Maternal mortality according to state abortion legislative climate following the US Supreme Court's

Objective: We aimed to evaluate how maternal mortality rates have evolved across US states following the Dobbs ruling, while accounting for the confounding influence of the coronavirus disease 2019 (COVID-19) pandemic. Study design: We conducted a retrospective analysis of publicly available data from the Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research (CDC WONDER) database from January 2018 to December 2024. This study period was divided into three intervals: (1) pre-COVID (January 2018 to February 2020), (2) pandemic (March 2020 to September 2022), and (3) post-Dobbs (October 2022 to December 2024). Using the Kaiser Family Foundation classification, we designated 13 states as abortion-prohibited and 25 states plus the District of Columbia as abortion-supportive, based on contemporaneous legislation. The remaining 12 states were excluded from the analysis. Our primary outcome was maternal mortality, defined as "the death of a woman while pregnant or within 42 days of termination of pregnancy." To account for the clustering of outcomes by state, we employed generalized estimating equations with a Poisson distribution to compute difference-in-difference (DID) estimates with corresponding 95% confidence intervals (95% CIs). Results: Among 19,023,203 births included in the analysis, 6,633,011 (34.9%) occurred in abortion-prohibited states, and 12,390,192 (65.1%) occurred in abortion-supportive states. In all study periods, abortion-prohibited states exhibited higher maternal mortality rates than abortion-supportive states. This disparity widened notably during the pandemic period (DID 8.7 [95% CI 2.6, 14.7] per 100,000 births). In contrast, the post-Dobbs period was not associated with a further increase in this overall disparity (DID -0.7 [95% CI -6.1, 4.7] per 100,000 births). When each abortion-prohibited state was compared individually to the pooled abortion-supportive states, Texas and Louisiana showed a widening maternal mortality disparity in the post-Dobbs period compared to the pre-COVID period. Conversely, Alabama, Arkansas, Indiana, Kentucky, Mississippi, and South Dakota demonstrated a narrowing of this gap relative to abortion-supportive states. Conclusion: Maternal mortality rates remained consistently higher in abortion-prohibited states compared with abortion-supportive states throughout the study period. The COVID-19 pandemic substantially magnified these preexisting differences, whereas the Dobbs ruling exerted variable effects across individual states. These findings underscore both the persistent inequities in women's health outcomes and the urgency of implementing targeted policies to address and mitigate such disparities nationwide.