In a post-Roe world, reproductive health specialists warn, more mothers are likely to die — not only from a return of unsafe illegal abortions but also from pregnancy itself, which leads to a surprising number of deaths in the United States.
In 2020, 861 people died in childbirth or within 42 days of the end of their pregnancy, the US Centers for Disease Control and Prevention reported last January.
Women in the United States are more likely to die from childbirth or pregnancy-related causes than those in other developed countries. In 2020, the United States had the highest maternal mortality rate of 10 high-income countries, including Canada, France, and the United Kingdom.
An anticipated Supreme Court opinion overturning Roe v. Wade, the 1973 decision that made abortion legal nationwide, would land amid a dawning awareness that maternal mortality is worsening in the United States, driven by deep racial inequities. The Black maternal mortality rate was 2.9 times the rate for white people in 2020, according to the CDC.
“When people talk about women who get pregnant dying, it’s not just from unsafe self-managed abortions. People die because they are not in optimal health to have a pregnancy and now are being forced to continue a pregnancy,” said Jen Villavicencio, who handles equity transformation for the American College of Obstetricians and Gynecologists. “Especially for Black, Hispanic, and Indigenous women in this country, carrying a pregnancy to term and birthing a child can be a dangerous endeavor.”
Reproductive experts argue that the risk of death associated with childbirth is 14 times higher than it is for abortion. The American College of Obstetricians and Gynecologists cites that figure in an amicus brief in Dobbs vs. Jackson, the Mississippi abortion case now being decided by the Supreme Court, while also asserting that abortion poses less risk than wisdom-tooth removal, colonoscopy, or plastic surgery.
But abortion opponents challenge the methodology of the 2012 comparative study that produced the figure, noting that abortion data is not comprehensively tracked.
“Our data is simply inadequate and terribly flawed,” said Dr. Jim Studnicki, a research professor who serves as vice president and director of data analytics for the antiabortion Charlotte Lozier Institute. He noted that states are not obliged to provide abortion data to the CDC and that the most populous state in the country, California, does not. The CDC data that is available shows only two abortion-related deaths nationwide in both 2017 and 2018, while noting a substantial number of abortions took place in areas that didn’t provide data.
Studnicki also challenged the premise that maternal mortality will worsen and pointed to the relative scarcity of maternal deaths, under 1,000 a year.
“Maternal mortality is — even in the United States as such a big deal is made out of it — an extraordinarily rare event,” Studnicki said. He asserts that the maternal mortality ratio used worldwide is inherently flawed because it calculates maternal deaths based on live births — not the total number of pregnancies — and fails to account for miscarriage or abortion.
“Anyone who takes that figure or those numbers seriously has never looked at a statistics book in their life,” Studnicki said.
Data on maternal mortality was also lacking for years. The National Center for Health Statistics, recognizing that deaths were being undercounted, stopped releasing national estimates of maternal mortality from 2007 to 2020, while states phased in new reporting procedures — essentially a standardized check box on death certificates indicating the patient had been pregnant.
In early 2020, the first release of data collected with the new reporting method showed a dramatic increase in the 2018 maternal mortality rate — leading officials to warn that they may have overcounted deaths that were previously undercounted.
But the trend has continued since then, with maternal deaths climbing from 658 in 2018 to 754 in 2019, according to the CDC.
Overall, the maternal mortality rate rose to 23.8 deaths per 100,000 live births in 2020, according to the CDC. The increase was driven by Black maternal deaths — 55 per 100,000 births compared with 44 per 100,000 births the year before, the data show.
Black women are also dramatically overrepresented among those having abortions, according to the limited CDC data that are available. In the 30 areas that reported race by ethnicity data for 2019, non-Hispanic Black patients had the highest abortion rate (23.8 abortions per 1,000 patients) compared with white patients (6.6 abortions per 1,000) and Hispanic patients (13 per 1,000). The comparison of abortions with the number of live births in each racial group was also skewed. There were 386 abortions for every 1,000 Black births, compared with 117 abortions for every 1,000 white births, and 236 abortions for every 1,000 Hispanic births.
That means Black women will be disproportionately affected by abortion restrictions that states impose if the Supreme Court rules, as expected, that abortion is not a constitutionally protected right.
“The United States is facing this Black maternal health crisis, which will be further exacerbated in areas where abortion care and abortion access is going to be banned,” said Ndidiamaka Amutah-Onukagha, a professor at Tufts University School of Medicine who recently founded the Center for Black Maternal Health and Reproductive Justice there.
Racial disparity was not as extreme in Massachusetts, according to the most recent data available from the Massachusetts Department of Public Health. But that was woefully out of date — a 2014 report on people who gave birth at the start of the millennium. The Massachusetts Maternal Mortality and Morbidity Review Committee found 168 pregnancy-associated deaths from 2000 through 2007, with Black women 1.9 times more likely to die during pregnancy or within one year postpartum as white women. (Both categories exclude Hispanic women.)
“Things are worse in other places, definitely. But that doesn’t let Massachusetts off the hook,” said Amutah-Onukagha. “Massachusetts is not immune to what’s happening in other parts of the country.”
Women of color are more likely to have high-risk pregnancies and less likely to have access to health care and resources to manage those risks. Maternal deaths are often attributable to hypertension, gestational diabetes, eclampsia, or hemorrhage, conditions exacerbated by the trauma of pregnancy, she noted.
Of most urgent concern are conditions of pregnancy that present a direct threat, such as Preterm Premature Rupture of Membranes (PPROM), in which a patient’s water breaks well before the baby is due, or often even viable. Fetuses typically only survive the condition if close to viability, around 23 weeks. It often causes a life-threatening infection for the mother.
Advocates are concerned that state laws that restrict second-trimester abortions — such as those passed in Texas and Mississippi — will stymie doctors from quickly providing life-saving care to such patients. The New York Times reported this week on a woman in Poland, where abortion is prohibited, who died in a hospital after her water broke prematurely.
However, technically, abortion is still permitted to preserve a patient’s life in Poland — as it would be in many of the states that would seek to restrict abortion, noted Dr. Ingrid Skop, a Texas OB-GYN and director of medical affairs for the Charlotte Lozier Institute, a research affiliate of Susan B. Anthony Pro-Life America.
“Doctors can still do what they need to do to help a woman when her life is threatened by her pregnancy,” Skop said.
But she, too, has pondered what impact anticipated changes to abortion law might have on maternal mortality.
“All of us, no matter of what we think about abortion, we want women to do well,” Skop said. “And the idea of a mother dying in childbirth is devastating.”
Massachusetts reproductive rights advocates now trying to shore up coverage for a post-Roe future are also pushing for systemic changes in health care to better protect those who give birth.
“We have to look holistically at maternal justice. That includes access to abortion, but it also includes access to safe labor and delivery,” said Rebecca Hart Holder, executive director of Reproductive Equity Now. Her organization’s “Beyond Roe Coalition” is championing a state bill that would abolish copayments and any out-of-pocket costs for prenatal and postnatal care. Prenatal care is covered in Massachusetts, but deductibles and copayments often make appointments cost-prohibitive for low-income patients.
The bill is shelved for now, though, and the Massachusetts Association of Health Plans raised concerns about its cost, saying it would increase members’ premiums by $1.51 to $2.31 a month.
“The financial impact of this legislation would fall squarely on insured individuals, families, and small businesses in the state,” the association’s president, Lora Pellegrini, said in a statement.
Hart Holder viewed it differently, calling it the equivalent of a “cup of coffee every month.”
“This is a negligible cost for an extraordinary public health outcome,” she said.