Earlier this month the Fifth Circuit Court of Appeals ruled that the final portion of HB 2, the omnibus abortion bill passed in Texas in 2013, may go into effect. The U.S. Supreme Court has issued a stay until it has determined whether it will review the case. If the circuit court’s decision eventually goes into effect, it will force all but one of the facilities that provide abortion services in the state to meet the standards of ambulatory surgical centers (ASCs), a move that will lead to the closure of about half of the remaining clinics. Applauding the circuit court’s decision, Texas Attorney General Ken Paxton said such regulation was needed to “establish safe, common-sense standards of care necessary to ensure the health of women.”
Around the same time, the Texas Department of State Health Services finally posted on its website the state’s abortion statistics for 2013. Although the vital statistics didn’t get much attention in the press, the report was newsworthy because it was so uninteresting. 2013 was the fifth year in a row without a death among women undergoing abortion in the state. Meanwhile, the number of women dying in childbirth and from other conditions related to pregnancy has increased in Texas in recent years; in 2013 alone there were 153 maternal deaths.
The 2013 Texas abortion report also includes information about complications, and less than 0.03 percent of procedures reportedly had a serious complication. Even if there is some under-reporting in Texas, these low complication rates are corroborated by evidence from other parts of the country. A recent analysis of more than 50,000 abortions in California that included data on follow-up care found that about 0.2 percent of abortions were associated with a major, or serious, complication. And again, there were no deaths.
All of this evidence points in the same direction: Abortion as currently practiced in the United States is very safe—and certainly safer than continuing the pregnancy to term. An analysis of national data found that the risk of death associated with childbirth was 14 times higher than the risk associated with abortion. Another study found that the low risk of mortality associated with abortion was similar to the risk of death with outpatient plastic surgery and dental procedures requiring anesthesia. The risk of death with abortion was also similar to running a marathon—and less than riding in a multi-day bicycle touring event.
But returning to the stated objective of HB 2, is there any evidence that performing an abortion at an ambulatory surgical center is any safer than having it done in a clinic like the ones that will be shut down when the law goes into effect? My colleagues and I at the Texas Policy Evaluation Project (TxPEP) reviewed the complications associated with abortion up to 16 weeks of pregnancy at several facilities that are part of a clinic system in Texas that has both ASCs and non-ASC clinics. While we found that overall there were very few serious complications that required transfer from the facility to a hospital (and no deaths), these complications were actually slightly more common at the ASCs. We found no evidence that abortion care was intrinsically safer when performed at an ASC as compared to a non-ASC clinic.
Rather than making abortion safer, HB 2 may actually compromise the health of Texas women. First, there is some evidence that the closure of clinics in the state is leading to an increase in second-trimester abortion. While later abortion is still very safe, procedures in the second trimester are associated with a higher rate of complications compared to those done in the first trimester. Second, studies have shown that women attempt to self-induce their abortion in Texas at higher rates than the rest of the country, and this may only increase as clinic-based care becomes harder to access. And finally, as clinics close, more women have to drive farther to access abortion care, putting themselves at risk of motor vehicle accidents. A woman is more likely to die driving 800 miles than she is from having an abortion.
The political rhetoric behind HB 2 and similar laws that will end up restricting access to abortion care does not reflect the evidence of the safety of this procedure. If politicians were serious about improving the health of women, there are a lot of things they could do—including improving access to high quality health care for marginalized populations and addressing the high rate of maternal mortality, particularly among women of color. But it’s very hard to make abortion in Texas any safer.