Increased Neonatal Deaths in Texas After SB8, a Cardiac Activity-Based Abortion Ban

Compared with states w here abortion rema i ned legal, approxim ately 17 7 all- cause excess neo nat al deaths (2.3 per 10,000 births, interactio n p<0 .003) occurred in Texas. A sens itiv ity a naly sis us ing Joi npoi nt logist ic regression spo nt aneo usly ident if ied a mortality trend cha nge i n Texas coincidi ng with SB 8 enactme nt. A pproximately 1 13 excess deaths (1.5 per 10,000 birth s, interactio n p<0.00 1) due to con genital malformat io ns, deformati ons and chromosomal a b normalit ies occur red among Texas neonates after S B8 en actment. Co mpared to expected deaths based on prior inter nal trends (sARIMA), Texa s recorded 289 (95% CI 18 -559) excess neon a tal deaths (3.7 per 10,000 b irths; 95 % CI 0.2-7.2) i n 2022-2023. A preliminary a naly si s of post-S B8 sh ares of neon ates listed as “ not alive” on birth certificates by race/ethn icity fou nd increased relative contrib utio ns from no n-H i span ic White a nd Hi spa nic popul a tions. Con clusion : Texas SB 8 was resp onsi ble for between 1 77-2 89 exces s neon atal deaths from Qu arter 4, 2021-Qu arter 4, 2023. These results suggest that if o ther SB8-li ke abortio n ba ns are enacted, i ncreases in neonat al mortalit y may occ ur elsewhere. . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309400doi: medRxiv preprint 3 Intr oduc ti on: On September 1, 2021, Texas en ac ted Senate Bill 8 ( SB 8), a law ba nn ing a bortio ns after the detection of fetal heart activ ity, without exceptio ns for early detectable fetal ab normal ities with low s urvival pr oba bil ity. 1 We hypothesi zed that m ortality i n Texas neonates ( ages 0-27 day s) mig ht i ncrease, given i ncreased driving di stances to the nearest legal ab ortion facil ity after SB8 e nactment and f urther after the Dobbs v. Jackson Wo me n’s Health decis ion . 2 M e th o d s: Accordingly, we deployed difference-in-dif ferences an alyses compari ng neo natal mortality trends i n Texas to st ates where abortion rema ined legal (Ta ble S1). Separately, we used season al autoregressive i n tegrated moving averages (sA RIM A) to meas ure excess deaths by compar ing o bser ved to modeled expected deaths by jurisd ictio n (i.e., intern al synt hetic controls) (See S upplementary Methods).

After SB8 ( Qu arter 4, 2021-Qu arter 4, 2023), a long-sta ndi ng downw ard trend in neonat al mortal ity i n Texas reversed (Figure, Panel A). Compared wi th states where abortio n rema ined legal, approxi m ately 17 7 all-ca use excess neo natal deaths (2.3 per 10,000 b irths, i nteractio n p<0.00 3) occurred in Texas. A sen sit ivity anal ysis us ing Joi npoi nt logist ic regression spo nt aneo usly ident if ied a mortality tre nd change i n Texas coincidi ng with SB 8 enactme nt (S upplementary Methods, F igure S 1, Table S2). Approximately 113 excess deaths ( 1.5 per 10,000 births, interactio n p<0.001) due to congenit al mal formati ons, deform atio ns a nd chromosomal ab norma lities occurred among Tex as neo nates after SB 8 enactment (F ig ure, Panel B). Comp ared to expected deaths ba sed on prior intern al trends (sARIM A), Texas recorded 28 9 (95% CI 18 -559) excess neonat al deaths (3. 7 per 10,000 births ; 95% CI 0.2- 7.2) in 202 2-2023 (Table S3). A prelimin ary a nalys is of post- S B8 shares of neo nates li sted as “not a live” on birth certificates by race/ethn icity f ound increased relative contrib utio ns from no n-H ispa nic White and Hisp an ic populat ion s ( Figure S2). Discussi on: The difference in S B8- associ ated mortality across the di fference-in - differences and sARIMA an alyses likely reflects complementary comparator strengt h s. The former used observed contemporaneou s morta lity i n states where abort ion rema i ned legal; the latter used Texas trends a nd modeled expected d eaths had there been no c hange wit h SB 8. Difference-i n-dif ferences approaches permit caus al i nference while synthetic intern al control excess mortality a naly ses ( e.g., sARIMA) ca n mi n imi ze spillo ver effects, in which policies i n one j urisd ictio n effects behavi ors in ot hers. Contrast ing previo us reports asses sing abort ion restrictio ns by race/ethnicity, prelimin ary an alys is fo und increas ed relative contribut ion s to neo nat al mortality from non- H ispa nic White mot hers (am ong whom mo st a bortion s ≥21 weeks of gestat ion occur). 3,4 This might reflect loss of abortio n access regarding fetuses with early detectable fatal conge nital ab norm alities. . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309400doi: medRxiv preprint 4 Higher neo nat al mortalit y has pre viously been reported in states wit h restrictive abortio n polic ies. 5 These results su ggest that if other S B8-l ike a bortio n b ans are enacted, increases i n neo nat al mor tality m ay occur elsewhere.

1. Texas Legislat ure. 87(R) SB 8 - En rolled ve rsion - B ill Text. Accessed May 14, 2024. https://capitol.texas.gov/tlodocs/ 87R/b illtext/html/S B00008F .htm 2. Rader B, Upadhy ay UD, Sehgal N KR, Rei s BY, Brow nstei n J S, Hswe n Y. Est imated Travel Time and Spat ial Access to Abortio n Facil ities in the US Befor e and After the Dobb s v Jack son Wome n’s Health Decision. JAM A . 2022;328(20):2041-204 7. doi:10.100 1/j ama.2022.20424 3. Fishm an SH, H ummer RA, Sierra G, H argrove T, Powers DA, Rogers RG. Race/Ethn icity, M aternal Ed ucati onal Att ai nment, and I nfa nt Morta lity i n the U nited States. B iod em ography Soc Biol . 2 020;66(1): 1-26. doi:10.10 80/194 85565.2020.1793 659 4. Kortsmit K. A bortio n S urveilla nce — United St ates, 2021. MMWR S u rveill Su mm . 2023;72. doi:10. 15585/mmwr.ss7 209a1 5. Burdick KJ, Co ughl in C G, D’A mbr osi G R, et al. Ab ortion Restrictiven ess and In fa nt Mortality: A n Ecolog ic St udy, 201 4-2018. A m J Pr ev M ed . 2024;66( 3):418- 426. doi:10.10 16/j. amepre.2023.10.010

The a uthors wish to tha nk Krist in a Fiore for su ggesting the st udy. . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309400doi: medRxiv preprint 5 Figure Legends. Figure 1. Trends in neonatal deaths by difference-in-difference logistic regression. Panel A: Fitted all-cause deaths per 100,000 births in Texas (red line), Restricted (excluding Texas) states (yellow line), Some restrictions states (green line), and Legal states (blue line) are shown. Counterfactual “expected” deaths for Texas, Restricted (excluding Texas) states, and Some restriction states are shown as dotted lines for their corresponding jurisdiction, and are based on the post-SB8 fitted mortality slope observed in Legal states. Interaction p values were significant for Texas compared to Legal states (P=0.003), but not for Restricted (excluding Texas) states (p=0.380), or Some restrictions states (p=0.642). Panel B: Fitted deaths due to congenital abnormalities (International Diseases Classification-10 Chapter Q00-99) per 100,000 births. Interaction p values were significant for Texas compared to Legal states (P<0.001), but not for Restricted (excluding Texas) states (p=0.886), or Some restrictions states (p=0.983). . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309400doi: medRxiv preprint 6 Figure Panel A Panel B . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309400doi: medRxiv preprint