currently to determine from publicly available data if abortion restrictions contributed to a particular death.”
The CDC “has the power to correct this,” she said, by asking states to collect information about whether abortion restrictions contributed to a death.
Amber Thurman with her son
(Via Facebook)
Inas Mahdi, a maternal health researcher who previously worked at the CDC for 15 years, said officials at her former agency know the power that investigating the impacts of policy can have. “The CDC is well aware that without data, there’s no action,” she said. But she added that officials likely experienced “trepidation” over wading into a “polarizing” topic without more direct support from the administration.
In Republican-led states, there’s little appetite to study the harmful effects of laws that their leaders avidly support, and any backlash could hamper efforts to improve maternal health that are seen as bipartisan, she said.
Her fellow CDC alum, Dr. Zsakeba Henderson, agrees. “If CDC were to request that of maternal mortality review committees, I know there would be pushback at the state level,” said Henderson, who previously worked in the agency’s reproductive health division supporting state-based perinatal quality collaboratives. The maternal mortality program is voluntary, and states could simply opt out. In the past year, for example, Texas decided to forgo federal funding and not share maternal death data with the CDC. Officials at the CDC declined to comment on the reason for the change. A spokesperson for the Texas Department of State Health Services said the Legislature directed the agency to do this.
A spokesperson for the Biden administration responded to ProPublica’s questions about whether his order had been fulfilled with a list of efforts to gather and make available data on contraception access and maternal health care outcomes. They said the administration had also “amplified” data from other sources on the impact of abortion bans in a memo.
When asked why the CDC has not created a checkbox to track deaths related to abortion access, a spokesperson for HHS, the CDC’s parent agency, said that the CDC “receives feedback from states on data fields.” The spokesperson noted that the discrimination checkbox was “added based on state requests” after a work group went through a multiyear process.
The spokesperson also said the lack of a checkbox does not mean HHS failed to meet the goals of Biden’s order. The spokesperson forwarded a 73-page update on the maternal mortality crisis that had been sent to Congress this past July. The report is packed with information on progress combating major maternal health risks: task forces to support mental health, initiatives to respond to the opioid crisis, research on intimate partner violence.
It doesn’t include a single reference to abortion access.
Ushma Upadhyay, a public health scientist at the University of California, San Francisco, said collecting data is crucial for understanding how the new abortion bans are impacting maternal health. Her research through WeCount, a project from the Society of Family Planning, has helped establish that the number of abortions has increased nationally since Roe v. Wade was overturned.
Though she has participated in roundtables with HHS officials about how it could better support reproductive health research related to abortion access, she never saw the agency take action based on these talks, she said. (When asked about what these conversations had led to, the agency shared a readout on an expert roundtable about contraception and said its work on studying how abortion restrictions impact maternal health care is ongoing.)
Upadhyay said sending a congressional update on maternal mortality with no mention of abortion access as evidence of fulfilling the order “kind of says it all.” When it comes to measuring the impact of abortion restrictions, “HHS is not doing much.”
The federal government’s largest contribution to this effort comes in the form of millions of dollars of NIH funding to research projects by academics looking into the impact of abortion restrictions, Upadhyay said. But more than two years after the Dobbs v. Jackson Women’s Health Organization decision allowed abortion bans to go into effect, none of those studies have been published and it’s unclear whether the incoming administration will continue funding them.
Researchers who track reproductive health lament the failure to think creatively and act urgently to monitor the fallout of abortion bans while the department had a chance.
“The Biden administration’s lost opportunity is that it viewed Dobbs as a political moment to gain advances for the Democratic Party,” said Tracy Weitz, the director of the Center on Health, Risk, and Society at American University. “It did not take this seriously as a public health crisis.”
The window is closing as President-elect Donald Trump prepares to take office. There is little chance a Republican administration will try to collect data that helps shed light on the impact of abortion bans, which were uniformly passed by Republican-majority state houses.
Last week, Trump named Ed Martin, a prominent anti-abortion activist, to be the chief of staff for his Office of Management and Budget, which oversees how the federal budget is administered. Martin has opposed abortion exceptions, supported a national ban and discussed the idea that women and doctors should be prosecuted for abortions.
If Project 2025 is any guide to how the Trump administration will approach abortion, the CDC may soon start a very different project: launching a mandatory, nationwide surveillance program aimed at portraying abortion care as dangerous.
The conservative blueprint for reshaping the federal government recommends that the agency require all states to report detailed data on abortions, miscarriages and stillbirths or risk losing federal funding.
It states that the CDC “should ensure that it is not promoting abortion as health care.” Instead, “It should fund studies into the risks and complications of abortion.”
Mariam Elba contributed research.
