Health: State Abortion Bans And Ectopic Pregnancies

0:28This is Ira Glass. Between 2020 and 2025, nearly 200 women in the U.S. died from ectopic pregnancies, almost double the number from the previous six years. Ectopic pregnancies happen when an embryo implants outside the uterus where it can't develop properly. If left untreated, the embryo can rupture, causing deadly bleeding. Several of you called to tell us about your experiences with ectopic pregnancies. Hi, I'm Alex. I actually had two back-to-back ectopic pregnancies four months apart. It was probably the worst experience that I've ever had in my entire life. And when I had them, I actually had a two-year-old daughter.

1:14Obviously, we had to end the pregnancy both times, but it was to save my life because I had a little girl that needed me. Hi, Winnie. My name is Annette. I live in Gloucester County, Virginia. But years ago, I suffered an ectopic pregnancy. I had no idea what was going on. I thought it was just a really severe menstrual cramps. And lo and behold, it turned out I was pregnant. And it got so bad, My sister had to rush me to the emergency room where they wheeled me in right away, but I did suffer hemorrhaging. I lost a fallopian tube, and I had excruciating pain. Alex, Annette, thank you for sharing your stories with us.

2:00The treatment for ectopic pregnancies, which are almost never viable, is termination. But since the fall of Roe v. Wade in 2022, terminating a pregnancy has become more complicated in states with abortion restrictions, even in cases where the mother's life is at risk. A new investigation from ProPublica explores the role state abortion bans could be playing in the rise in deaths related to ectopic pregnancies. I'm Jen White. You're listening to the 1A Podcast. We talk about that and more after a short break. Stay with us.

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3:09R-W-J-F is a national philanthropy working toward a future where health is no longer a privilege, but a right. Learn more at rwjf.org. Let's jump in with Andrea Suazo. She's a data reporter at ProPublica covering nonprofits and maternal health, and she joins us from Vermont Public in Burlington. Andrea, thanks for joining us. Thank you so much for having me. And with us from San Francisco is Dr. Heather Huddleston. She's an obstetrician, gynecologist, reproductive endocrinologist, and infertility specialist. She's also the chief medical advisor at Alara Health. Dr. Huddleston, it's great to have you.

3:46Great to be here. Andrea, let's turn to your analysis of CDC data. You found that nearly 200 women with ectopic pregnancies died between 2020 and 2025. That's compared to about 100 ectopic-related deaths in the previous six years. What were some of the biggest disruptions to maternal and reproductive health care during those years that could help explain the jump? Yeah. So the jump we saw, and I want to be clear here, deaths from ectopic pregnancies are rare. We saw about four per million live births prior to 2020. And then after 2020, it jumps to about eight deaths per million live births in the next three-year period, and then following that, 9.8 deaths per million live births.

4:35So that is, you know, that it's not a huge proportion of maternal deaths writ large, but it is a doubling of that rate. One thing we heard from quite a few experts we spoke to was that broadly COVID really disrupted maternal care, particularly maternal care that happens in the emergency department, as ectopic care often does, you know, both because hospitals were overburdened with, you know, a pandemic emergency and because, you know, people may have been delaying going to the emergency department at that time out of concerns for catching COVID, out of concerns that that was not a safe place to necessarily go.

5:29And so broadly, we saw quite a big jump in the pregnancy-related death rate during those years, during the height of the COVID pandemic. And then pregnancy-related deaths have largely returned to their pre-pandemic baseline, except in this group of ectopic pregnancies, which has continued to rise that death rate in the years since. And I think the other big change that has happened since 2020 is the Dobbs decision, the fall of Roe v. Wade, and many states implementing these abortion bans. Let's pause on the analysis for just a moment. Dr. Huddleston, Andrea said that deaths from ectopic pregnancy or ectopic related deaths are uncommon, but how common is the condition itself?

6:24The condition is somewhat rare, but it is about one to 2 % of all pregnancies. So it's certainly something that is seen in a busy emergency room very commonly. So it's something that needs to be, I think, staff in emergency rooms, OBGYNs, this is something that they need to be capable of managing, aware that they're going to be coming in at any given time, quite honestly. And are we seeing any changes in the rates of ectopic pregnancies? I think it's a good question. I don't think we know, and I think that's because they don't get tracked very easily. There are things that kind of happen before people get to OB care.

7:01There are things that are happening in the emergency room. They may get managed in a variety of different ways, so there's no tracking of it. So we actually don't know the answer to that question, which I think is important. We got this email from Brooke who says, I had an unusual ectopic pregnancy in 2015 and emergency surgery saved my life and also led me down the medical journey of getting diagnosed with a rare endometrial sarcoma. I live in North Carolina and the state abortion restrictions were lower to 20 weeks post-oms. The chilling effect of abortion restrictions will have cascading effects detrimental to women's health care in general.

7:34Now, Andrea, you said that the overturn of Roe is also something that you paid attention to in analyzing this data. And you're not making a direct correlation between that decision and the uptick in ectopic pregnancy-related deaths. But when you look nationwide, how are those deaths playing out in states with and without abortion restrictions? Yeah. So our analysis was not a causal analysis. It can't sort of link specific specific causes to what we're seeing in the death rate. However, when we grouped states that implemented a strict abortion ban, meaning restricting abortion at six weeks or a total abortion ban, and we compared the death rates there to death rates in states without a ban, We saw a really continued steep increase in those states with a strict ban and substantially lower death rate in states that did not implement a ban by that 2023 to 2025 period.

8:47And what we did then was we sort of went to lawsuits that we knew had been filed. We went to news reports where women were sort of alleging that there were delays in care. And we called off a lot of doctors and we just talked about what could be happening in that part of pregnancy, in what could be changing in care during that part of pregnancy. We'll talk a bit more about that. Dr. Huddleston, though, ectopic pregnancies typically occur within the first few weeks of pregnancy before that prenatal care begins. What are some of the challenges of diagnosing the condition? Right. So, I mean, one is that, yes, it's before prenatal care has been initiated.

9:34So a lot of times a person who is struggling with symptoms that could be an ectopic pregnancy may not have a provider at all that they're hooked in with. They need to then go to the emergency room. I think the other big thing is when someone comes into the emergency room with symptoms that could be an ectopic pregnancy, we know they're pregnant, they're early pregnancy, and they're having perhaps some bleeding. Very often we don't actually know for sure it's an ectopic pregnancy. It's actually somewhat rare that someone comes in and we do an ultrasound and we actually see the ectopic there and can say, oh, you have an ectopic pregnancy.

10:09When that happens, it's actually very easy and we know what to do. What's tricky is that very often it's much more complex. The patient will come in, we'll know they're pregnant, we'll look into their uterus with an ultrasound. We won't see a pregnancy clearly. We also won't see an ectopic. And so then they're in this zone of a pregnancy of unknown location. And at that point, it could be an early pregnancy that we just can't see yet because it's so early. It could be a pregnancy that's in the uterus that's going to fail, a miscarriage, or it could be an ectopic pregnancy. And to get to the sort of answer takes more information and often somewhat more time if the patient is stable.

10:50You need to be able to follow that patient closely. And so that takes an infrastructure in healthcare that also may not have, you know, been as robust as it was pre-pandemic. Well, and what kind of risk is there to the patient's life if there is a delay in treatment? Well, so I guess if you have a patient who is stable and you aren't sure where the pregnancy is, and it could still be a viable pregnancy in the uterus because it's that early, it's fine to observe them for a couple of days and to see what happens to their hormone levels, to see what happens with the imaging so you can get a definitive diagnosis.

11:32That is okay. I think if someone's unstable when they come in, you know that you need to act more quickly. But the stable patients, the key is close follow-up. Let's take a quick break here. But coming up, what we know about the trends in maternal and reproductive health in states with strict abortion bans. That's right after this.

11:55Support for NPR and the following message comes from the Robert Wood Johnson Foundation. RWJF is a national philanthropy working toward a future where health is no longer a privilege, but a right. Learn more at rwjf.org. Let's get back into the rise in deaths related to ectopic pregnancies and add a new voice. Carrie White is a non-resident fellow in maternal and reproductive health at Rice University's Baker Institute for Public Policy. She's also the executive and scientific director of Resound Research for Reproductive Health. Carrie, thanks for joining us. Thank you for having me. I want to turn to the lawsuits at several patients in states where abortion is restricted.

12:38They filed these lawsuits. Federal complaints have been made alleging that medical providers have delayed or refused to terminate their ectopic pregnancies. Andrea, you referenced it earlier. You spoke with some of these women who are filing suit in Oklahoma and Texas. What did they tell you about what they experienced? Yeah. So we spoke with Kylie Thurman, who in 2023 sought care several times over the course of a week at two different hospitals and was repeatedly sent home. And as I believe Dr. Huddleston said, there is some monitoring that you typically do where you kind of come back and you get your pregnancy hormone levels taken over the course of maybe two days.

13:28And that kind of gives doctors some idea of what the trajectory of the pregnancy is, can help you suspect an ectopic pregnancy. Um, Kylie Thurman, uh, had, had sort of a plateauing, uh, hormone level. And then in, uh, the last visit that, uh, where she was sort of really coming back in pain, um, she, doctors were able to see a mass, uh, in her, uh, in her fallopian tube and sent her home again. She then came back at the urging of her OBGYN, and her OBGYN actually had to come into the ED and take over her care in order to give her an injection of methotrexate, which is a cancer drug that kills cells, basically, and is often used to treat ectopic pregnancies.

14:28However, that injection came too late. And so about a week later, her fallopian tube ruptured. She was rushed into emergency surgery and lost that tube. Now, that was in 2023. But she, you know, she told us she genuinely thought she was going to die. She lost a lot of blood before they were able to stabilize her. And so the law last year, the Texas legislature passed the Life of the Mother Act, which does attempt to clarify that, you know, ectopic pregnancies are exempt from the law. It does clarify that a C-section scar ectopic pregnancy, which is in the uterus but is very dangerous, that is also an ectopic pregnancy that you can treat.

15:29And so it does make those clarifications. However, the malpractice lawyer who is representing many of these women in Texas told us, you know, she is still getting calls really frequently from women who have experienced delays in care. Well, Carrie, I want to come to you because over the past five years, your team has spoken with OBGYNs and health care providers in Texas about how the state's abortion ban has complicated their medical treatment for ectopic pregnancies. What have you heard from them? What we've heard from the physicians that we have surveyed and interviewed in our research is that they are aware of what treatment is needed for someone who is presenting for an ectopic pregnancy as well as a range of other complications that may arise in pregnancy.

16:17But what has changed is the policy environment in which they are operating that has instilled an intense culture of fear among providers about whether or not the care that they provide will be interpreted as providing an abortion that is prohibited by law if they are seen as intervening too early. And so as Dr. Huddleston described, it's not always obvious right away whether or not a pregnancy is an ectopic pregnancy. It may be difficult to determine. And what we've heard from the providers that we've talked to is that they are often waiting longer than they probably otherwise would have until there is absolute definitive proof that a pregnancy is ectopic.

17:04And as we know, that may be too late. Well, we're getting your stories and questions. We got this from Stephen who says, is there ever a possibility of an embryo being viable in an ectopic pregnancy? Now, we should note that 90%, over 90 % of ectopic pregnancies implant in the fallopian tubes, and those pregnancies are never viable. That's according to the American College of Obstetricians and Gynecologists. But they can also implant in the abdomen, the ovary, the cervix, even a cesarean scar. So, Dr. Huddleston, under what circumstances could an ectopic pregnancy be viable? Really none. I mean, it's essentially not a viable pregnancy and is dangerous to the mother because it's going to rupture at some point and cause bleeding.

17:50So I think that's very clear. What's not clear is when that patient is in that gray area where you're not sure it's in the tube or it could be in the uterus and could be viable. And so the doctor is having to sort of juggle that and wait until there's enough evidence to know for sure that it's not a viable pregnancy in the uterus. And that's where I think we're talking about the delay possibly happening because providers may be waiting for a level of definitive information that is beyond what we are waiting for in a state perhaps where we don't have that kind of culture. Well, let's turn back to you for more of your experiences with ectopic pregnancy.

18:31Hi, my name is Olivia. I'm from Boone, North Carolina. I have had two ectopic pregnancies. I was treated with methotrexate, which has a 65 % success rate. And unfortunately, it did not work. So my tube ruptured and I was bleeding internally for a couple hours before I could be treated. The second one, I was also treated with methotrexate and it was successful. I was able to keep both of my tubes, but had I not, I would have less of a chance to get pregnant in the future. And North Carolina, the laws, as far as abortion goes, are easier than other states. But I fear that if I was to have another ectopic pregnancy in the future and the laws change, I wouldn't be as lucky.

19:21I might not even be here. Thanks for that message. Dr. Huddleston, from a physician's perspective, during a pregnancy, there are complications that can arise that don't fit neatly into exemptions covered in strict abortion laws. So what does that mean for a health care practitioner trying to deliver the best care possible for their patients? I mean, I think it's really tough. And I'm, you know, to be clear, not operating in one of those states. And so I can only imagine how difficult it would be to feel that your ability to sort of practice the care that we know is the right care that is supported by national guidelines of what we should do, to feel that executing that care and those protocols potentially could be questioned would be a really difficult place to be.

20:12And I think what we need to do is to really get the word out that these rises and deaths are happening. And I would say for every one of these deaths, there's probably many more close calls, many more cases of increased hemorrhage. But getting the word out that this is happening and that we need to allow providers to, you know, execute care according to the guidelines that we have in place from American College of Obstetrics and Gynecology to provide the best and safest care. Andrea, what other health complications showed up in the data you analyzed? Yeah. So we sort of separately from our analysis of death certificate data, we also had we have Texas hospitalization data.

21:02And we were able to narrow in encounters, both inpatient encounters and emergency department encounters, where someone had a diagnosed ectopic pregnancy. And then within those encounters, we kind of looked for indications that someone had kind of serious bleeding. So either a code that indicated a hemorrhage or a transfusion. And that jumped by, I believe, 29 percent comparing 2018 and 2019 to 2023. in 2024. So about 310 more women experience significant bleeding in that post-abortion ban period. And, you know, I think that sort of gets a bit to Dr. Huddleston's point that, you know, deaths are a rare outcome, but there are really serious outcomes that appear to be more common and increasingly common.

22:15Last week, the Texas Department of State Health Services announced it will postpone the release of its latest maternal mortality report until after the midterms. Now, the report is expected to contain the first full year of data on maternal mortality in the state since its near-total abortion ban went into effect. Carrie, why are officials delaying the report's release? What have they said? There are a couple of reasons for the delay, but the reason that has been provided by officials at the Department of State Health Services is that the additional time is going to give them an opportunity to provide more informed recommendations about what can be done to address maternal mortality in the state.

23:01And so when that report is released, how will healthcare providers and researchers use the data to better understand the connection, potential connection between the state's abortion ban and maternal health outcomes? The report that will be released will contain data from 2024. The last report that was issued reported on maternal deaths from 2020 to 2021. So there's going to be a notable gap of information on maternal deaths in 2022 and 2023, which were the first two years in which Texas's abortion ban had gone into effect. And this is a really meaningful gap. It's going to make it difficult to identify any clear trends over time when you're missing this two-year period of data.

23:57So we might find some information or see some changes. But without a longer time series, it's difficult to really know what else might have been happening in that intervening period to see if there was a shift that was already taking place or if whatever is happening in 2024 is unique. I think what's also important about the omission of these deaths is that in 2022 and 2023 is that every single one is a person who has a family. And those families deserve information about what happened and a full investigation of the cause of death that led to the end of their family members' lives. And without including an analysis of those data, we're really leaving Texans without the full information that they need to understand the policy changes and system level changes that are going to prevent these kinds of deaths in the future.

25:08Well, Andrea, beyond Texas, a ProPublica investigation from December of 2024 found that states with strict abortion bans are not looking into whether their laws contribute to maternal deaths. Why not? Yeah, I, you know, I was not one of the writers of that piece, so I can't speak specifically to that. You know, I know every state has sort of different criteria for how to kind of how to examine maternal deaths. And some states are kind of choosing to not look at specific subsets. You know, I think the interesting thing about what we saw in the ectopic pregnancy death numbers is that there really is, it's a rare enough type of death that when you look at any one state, you don't see this trend.

26:11You see kind of small numbers every so often. And it's only at the national level that you can really even see this. And we should note that the U.S. doesn't do national maternal mortality reviews. Instead, it leaves that task up to state and local maternal mortality review committees. And as we said, some states are declining to convene those committees or choosing to exclude certain data from their analysis. So to come, the Trump administration has gutted the CDC's staff and funding dedicated to bettering maternal health outcomes. What does that mean for ectopic pregnancy-related deaths? That's just ahead.

26:48Support for NPR and the following message comes from the Robert Wood Johnson Foundation. RWJF is a national philanthropy working toward a future where health is no longer a privilege, but a right. Learn more at rwjf.org. Since the start of President Trump's second term, the administration has slashed the CDC's funding and staffing dedicated to health care research, including reproductive and maternal health. Lee Warner is the former chief of the Women's Health and Fertility Branch and the CDC's Division of Reproductive Health. He worked at the agency for 29 years before retiring in 2025. We asked him how recent funding and staffing cuts are affecting the agency's work, specifically on reproductive outcomes.

27:31Deaths from hemorrhage remain a leading cause of pregnancy-related death, with ectopic pregnancy playing a significant role. it's ironic that despite all the attention given to maternal mortality two-thirds of the staff from cdc's division of reproductive health with subject matter expertise that could help address this problem are on paid administrative leave and remain so since april of last year these individuals should be allowed to return to their positions to fulfill our collective mission of protecting the health of mothers and infants in this country. I mean, Carrie, just put this conversation in the context of the state of maternal health more broadly in the U.S.

28:15right now. Yeah, I mean, we know that there is a problem with maternal mortality in the United States. The rates of maternal death in the United States are higher than in many other developed countries with high incomes. And it has been that way for some time. What we also know is that in many of the states that have enacted abortion bans, maternal mortality was higher in those states before the bans went into effect. So these are also states that have, many of them have not expanded Medicaid, where there are a lot of reproductive age women who lack health insurance or who lack consistent access to health care as a result of this.

29:08And they're not able to get the kinds of medical care to help address preventable health problems that may complicate a pregnancy or manage health problems that they have so that they can enter and go through pregnancy as healthy as possible. And we also know from the analysis of state-level data and national data that a lot of these maternal deaths are preventable. There are things that can be done to help reduce the number of people who are dying in their pregnancy. And having access to consistent health care is one of the things that is going to help drive down those deaths. Well, and Dr. Huddleston, because ectopic pregnancies, as we said, typically occur before prenatal care begins at 10 weeks, patients may turn to an emergency department for care where doctors are typically less familiar with the complication.

30:02They may be less familiar with its dangers and just overall gynecological and obstetric care. So what does that mean for the patient's treatment? Right. I mean, I think this is where there's a big gap in our system where patients don't maybe have a primary care doctor they know or an OBGYN that they can get into when they're in an early pregnancy situation. So they're showing up at the emergency room, which I think really isn't an ideal place, especially when we know there may be some long-term follow-up. So if part of the process of understanding whether someone has an ectopic pregnancy requires that patient come back the next day for another blood test or two days later for another ultrasound so we can get the additional data we need to make a definitive diagnosis.

30:48The emergency room clearly is not set up for long-term care or following patients. And so in some ways, I think one gap we have, and this is in every state, is a better way to have that sort of outpatient management happening in an efficient way. And so I certainly think a solution that we could think to is, are there better systems that we can put in place for helping women who are in the very early stages of pregnancy? But Carrie, better understanding which systems could help prevent death, that comes from research. You have to understand how the systems in place are actually working. But we heard from Lee Warner about the institutional knowledge that has left the CDC.

31:33And when we think about that or when research into critical maternal and reproductive health outcomes is interrupted or canceled, what does that mean for how we understand maternal health outcomes and maternal mortality? Yeah, we really need these longstanding systems of public health surveillance and institutional officials who are committed to maintaining these systems to help all of us understand what is happening in maternal health at the state level, at the national level. And we have really seen a weakening and in some cases dismantling of these systems over the last several years. This not only includes the officials who have been put on administrative leave at the CDC, but at the state level, some of these other key systems of surveillance around or monitoring around pregnancy-related health, like the Pregnancy Risk Assessment and Monitoring System that many states run to assess people's access to prenatal care, pregnancy-related care, and early infant health.