All-Cause Mortality in Reproductive-Aged Females by State: An Analysis of the Effects of Abortion Legislation
Authors: Harper Lorie M. , Leach Justin M. , Robbins Lindsay , Blanchard Christina , Metz Torri D. , Mazzoni Sara , Nash Elizabeth , Szychowski Jeff 
Published: March 2023

ABSTRACT
It is estimated that the Supreme Court decision in Dobbs v Jackson Women's Health Organization will leave approximately 33 million US women in states without available abortion services. Even before this decision, there was wide variation in abortion access across the United States. In 2019, 43% of reproductive-age women lived in states with policies overall restrictive to abortion because of the 26 abortion bans that had been enacted, with many more introduced. In contrast, other states have passed laws supportive of and protective of abortion. Many laws restricting abortion were supposedly aimed at protecting women's health by regulating abortion facilities as ambulatory surgery centers, dictating the types of health care providers who can perform abortion, and requiring admitting privileges to hospitals for clinicians providing abortion care. Opponents of these regulations assert that they are designed to restrict access without evidence that they decrease risks associated with abortion.
These laws purporting to protect women with safer abortions have actually done the opposite; restricted abortion access results in increased pregnancy-related deaths. The focus of abortion regulations and restrictions is also aimed at protecting the fetus (and subsequent neonate), but prior studies have demonstrated an association between restricted access to abortion and increased infant mortality. Moreover, prior studies demonstrated that abortion restrictions increase maternal and infant mortality.
The aim of this retrospective cohort study was to evaluate the association between state-level abortion legislation and all-cause mortality among females of reproductive age and maternal, fetal, and infant mortality. This study compared mortality rates in states categorized as supportive, moderate, and restrictive with regard to their laws. The Centers for Disease Control and Prevention's WONDER (Wide-ranging ONline Data for Epidemiologic Research) database was used. The association between supportive, moderate, and restrictive state abortion regulations and all-cause mortality in reproductive-age females was estimated using generalized estimating equations.
The primary study outcome was all-cause mortality in reproductive-age females (aged 15–49 years). Issues examined included specific, common legal restrictions placed on abortion, including in-person counseling, restrictions on insurance coverage, waiting periods, requiring inaccurate or misleading counseling to pregnant women (such as information on medical abortion reversal or fetal personhood), prohibiting telemedicine for medication abortion, and requiring parental consent for minors. Secondary outcomes included maternal mortality, fetal mortality, and infant mortality. All-cause mortality in reproductive-age females was defined as death at a reported age of 15 to 49 years.
Compared with restrictive states, moderate and supportive states were not associated with a significant decrease in all-cause mortality, and maternal mortality (per 100,000 live births) was significantly lower in moderate (25.79; 95% confidence interval [CI], 29.88–21.70), but not supportive states (22.51; 95% CI, 26.75–1.72). In both moderate (20.56; 95% CI, 21.09–20.04) and supportive (21.10; 95% CI, 21.56–20.64) states, infant mortality (per 1000 live births) was significantly lower. In moderate states, fetal mortality was significantly lower (20.69; 95% CI, 21.18–20.20) but not in supportive states (20.64; 95% CI, 21.14–0.13). With each additional abortion regulation, there was an increase in both maternal mortality (1.09; 95% CI, 0.36–1.82) and infant mortality (0.20; 95% CI, 0.12–0.26).
These findings show that compared with restrictive laws, moderate state abortion legislation is associated with lower rates of maternal, fetal, and infant mortality but not lower all-cause mortality in reproductive-age females. Restrictive laws enacted with the purported intent of protecting women's health and fetal health by regulating abortion fail to do so and do not decrease all-cause mortality in reproductive-age women or maternal mortality. Repealing certain types of laws may decrease all-cause mortality in reproductive-age females, maternal mortality, and infant mortality. Allowing an abortion at any gestational age does not substantially increase fetal death rates compared with states that restricted termination after a certain gestational age.