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In states with abortion bans, ProPublica has found, pregnant women have bled to death, succumbed to fatal infections, and wound up in morgues with what medical examiners recorded were "products of conception" still in their bodies.
These are the very kinds of cases state maternal mortality review committees are supposed to delve into, determining why they happened and how to stop them from happening again.
But panels in states that have recently imposed strict bans on abortion have done little to uncover whether the laws are contributing to maternal deaths, including tracking delays in care for pregnancy complications and making these problems known, a ProPublica investigation shows.
In fact, we found that in a few states, political leaders who backed the bans have stood in the way of measuring their consequences.
They have dismissed committees, slowing down their work. They have weeded out members openly critical of abortion bans and supportive of transparency.
Texas has gone as far as to legally prohibit its committee from reviewing deaths that are considered abortion-related. This could include some miscarriage care, health officials told ProPublica.
In two deaths of Texas women that ProPublica investigated, and had already miscarried when they were given misoprostol to help complete the process. The committee does not review cases that involve that drug because it's also used for abortions, said committee chair Carla Ortique, MD: "If they received medication, if they received any procedure, we will not get those records." Chris Van Deusen, the spokesperson at the Texas Department of State Health Services, would not say whether Ngumezi's and Barnica's deaths would be reviewed.
Other state committees have not made changes to systematically examine the role abortion bans are playing in maternal deaths, officials acknowledged, though some said they might note it as a contributing factor if it appears in the records. "If the committee discovers a trend that raises a particular concern, it could decide to include that information in its reports," South Carolina officials said.
Some noted that they follow guidelines from the CDC, and that those recommendations don't direct committees to consider abortion access or delays in abortion care. Indiana's law directs committee members to determine whether the person who died had an abortion and whether that contributed to their death; it does not focus on delays in access to abortion care.
States can direct their committees to look at any important health issue; Texas' panel added new questions to its process to help capture the , for example.
ProPublica asked governors in 15 states with strict abortion bans whether committees should examine the impact of the laws on maternal deaths; most did not respond. None directly answered the question or advocated for specific changes. ()
"We're not acting like we want to know the answer to this question. And that concerns me," said Caitlin Myers, PhD, an economics researcher at Middlebury College who is studying the impact of abortion access on maternal health. "However you feel about the ethics of abortion, we should want to understand how these policies are affecting women's health."
Experts interviewed by ProPublica say state maternal mortality review committees are uniquely well-positioned to examine the impacts of abortion bans on maternal health. The panels are often made up of practicing ob/gyns, cardiologists, and nurses, and they can also include doulas, medical examiners, and experts in mental health, substance abuse, and domestic violence. They review summaries of medical records to determine whether deaths were preventable and to identify contributing factors. This allows researchers and government officials to see patterns and come up with ways to improve the country's poor maternal health outcomes.
Committees are not systematically tracking an issue that came up throughout ProPublica's reporting on deaths in states with abortion bans: delays and denials of procedures, like dilation and curettage, which are used to empty the uterus during miscarriages to avoid hemorrhage and infection. The procedures are also used for abortions, and doctors face prison time for violating restrictions. Women have died after they could not access these procedures, ProPublica found.
Nevaeh Crain, a , was made to wait 90 minutes for a second ultrasound to confirm fetal demise. Amber Thurman while sepsis spread. And Barnica was while doctors monitored the fetal heartbeat until it stopped.
Studying such delays "needs to be a part of these kinds of reviews," said Daniel Grossman, MD, a leading reproductive healthcare researcher and professor of obstetrics and gynecology at the University of California San Francisco.
Grossman has collected dozens of accounts from healthcare providers detailing substandard treatment and poor outcomes in states that banned abortion. But he and others recognize who is ultimately in charge of state maternal mortality review committees.
"I can't imagine the states that passed restrictions saying, 'Now we want to know if that caused any deaths,'" said Eugene Declercq, PhD, a professor at Boston University's School of Public Health who serves on Massachusetts' maternal mortality review committee. "The clinicians and the public health people might want to know, but the political leaders would be aghast."
Even if they start to pursue such answers, states are years behind in reviewing deaths, ProPublica found in a survey of 18 states with the most restrictive abortion laws. Most have not finished reviewing deaths from 2022, the year most bans became effective after the Supreme Court overturned the constitutional right to abortion. Two states are still reviewing 2021 deaths. Three states -- Florida, North Dakota, and South Dakota -- did not respond.
Reviews typically lag years behind deaths because of the time it takes state health department employees to learn of cases, track down records, and wrestle them free from hospitals and doctors before they summarize and redact them for review. "We have one person in the entire state that has to collect all that data. Literally one," said Stacie Geller, PhD, a founding member of Illinois' committee. "I live in fear of her retiring."
The CDC, which has pumped tens of millions of dollars into helping states establish these committees and standardizing their work, has tried to reduce the backlog by setting a goal for committees that receive funding to review cases within 2 years. However, there's no way to compel states to do so, and not all have caught up.
Such lags matter more in places where there has been a seismic shift in abortion access, experts told ProPublica, because there isn't a full understanding yet of the laws' effect on maternal healthcare.
Marian Knight, MBChB, MPH, DPhil, leads the United Kingdom's maternal mortality review program, widely seen as the world's best. She said if there were a major legal shift like this in her country, she and her colleagues would adapt to track the impact in close to real time. "I would be monitoring that in the same way as I did during COVID, where we were analyzing data weekly and feeding it in," Knight said.
As of last month, only five states -- Iowa, West Virginia, Indiana, Georgia, and Tennessee -- had finished reviewing cases from 2022, ProPublica found. None had yet published a report on its findings for that year.
Seven other states were still examining 2022 cases: Alabama, Oklahoma, South Carolina, Mississippi, Missouri, Arkansas, and Louisiana.
Idaho, Texas, and Kentucky had not yet started looking at cases from that year.
Even though North Dakota did not respond to ProPublica's survey, reporters found that its committee, formed by state legislation in 2021, has never met to review cases, according to two members.
In some instances, state officials are responsible for delays.
Idaho in summer 2023 after a conservative group argued it was unnecessary and attacked members for recommending that the state expand Medicaid for postpartum patients. The move froze the group's work until last month, when a reconstituted, smaller committee met for the first time. Two members who had spoken out against the ban's impacts on maternal health, and are suing the state over it, were not brought back onto the committee. The state is defending its anti-abortion laws; the Idaho Attorney General "will not stop protecting life in Idaho."
It is unclear how long Georgia's reviews will be stalled after state officials after ProPublica reported on internal documents in stories about two preventable deaths examined by the group. The Georgia Department of Public Health said in a letter about the dismissal that this would not result in any delays to the committee's responsibilities.
In a move that confused maternal research experts, Texas' committee said it would not review data from 2022 and 2023 and begin with reports from 2024 to get a more "contemporary" view of deaths. The committee has skipped years in the past to address gaps, and at its recent meeting, Ortique, the chair, said that the decision had "absolutely no nefarious intent." The period it plans to skip includes two of the preventable deaths ProPublica reported.
Romy Ghosh, MD, an ob/gyn in Austin, Texas, pleaded with the maternal mortality review committee at a public meeting this month to reconsider its decision to skip those years.
"There's been a lot of fear in my patients. They wonder, can I save their life if something goes wrong?" she said. "I think that this information will tell us there's either nothing to worry about or it will be damning."
Between the decision to skip years and the legal prohibition against examining cases involving abortion-related care, it appears Texas will not review any of the three preventable deaths ProPublica identified.
There is a limit to how much committee members can push back against state leaders.
When Texas delayed publishing its maternal mortality report in 2022, an election year, then-committee member Nakeenya Wilson, a community advocate, spoke out, saying "withholding data that does not make us look good is dishonorably burying those women."
The next session, Texas lawmakers passed a bill changing the requirements for the position that Wilson held, effectively removing her from the committee. State officials appointed Ingrid Skop, MD, a Texas ob/gyn who is the of a prominent anti-abortion organization.
Wilson said maternal mortality review committees must be free to speak candidly about patterns they see in maternal deaths and to release information in a timely fashion.
"If it's not the committee, then who is it?" she said. "There has to be increased accountability."