Episode Transcript
[00:00:00] Before we begin. This episode contains content that some listeners may find sensitive. Listener discretion is advised.
[00:00:27] This is the Access Pregnancy Post Roe Podcast and I am Mia Braun.
[00:00:34] Many people do not understand that the risk of maternal mortality is not just about the dangers of childbirth itself, but the continuing effects of pregnancy and delivery which may not show up until months later. Like high blood pressure, heart conditions, infections or hemorrhage, the maternal mortality rate in the United States has been higher than in any other major industrialized country for more than two decades.
[00:01:04] Senator Laphonza Butler of California emphasized the Our health care system and the state of maternal health in this country is at an inflection point that requires the urgent attention of this committee. The numbers should alarm all of us. The United States has the highest rate of maternal mortality among high income nations. In recent years, thousands of women have lost their lives due to pregnancy related causes and over the past decade, while the birth rate in this country has declined by roughly 20%, maternal mortality rates have steadily risen. The crisis is exacerbated in communities growing grappling with the lack of access to essential maternal health care.
[00:01:56] Before the Dobbs decision, it was estimated that more than 80% of pregnancy related deaths and more than 60% of infant deaths in the first week were preventable.
[00:02:09] This episode will focus on a variety of components that affect the mortality rate of mothers in the United States from abortion bans, unsafe abortions, maternal mortality committees, racism and discrimination, and infant mortality.
[00:02:29] The maternal mortality rate in the United States is far higher than in any other high income country.
[00:02:37] Abortion bans are overwhelmingly likened to worsen morbidity rates.
[00:02:43] Longitudinal research shows that women who are denied abortion care are more likely to experience poorer health outcomes, including gestational diabetes and gestational hypertension, which is a contributor to eclampsia, for which abortion is one option for treatment.
[00:03:06] Georgia has one of the highest maternal mortality rates in in the country and the state has failed to adopt policies necessary for improving maternal and infant health outcomes. Ever since these abortion laws were written, doctors, major medical organizations and patients who have experienced these issues themselves have been speaking up and warning that these bans are not clear and can lead to women dying unnecessarily.
[00:03:36] In some states, there have been efforts to propose small changes that doctors state would help them avoid situations of delayed care. However, we continue to see major anti abortion organizations oppose these changes.
[00:03:57] Pregnancy has become more dangerous for women in the state of Texas since the state banned abortion in 2021, the rate of sepsis shot up more than 50% for women hospitalized when they lost their pregnancies in the second trimester, according to ProPublica. This life threatening condition, which is caused by an infection, was most common for patients whose fetus may still have had a heartbeat when the patient arrived at the hospital.
[00:04:29] ProPublica has already reported the case of two women dying due to sepsis while miscarrying. Doctors delayed evacuating their uteruses because it would have been considered an abortion in the state.
[00:04:44] Maternal health experts who reviewed ProPublica's findings say they add to the evidence that the state's abortion van is leading to a dangerous delay in care.
[00:04:57] Texas law threatens up to 99 years in prison for providing an abortion. The ban does include an exception for medical emergency, but the definition of what constitutes an emergency has been subject to confusion and debate.
[00:05:13] Many experts have concluded that the sudden jump of sepsis cases must be related to the abortion ban within the state.
[00:05:23] The standard of care for miscarrying patients in the second trimester is to offer to empty the uterus, which can lower the risk of contracting an infection and developing sepsis. If a patient's water breaks or her cervix opens, that risk rises with every passing hour.
[00:05:45] Sepsis can lead to permanent kidney failure, brain damage and dangerous blood clotting. This is one of the leading causes of death in hospitals nationally.
[00:05:57] While some doctors have stated they regularly offer to empty the uterus in these cases, others say their hospitals won't allow them to do so until the fetal heartbeat stops or they can document a life threatening complication.
[00:06:17] Research conducted by ProPublica determined that before the abortion bans in Texas, the rate of sepsis for pregnant women was relatively steady when the state made it a civil offense in 2021 to end a pregnancy after a fetus developed cardiac activity and then in the summer of 2022 made it a felony to terminate any pregnancy. With few exceptions, the cases of sepsis rose in the year 2021, 67 patients who lost a pregnancy in the second trimester were diagnosed with sepsis. This accounted for about 3% of the hospitalizations in 2022. The number of women increased from 67 to 90. In 2023, that number would rise again to 99 women contracting sepsis due to miscarrying in their second trimester of pregnancy in the state.
[00:07:21] These numbers are conservative, as ProPublica did not capture what happened to miscarrying patients who were turned away from emergency rooms or those who were made to wait discharged home before returning with sepsis. A study conducted by the University of Texas Science center in Houston found that the rate of sepsis tripled after abortion bans were created.
[00:07:49] ProPublica's analysis showed that patients who were admitted while their fetus was still believed to have a heartbeat were far more likely to develop sepsis.
[00:08:01] Dr. Christina Adams Waldorf, a professor of obstetrics and gynecology at UW Medicine Medicine, is quoted saying, what this says to me is that once a fatal death is diagnosed, doctors can appropriately take care of someone to prevent sepsis. But if the fetus still has a heartbeat, then they aren't able to act. And the risk for maternal sepsis goes way up. These bans are needlessly putting a woman's life in danger.
[00:08:36] Waiting to evacuate the uterus increases rates of sepsis for patients whose water breaks before the fetus can survive outside the womb due to the risk of infection. Major medical organizations like the Society for Maternal Fetal Medicine advise doctors to always offer abortions before the state's abortion bans. In the year 2018-2019, there were 79 maternal deaths reported in Texas since the abortion bans. In the years 2022 and 2023, there were a reported 120 maternal deaths.
[00:09:20] Abortion bans cause patients to come close to death because doctors are too afraid to treat them. Abortion bans force patients to carry dying fetuses to term.
[00:09:32] Abortion bans prevent doctors from helping patients with complicated risk factors.
[00:09:42] It has been suggested that within the next few years we will see the infant mortality, preterm birth, maternal mortality, and maternal morbidity numbers rise for everyone, particularly for folks from racially marginalized and low socioeconomic communities.
[00:10:05] The consequences of restricted access to safe abortions are devastating, most tragically seen in the preventable deaths of mothers. Before the legalization of abortion, unsafe procedures claim claimed countless lives.
[00:10:23] According to a systematic review by the National Institutes of Health, the barriers to accessing safe abortion present a serious health risk for women globally.
[00:10:35] Between the years of 2010 and 2014, out of the 25.1 million abortions that occurred worldwide, 45.1% abortion were unsafe, provided by unskilled practitioners, or used outdated or harmful methods.
[00:10:55] Mortality after safe abortion is negligible and serious adverse events are rare. Unsafe abortion is estimated to cause 23,000 deaths globally each year.
[00:11:10] Before legalization, many deaths from unsafe abortions were likely underreported due to stigma, fear of legal repercussions, and inadequate record keeping. While the exact numbers are debated, it's undeniable that many women died from complications of illegal abortions.
[00:11:31] Historical records show that abortion related deaths were a significant contributor to maternal mortality.
[00:11:39] As stated by the Guttmacher Institute In 1930, abortion was listed as the official cause of death for almost 2,700 women, nearly 1/5 or 18% of maternal deaths recorded in that year.
[00:11:55] Women of color and low income women were disproportionately affected by unsafe abortions as they often lacked access to even the limited safe medical care that was available.
[00:12:08] The legalization of abortion threw Road v. Wade significantly reduced the number of deaths and complications from unsafe abortions. The introduction of antibiotics also played a large role in the reduction of deaths from infections caused by unsafe abortions.
[00:12:26] The illegal nature of abortions before Roe v. Wade made it difficult to collect accurate data. Many women who experience complications from unsafe abortions may have been reluctant to seek medical care, further contributing to underreporting.
[00:12:44] While precise numbers are elusive, historical accounts and medical records confirm that unsafe abortions posed a serious threat to women's lives before Roe v. Wade and that the legalization significantly improved women's safety.
[00:13:01] When we look at the landscape of abortion now, now within the United States, the combination of restricted access to safe abortions and the historical evidence strongly indicates that abortion bans will likely lead to a rise in unsafe abortions.
[00:13:23] The connection between abortion bans and maternal mortality is a growing concern.
[00:13:29] Maternal mortality review committees, which meticulously review pregnancy related deaths, can offer concrete evidence of how these restrictions are putting women's lives at risk.
[00:13:43] Maternal mortality review committees exist in every state. These committees are tasked with examining the deaths of women during pregnancy or up to a year after and determining whether whether they could have been prevented. These committees have members from a variety of backgrounds, including obgyns, cardiologists, mental health care providers, medical examiners, health policy experts, and community advocates.
[00:14:12] The job of this committee is to collect data and make recommendations aimed at combating systemic issues that could help reduce deaths and publish them in reports.
[00:14:23] The recommendations have led to changes in hospital care to improve the response to emergencies during labor and delivery and in order to increase access to psychiatric treatment.
[00:14:37] Due to the nature of the information, these committees review members are expected to keep the information found confidential. Some experts say that keeping the reports of maternal mortality review committees confidential is important for a committee to serve its purpose. They are set up not to assign blame, but instead to create a space for clinicians to investigate broad causes of maternal health failures.
[00:15:05] When confidential information is shared publicly, it can lead to a decision to dismantle the current committee and obtain new members. This can cause a delay in reviewing current data and making changes to better the lives of of pregnant women.
[00:15:22] California was one of the first states to start formally investigating maternal deaths in the mid 2000s. By following the recommendations adopted by the state and healthcare professionals, it helped cut the maternal mortality rate in half by the year 2013.
[00:15:44] The Texas Maternal Mortality Committee has come under some scrutiny since the state's abortion ban went into place in the fall of 2021 and in the summer of 2022 when it expanded the ban to all abortions from the moment of conception unless the life of the mother is in jeopardy. Some of the criticism has come due to the legislation in Texas which prohibits the review of abortion rights related deaths, a caveat that even committee members were not aware of until months ago.
[00:16:19] The legislation also allocated money in the last year with the intent of cutting Texas out of the federal maternal death tracking system.
[00:16:31] Despite committee members concerns, lawmakers have also expanded the committee, replacing the six single community advocate position with two community member roles to represent the urban and rural areas of the state.
[00:16:47] One of these new members is an anti abortion obgyn from San Antonio.
[00:16:53] The Maternal Mortality Committee in Texas started to review the data on maternal deaths for the year 2024, but skipped the first two years of data in and review since the state's abortion ban. In September, it was announced that the committee would not review maternal deaths that occurred in the year 2022 and 2023.
[00:17:18] A committee chair reported there was no political influence the committee was skipping the first two years of the abortion ban was merely a coincidence.
[00:17:28] The reasoning provided for this decision was to offer analysis and recommendations based on the most recently available data.
[00:17:38] The committee chair, Dr. Carla Ortik, said skipping those years would help avoid a backlog of older cases so they could work on more recent deaths.
[00:17:50] This decision means that the committee won't investigate any potential deaths that could be connected to the state's abortion ban for the first two years it was in effect.
[00:18:01] Dr. Jonas Schwartz, a professor at Duke University, stated, the fact that Texas is not reviewing those years does a DisService to the 120 individuals who identified who died inpatient and were pregnant, and that is an understatement of the number of people who died.
[00:18:22] According to ProPublica's reporting, they have already tied three deaths of Texas women to ban related delays in care.
[00:18:31] Rather than investigate this large increase, the state is admitting that the bodies are piling up faster than the state can address them.
[00:18:40] Instead of dedicating more time and effort, like increasing the size of their committee to look into these deaths, they simply want to brush these women's lives under the rug and Skip ahead to 2024.
[00:18:54] According to ProPublica's research and findings, not all maternal deaths take place in hospitals, and the Texas hospital data did not include cause of death, so the company also looked at data compiled from death certificates by the Centers for Disease Control and Prevention.
[00:19:14] This data shows that the rate of maternal deaths in Texas rose 33% between 2019 and 2023, even as the national rate fell by 7.5%.
[00:19:34] The maternal mortality Review Committee in Georgia was disbanded in November of 2023 due to commitment committee members violating state laws by sharing confidential information.
[00:19:47] Georgia spent over a year replacing the committee with new appointees. This new committee was finally created and met for the first time in February of 2024.
[00:19:59] An Atlanta father who lost his wife, Kira, in a 2016 routine cesarean section has been advocating for maternal health committees and said the dismissal of the Georgia panel appears to be an attempt to retaliate for exposing some of the unfortunate outcomes of Georgia's laws. The removal of Georgia's panel will hinder the reviewal process and recommendation process, and it could potentially harm pregnant women. In the process.
[00:20:32] These committees perform comprehensive, deep dive reviews of any deaths in the state that occur during pregnancy or within the year following pregnancy. This ruthless move of disbanding the committee delays the work, but also seems to focus more on the importance of leaks to media instead of investigating women's deaths.
[00:21:00] In 2022, Idaho effectively disbanded its committee after conservative groups attacked members for calling on the state to extend Medicaid coverage for postpartum women.
[00:21:14] The Idaho Freedom foundation and other conservative groups blasted the state's Maternal Mortality Review Committee for recommending the extension. The Idaho Freedom Foundation's opposition to extending Medicaid care for postpartum women stems from their core ideological stance, which generally advocates for not expanding government funded programs because they view them as an increase in government intervention. These groups also express concerns about the cost of Medicaid expansion and its contribution to the federal debt.
[00:21:54] They have also suggested that existing programs could potentially cover the needs of postpartum women and that expanding Medicaid is not the necessary solution.
[00:22:05] State lawmakers tabled the bill partly because of concerns over the cost of extending pregnancy Medicaid.
[00:22:14] When the state legislators passed a law reinstating the Maternal Mortality Rate Review Committee, the House Majority leader, Megan Blacksma, lost to a candidate backed by the Idaho Freedom Foundation.
[00:22:30] The need for these committees is extremely vital to the lives of pregnant women during their pregnancy as well as after their pregnancy. States that disband these committees are doing a disservice to the medical care these women are receiving.
[00:22:46] One should question if these decisions are based on the fact that these states have abortion regulations or bans and maybe don't want the public to know how these bans are truly affecting the population of women in their reproductive years.
[00:23:03] Tennessee Democratic Senator London Lamar is quoted saying the following they don't want the public to know that the policies they're passing to hinder women's reproductive rights are having a negative impact.
[00:23:22] The Arkansas Maternal Health Advisory Groups have also opposed extending Medicaid coverage to low income postpartum women.
[00:23:32] Arkansas is the only state in the nation that hasn't taken steps to extend Medicaid coverage to one year postpartum. Medicaid covers about 40% of births, but about 40% of low income pregnant women in Arkansas lose their eligibility two months after giving birth.
[00:23:54] Within the past few years, the Arkansas Maternal Mortality Review Committee has recommended Medicaid extension as a way to reduce maternal deaths. However, their governor remains staunchly opposed, stating that the state already offers other options for insurance coverage and increasing Medicaid would be redundant.
[00:24:18] Governor Sanders has been quoted we want to make sure that we are transitioning women to coverage that already exists in the state. I don't believe creating a duplicate educative program just for the sake of creating a program is going to fix the issue. We already have so many women who aren't taking advantage of the coverage that exists.
[00:24:41] Even though Arkansas offers these other options, obviously there is a large number of women who are not using these services. They're either not being informed of these options or these options are not easily accessible.
[00:24:57] Navigating health care coverage after Medicaid postpartum benefits end can be complex.
[00:25:04] If women in the state of Arkansas are losing their Medicaid benefits within two months postpartum, we need to reflect on the psychological and physical changes that are still occurring for the mother, which can also hinder their ability to properly locate and access other health services the state offers.
[00:25:27] If the governor's concern is women not using the resources that they already have available to them, the government needs to look at how easily accessible these services are to obtain and make changes for these services to be used.
[00:25:44] The American Rescue Plan act of 2021 gives states the options of of extending Medicaid coverage for up to one year following a Medicaid finance pregnancy or birth. With the federal law requiring coverage for 60 days postpartum less than one third of abortion restriction, states have adopted this coverage extension or have plans underway to do so. Compared with almost half of abortion access states, women in states that have not expanded Medicaid eligibility are most at risk of lacking coverage and skipping needed care due to cost.
[00:26:27] Nationally, researchers and advocates have stressed the importance of continuing insurance coverage after birth. Because more than half of pregnancy related deaths in the United States occur in the year following the pregnancy, many states have adopted their committee's recommendations. Illinois was the first state to extend Medicaid coverage to all women for one year postpartum after legislators followed the advice of its Maternal Mortality Review Committee. When the State of Washington's committee noted that pregnancy related deaths weren't always referred to the local medical medical examiner for an autopsy, the state legislator passed a law requiring birthing hospitals to refer those deaths to the local coroner or medical examiner and then provided funding for those autopsies.
[00:27:27] States with restrictive abortion policies have effectively created a system in which abortion is inaccessible but families have access to few supports to raise children safely and sustainably.
[00:27:42] This is troubling for individuals relying on public benefits who are also less likely to be able to overcome the barriers to obtaining an abortion created by state level abortion restrictions.
[00:28:04] A deeply concerning disparity exists within maternal health outcomes. Black and Brown women experience maternal mortality rates that are alarmingly disproportionate. Compared to their White counterparts, Black women are more than twice as likely to die during pregnancy or after birth than the national average.
[00:28:28] This is a deeply concerning issue with complex interwoven causes.
[00:28:34] Black women in the US Experience maternal mortality rates significantly higher than those of White women. Hispanic women also face disparities. Although the rates vary, the Centers for Disease Control and Prevention or CDC data consistently shows these stark racial disparities.
[00:28:57] Racism within the health care system plays a significant role in these disparities.
[00:29:04] This includes implicit bias, discrimination, and unequal access to quality care.
[00:29:11] Black women's lives are shaped by their interactions within political, cultural, and economic systems, systems that continue to be shaped by centuries of discrimination, bias, and systemic oppression, which includes the context of reproductive health.
[00:29:31] More than 80% of the deaths that occur for Black women are preventable, but due to systematic racism and discrimination, inadequate access to high quality and culturally affirming maternal health care, including doulas, midwives, labor and delivery classes, and other social drivers of health, Black women become the brunt of this crisis.
[00:30:01] Factors such as poverty, lack of access to health care, and inadequate housing contribute to poorer health outcomes for Black and Brown women.
[00:30:11] They often face barriers to accessing quality prenatal labor and postpartum care.
[00:30:19] This includes limited access to health care providers, hospitals and specialists.
[00:30:26] A recent poll conducted by In Our Own voice concluded that 54% of black women said that they have experienced racial and gender gender bias in the healthcare system.
[00:30:38] One in five women also stated that they felt their healthcare provider did not take their pain seriously during pregnancy or childbirth due to race and or gender.
[00:30:51] Black women are more likely to have pre existing health conditions such as hypertension and diabetes which can increase the risk of pregnancy complications.
[00:31:04] They are disproportionately affected by severe maternal morbidity which is unexpected outcomes in labor and delivery such as hypertension and or anxiety.
[00:31:16] It results in short term or long term consequences to the childbearing person's health and wellness.
[00:31:25] Implicit bias among healthcare providers can lead to disparities in the quality of care received.
[00:31:33] This can result in delayed diagnoses, inadequate treatment and dismissal of patient concerns.
[00:31:40] The chronic stress of experiencing racism and discrimination can have a detrimental impact on health.
[00:31:48] Environmental factors in certain communities can also contribute to health disparities.
[00:31:55] The maternal mortality crisis is a racial justice issue. Addressing this crisis requires a multifaceted approach that tackles systematic racism, improves access to quality health care and addresses socioeconomic factors.
[00:32:13] Dr. Jamila Parit is quoted the fact that black women and birthing people are dying at three to four times greater risk of than white women is shameful and it's preventable. One death is too much, one is too many.
[00:32:31] The systems and policies that harm black communities, including inequitable access to healthcare, limited access to paid leave, discriminatory health care practices and more, have led to a maternal health crisis for black women.
[00:32:49] These same barriers undermine access to abortion care and have only been exacerbated by abortion bans that have been enacted in the wake of the Dobbs decision.
[00:33:05] As states enact increasingly restrictive abortion laws, concerns also arise regarding the potential consequences for infant health.
[00:33:16] The American Civil Liberties Union of Texas stated that doctors and abortion care experts had warned that infant mortality would increase in states with abortion restrictions or abortion bans.
[00:33:32] In the year following the abortion ban in Texas, child mortality shot up by 12.9% compared with a 1.8% increase through the rest of the country, according to the Johns Hopkins Bloomberg School of Public Health. It is estimated that abortion bans in 14 states have resulted in 22,180 live births and 478 additional infant deaths above what would have been expected expected in the absence of these bands.
[00:34:10] According to the research, the increase in infant mortality due to congenital malformations was consistent with women being denied abortions for non viable pregnancies, which is when pregnancy cannot possibly result in a live born baby.
[00:34:28] Sarah Corning, a staff attorney with the AC aclu, is quoted, when the state invades our hospital rooms, people are forced to carry fetuses with fatal abnormalities and either experience a stillbirth or watch their baby die shortly after birth. It is shameful that our state's laws create such unnecessary physical and emotional harm.
[00:34:55] Among the 14 abortion ban states, black infants died at an 11% higher rate than would have been expected if the bans were not in place. There was a larger increase in infant deaths within the southern states, especially black infants. Infant mortality had been decreasing in the US in recent decades. However, researchers estimate that infant deaths were 5.66% higher than they would have been in the 14 states with abortion bans had the bans not been enacted, resulting in an estimated 478additional deaths.
[00:35:38] Most of these 384 were in Texas, which enacted an abortion ban nearly a year ahead of other states.
[00:35:47] These findings suggest that restrictive abortion policies may be reversing decades of progress in reducing infant deaths in the United States.
[00:35:58] The data also shows a clear pattern of abortion bans disproportionately affecting regions and populations already struggling with poor health outcomes, including Black infants and infants born in the South.
[00:36:19] Abortion is not a solution to the maternal mortality and morbidity crisis.
[00:36:25] Every person should be able to have a healthy pregnancy, birth and postpartum period.
[00:36:32] However, banning abortion will only worsen the country's already devastating rates of maternal mortality and morbidity. When a person is barred from access accessing abortion care, she is compelled to continue a pregnancy against her will, even when serious health threats exist. This is itself a violation of human rights.
[00:36:58] Women of reproductive age and birthing women in states with current or proposed abortion bans have more limited access to affordable health insurance coverage, worse health outcomes, and lower access to maternity care providers. Making abortion illegal risks expanding these disparities. As states with already limited Medicaid maternity coverage and fewer maternity care resources lose providers, they are reluctant to practice in states that they perceive as restricting their practice.
[00:37:36] The result is a deepening of fractures in the maternal health system and is a compounding of inequities by race, ethnicity, and geography.
[00:37:50] States have the power to avoid this outcome through partnerships with health plans, providers and residents, state leaders could attempt to recruit more maternity care providers, which would include midwives, physicians, doulas, and nurses. They could also help promote the operation of more birthing facilities and birthing units.
[00:38:15] Adopting the Affordable Care Act's Medicaid eligibility expansion for low income adults and extending Medicaid postpartum coverage to one year could allow also help states enhance the health and well being of mothers and infants before, during and beyond pregnancy.
[00:38:37] There should be increased federal funding for reproductive healthcare, family planning, maternity care, and care delivery system transformations that could help mitigate the impact of the Dobbs decision and the state abortion bans on people's lives.
[00:38:55] State, congressional and executive branch actions are all needed to protect the health of women and ensure optimal and equitable outcomes for mothers and infants.
[00:39:12] On our next episode, we will look at when state voters approve of abortion within their state. However, lawmakers are still trying to propose barriers.
