Maternal mortality is worse in Washington, D.C. than Syria. Abortion access is one reason why.

My research shows that as states restrict access to reproductive health care options, maternal mortality rates climb precipitously.
Image: a pregnant woman sitting on a bench.
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By Summer Sherburne Hawkins, associate professor, Boston College's School of Social Work

From 2007 to 2015, Syria's maternal mortality rate rose from 26 deaths per 100,000 live births to 31 deaths per 100,000 live births, a result of the country's war and a crumbling health care system.

In Washington, D.C., where politicians make decisions about both what the United States will do about the war in Syria and American women's access to reproductive health care, the average maternal mortality rate across the same eight-year period was 33 deaths per 100,000 live births.

And that is for woman of all races: The rate of maternal mortality for African American women living in our nation's capital is 59.7 deaths per 100,000 live births — worse than Panama (52) or Ecuador (59).

There is no war on American soil and we spend more on health care per capita than any other country in the Organisation for Economic Co-operation and Development. However, the maternal mortality rate in the U.S. continues to be higher than most other high-income countries — and, as social scientists, we need to understand why in order to change.

A 2019 study, "The Impact of State-Level Changes on Maternal Mortality: A Population-based, Quasi-Experimental Study," which I led, sought to examine whether there were differences among states that affect maternal mortality rates overall, and whether they affect women differently across racial or ethnic groups.

Using maternal mortality data from 38 states and Washington, D.C., we found that pregnant women in the nation’s capital are over four times more likely to die during or after childbirth than women in Nevada, which has a maternal mortality rate of only 7.6 per 100,000 live births, similar to France or the United Kingdom. Even more striking, as noted previously, is that black women residing in the capital are nearly 11 times more likely to die than white women in Nevada — 59.7 versus 5.6 per 100,000.

In the U.S., both place and race increase women’s risk of of suffering a maternal death. The Centers for Disease Control and Prevention have concluded that the majority of maternity deaths could be prevented by addressing "access to appropriate and high-quality care, missed or delayed diagnoses, and lack of knowledge among patients and providers around warning signs."

What, we asked, might then allow for such broad disparities in maternal mortality rates to develop across states?

Over the past decade, the U.S. has witnessed a changing political, economic and social climate related to women’s reproductive health. Many states have restricted women’s access to abortion, and funding cuts to Planned Parenthood have resulted in clinic closures. Nine states passed bills in 2019 to reduce the window of opportunity for when women are allowed to have an abortion, including Georgia, Kentucky, Louisiana, Mississippi and Ohio which prohibited abortions after a fetal heartbeat could be detected — effectively banning the procedure for many women who do not realize they are pregnant until later than that. As of February 1, 2020, the Guttmacher Institute found bills in another 17 states that would effectively ban all abortions based on various criteria and 16 states has bills to ban abortions after 12 weeks.

Linking our mortality data to state-level indicators, we found that in the same period of time as our study, five states required abortion providers to obtain admitting privileges or transfer agreements, 12 states created maternal mortality review committees, 12 states enacted laws that prohibit abortions based on gestational age and 20 states restricted coverage of abortions by insurance purchased through the Affordable Care Act marketplace. Meanwhile, Planned Parenthood clinics closed in 27 states — an average reduction of 35 percent.

We found that both a state's enactment of gestational limits for abortion and the Planned Parenthood clinic closures in a state increased its maternal mortality rates. Legislation that restricted abortions based on gestational age — often, in the time period we studied, by prohibiting abortions later than 20 weeks, though more recent bans are proposed to start earlier — increased mortality by 38 percent, primarily among white women, although rates were higher across all racial/ethnic groups.

A 20 percent reduction in Planned Parenthood clinics increased mortality by 8 percent on average and negatively affected all women, increasing mortality rates by 6 to 15 percent among black, white and Hispanic women, as well as those identified as other race/ethnicity.

Those findings suggest that even more recent fiscal and legislative changes aimed at further reducing women’s access to family planning and reproductive health services have likely contributed to the rise in maternal mortality rates.

And there is more to come. Currently, seven states have passed bills to prohibit abortion after eight weeks of pregnancy or earlier, but those laws are not yet in effect. Additional states are anticipated to introduce new bills this year.

Based on our results, continuing to restrict women’s access to health services through gestational limits or closing Planned Parenthood clinics will likely increase maternal deaths.

The bipartisan passage in 2018 of the Preventing Maternal Deaths Act of 2018 reflects some progress on reducing maternal mortality; however, to improve maternal health, we need politicians to move beyond short-term political decisions and consider the longer-term impact of policies on women’s health.

The maternal mortality rate of black women in the nation's capital should not be nearly twice as high as for women in Syria. A pregnant woman’s risk of death should not be determined by her race and the state in which she lives — and she shouldn't have a better chance of surviving pregnancy in a war zone than in walking distance of the White House.