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A 2021 Texas ban on abortion in early pregnancy was associated with increases in infant and neonatal deaths, according to a population-based cohort study.

From 2021 to 2022, infant deaths in Texas increased by 12.9% -- from 1,985 to 2,240 -- while infant deaths across the rest of the U.S. increased by 1.8%, reported Alison Gemmill, PhD, of the Bloomberg School of Public Health at Johns Hopkins University in Baltimore, and colleagues.

In a counterfactual analysis that used data from Texas and eligible comparison states, an excess of 216 infant deaths occurred from March to December 2022 -- a 12.7% increase above expectation, they noted in .

Corresponding estimates for neonatal deaths showed a similar pattern. During the same time year-long period, neonatal deaths in Texas increased 10.4% -- from 1,295 to 1,430 -- compared with 1.6% in the rest of the country.

"There have been previous studies that show an association between abortion restrictions in states ... and increased infant mortality rates," Gemmill told MedPage Today in an email. "Here, we had the opportunity to study the causal impact of one of the most restrictive abortion policies on infant deaths to shed light on this important question."

The infant mortality rate increased by 8.3% between 2021 and 2022 in Texas, from 5.31 per 1,000 live births to 5.75, while the rate increased by just 2.2% in the rest of the U.S. Additionally, the Texas neonatal mortality rate increased by 5.8%, from 3.47 per 1,000 live births to 3.67, but decreased in the rest of the country.

In 2021, Texas Senate Bill 8 (SB8) was passed, which prohibited abortions after embryonic cardiac activity and did not allow exemptions for congenital anomalies.

Among the top 10 causes of infant deaths, Gemmill and colleagues noted, there was a 22.9% increase in congenital anomalies in Texas compared with a 3.1% decrease for the rest of the U.S.

"This finding suggests that one important way that highly restrictive abortion policies might lead to more infant deaths is because birthing people no longer have the option to legally terminate congenital anomalies, especially those that are highly incompatible with life, if they are detected," Gemmill said.

Texas also appeared to have "unique increases" compared with the rest of the country in infant deaths attributed to unintentional injuries (20.7% vs 1.1%) and necrotizing enterocolitis of the newborn (73.3% vs 6.4%).

In an , Atsuko Koyama, MD, MPH, of the University of Arizona in Phoenix, and colleagues noted that "emerging research from Texas in the wake of the passage of SB8 illustrates a gruesome reality far removed from dignity for anyone -- healthcare professionals, pregnant people, or newborns and infants."

"Interviews of Texas physicians after enactment of SB8 describe the moral injury physicians face when legally restrained from providing evidence-based care, with some stating they felt like worse physicians as a result of the law and others leaving the state entirely," they wrote.

"Pregnant people in Texas diagnosed with a life-limiting or lethal fetal condition have described not only a loss of the patient-physician relationship as a result of SB8 but also feelings of isolation and fears around confidentiality because of the law's potential consequences," they added.

For their study, Gemmill and colleagues examined all recorded infant deaths from the state of Texas and 28 comparison states. They used a comparative interrupted time series analysis and national birth certificate data from January 2018 through December 2022 to estimate the difference between the number of observed and expected infant and neonatal deaths and death rates.

Between 2018 and 2022, there were 102,391 infant deaths nationwide, with 10,351 occurring in Texas.

Deaths in March 2022 were treated as the first cohort exposed to the SB8 abortion policy because these infants were approximately 10 to 14 weeks' gestation when SB8 went into effect on Sept. 1, 2021. The exposure period was March through December 2022.

Available data on infant deaths in 2022 did not include birth month or gestational age, which may have resulted in some exposure misclassification, Gemmill and colleagues noted.

These data also did not allow for investigation of maternal or clinical characteristics of infant deaths, and the researchers were unable to examine differences by race and ethnicity.

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