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In many ways, the end of Roe v Wade didn’t happen when the US Supreme Court issued its decision to overrule Roe in the Dobbs case in June 2022. Rather, it came nine months earlier, on September 1, 2021, when the Texas Heartbeat Act, also known as SB8, took effect. The law banned abortion after embryonic cardiac activity became detectable, around six weeks of pregnancy, with no exceptions for fetal abnormalities. The job of enforcement was outsourced to private citizens (also known as “bounty hunters”), thereby making the law much harder to challenge in court. Since then, as wave after wave of post-Dobbs abortion restrictions have been enacted in deep-red states, reproductive rights advocates and journalists have—rightly—focused their attention on the effects of those draconian laws on the health and autonomy of women.
The reports of harm to pregnant patients, however, though wrenching, have been anecdotal, which has limited their ability to move the most conservative hearts and minds. Then there is an additional factor: It’s not clear that many far-right lawmakers and courts actually care about the well-being of women.
But they do claim to care about babies, which is why a new study about SB8 and infant mortality is so important. A team of researchers at Johns Hopkins University has spent the two-and-a-half years since SB8 took effect crunching data on infant deaths in Texas and other states, then re-crunching it to confirm their results. They found that as women whose access to abortion was drastically curtailed by SB8 began to give birth in 2022, those infants were dying at much higher rates compared both to the period before the law took effect and to other states that didn’t have near-bans.
The likeliest reason, according to Alison Gemmill, a lead author on the study, is that more women were forced to carry what are sometimes called “medically futile” pregnancies to term. These are pregnancies in which the fetus had catastrophic genetic and other anomalies incompatible with life outside the womb. Unsurprisingly, many of those newborns quickly died. The study’s measured academic language— “Restrictive abortion policies may have important unintended consequences in terms of trauma to families and medical cost”—barely hints at the depth of suffering imposed by SB8.
Today, with even more restrictive bans in effect in Texas and 13 other states since Dobbs, the human toll is only becoming more profound. But why might the process of examining infant deaths provide the kind of undeniable evidence of harm that studies about women have so far lacked? I reached out to Gemmill, a demographer and reproductive epidemiologist with 113 peer-reviewed studies to her name, to find out the answer to this and other questions.
What made you decide to take on the topic of abortion bans and infant mortality?
I mostly study pregnancy and fertility. Recently I’ve been really interested in what I call macro social stressors—large changes in the political and social environment that can disrupt health care access and affect outcomes. Often those occur through policy shocks, like legislation. I’ve also studied things like the 9/11 terrorist attacks and how population-wide stressors can impact pregnancy outcomes for both the mom and the baby.
So when Texas passed its six-week ban, my colleagues and I were very interested in measuring the spillover effects. At that point, SB8 was the most restrictive abortion policy in the country. It was the first time that we could actually look at the impact of severe abortion restrictions on health.
There had been some prior studies that showed that living in an abortion-hostile state was associated with higher rates of infant mortality. But the links were correlational. With SB8 we had the opportunity to see if there was a causal link between more severe restrictions and infant deaths.
Since the end of Roe v Wade, there has been a lot of discussion about how abortion bans will likely contribute to a rise in maternal mortality. But the data has been lacking. Why is it easier to study abortion bans’ impact on infant mortality?
The problem is that maternal deaths are quite rare. According to data [from the National Center for Health Statistics, part of the Centers for Disease Control and Prevention], there were 817 maternal deaths in the US in 2022—and that’s out of 3.6 million live births. Those deaths can be hard to identify. The data can be very messy.
Infant mortality is likewise a somewhat rare event. But the number of infant deaths in the US is a little over 20,000 a year, which dwarfs maternal deaths. Because the numbers are so much bigger, we get more statistical power with infant mortality data to detect the real effects from the bans.
Counting infant deaths also turns out to be a lot more straightforward than counting maternal deaths. Whereas a lot of factors go into determining whether the death of a mother is related to pregnancy or childbirth, infant deaths are, by definition, based only on age—a death before the first year of life. So they are less likely to be misclassified.
To measure the impacts of the Heartbeat Act, you had to wait for babies to be born. The first study you published showed a big jump in overall births.
Yes, we found a greater-than-expected number of births in Texas in the months after SB8 went into effect. Almost 10,000 more births from April through December of 2022.
Then it took another year before you could assess the impact on infant mortality. Once you did your analysis, what stood out?
Overall, we found a 13 percent increase in the number of infant deaths in Texas after the law went into effect. For the rest of the United States, the increase was 2 percent. And deaths due to congenital anomalies—a fancy term for birth defects and the leading cause of infant mortality overall—rose by 23 percent in Texas, while in the rest of the US, there was a decline.
“We expected to find an increase, based on the prior studies. But I was surprised at the magnitude of the change, especially the increase in babies who died from congenital anomalies. “
We expected to find an increase, based on the prior studies. But I was surprised at the magnitude of the change, especially the increase in babies who died from congenital anomalies.
We did our analyses in a number of different ways, and the findings were consistent. All of this very much points to a causal connection between the abortion policy and an increase in infant deaths.
Do you have an idea of what might have caused that spike in infant deaths?
No doubt, some deaths were related to complications suffered by the mother. The connection between maternal complications, for example preeclampsia [pregnancy-related hypertension], and the health of the infant is very real. But above and beyond that, there’s a more direct mechanism. Before SB8 parents who got a diagnosis of a serious fetal abnormality had the option to terminate. But after the law took effect, abortion was completely off the table. So you’re going to see more births of babies with congenital anomalies that are incompatible with life. And shortly after birth, those infants are going to die.
Could you explain what kind of birth defects you are talking about?
There are many types of congenital abnormalities, some of which are less serious. But in the case of this study, these were profound abnormalities—things like major heart defects, or vital organs that are missing or incomplete or not functioning properly. These are conditions that wouldn’t be detected before six weeks of pregnancy and once they were detected, might lead many parents to choose termination, because there’s a lot of potential suffering and pain associated with those cases, for the infant and for the families that have to go through that. But because the Texas law didn’t have an exception for fetal anomalies, they had to carry the pregnancy to term, even knowing the baby would die.
One would assume, based on other research, that Black and brown babies would have the highest rates of infant mortality. But your study doesn’t go into racial disparities.
No, that is work that we’re doing right now. Because infant deaths are already such a rare outcome, when you start looking at subgroups, it gets more challenging from a statistical standpoint.
I imagine that people on the anti-abortion side might respond to your study by saying, “Well, how do you know it’s the heartbeat law that’s responsible for this increase in infant deaths? Maybe women aren’t eating the right foods, or maybe they’re not going to their prenatal appointments.” Instead of blaming the policy, blame the mom. What’s your response to that kind of pushback?
I have a really hard time coming up with an alternative explanation that could explain such a big increase in infant deaths in Texas. Any other explanation for these findings would have to be unique to Texas and unique to this post-SB8 period.
I’ll also say that our analyses have been replicated by others—studies that haven’t been published yet but have been shared with me personally. Replication is important. When it comes to this research, there are many cooks in many kitchens, and we’re all working on the same kinds of questions. I’ve heard from colleagues, “Oh, well, I was working on that too. But glad you found the same thing.”
Since Dobbs, 14 states have enacted laws that are more draconian than SB8, including Texas itself, which now has a near-total ban. What would you expect to see as you begin looking at infant mortality data in states that ban abortions at any gestational age with no exceptions for fetal anomalies?
We have no reason to think that the relationship between those abortion policies and infant mortality would be any different in other states. This is something we’re looking into now.
Recently, I’ve been hearing a lot of anti-abortion leaders taking up the same message: abortion supporters who talk about pregnancy emergencies and life-threatening complications are just “fear-mongering.” You know, “Complications hardly ever happen, you’re exaggerating the risks.” Your study seems to show the opposite—a big rise in infant mortality is not what I’d call “fear-mongering.”
To be clear, from the maternal health standpoint, pregnancy can be very dangerous for women. While maternal death itself is rare, severe maternal complications are not nearly as rare as people might think, especially if you have risk factors. In the US, a lot of people have risk factors.
And then there are complications like miscarriage, which are a very common experience that people don’t talk about enough. About 10 to 20 percent of known pregnancies in the US end in miscarriage. Miscarriage management is an important issue to bring into this conversation because sometimes you need to have an induced abortion to treat that miscarriage.
Another complication that comes to mind is preterm birth. In the US, 1 in 10 babies are born prematurely, and the rate is much higher if you’re Black or live in certain states. About 1 in 12 babies are born too small. These are not rare outcomes, and they have lifelong impacts.
As you study the effects of abortion restrictions on infant health, what are the kinds of things you and your colleagues are looking at next?
We’re looking at the subgroup effects—disparities by race and other characteristics. We’re interested in infant morbidity [complications] because deaths are just the tip of the iceberg. Are abortion bans associated with changes in rates of complications like preterm birth and low birth weight? How long do infants have to stay in neonatal intensive care? For children with severe congenital anomalies, what kinds of medical interventions will they require?
And we’re looking at impacts on pregnancy care—what happens to people who show up to the clinic with life-threatening conditions in states that have bans? Did they experience severe maternal morbidity that potentially could have been avoided if they had received the care that they would have gotten prior to these bans?
How do you hope this new research on abortion bans and infant health might improve care for mothers?
In a lot of ways, the mother is an afterthought. Too often, it’s all about the baby. We need to be thinking about the mother-infant dyad more holistically. It’s like, why not care for both in a way that is reasonable and respectful? But if the mother’s life is in danger, I would say, prioritize the mom. Because, obviously, what is that infant without their mother?
This interview has been edited for length and clarity.
