Recent news coverage on the increase in maternal mortality in the U.S. overall has highlighted the spike in deaths among pregnant women in Texas. It went from 19 deaths per 100,000 live births in 2010 to 33 deaths per 100,000 in 2011-2012.
Although all the reasons for this increase are not clear, one thing is clear: It is partially a consequence of the severe cuts to family planning services by the 2011 Texas Legislature.
As a result of reduced access to contraception, some Texas women have been more likely to experience an unplanned pregnancy, with potentially adverse outcomes occurring among women at high risk for pregnancy-related complications. And with the closure of many of the abortion clinics in the state after implementation of Texas House Bill 2, women faced greater challenges accessing abortion care if they had an unplanned pregnancy or developed a medical complication during pregnancy.
The state abortion statistics for 2014, recently released by the Department of State Health Services, show new evidence that the family planning funding cuts in 2011 made it difficult for low-income women to prevent unplanned pregnancies. In fact, the county-level data show dramatic increases in abortions and demonstrate a connection between cuts to family planning, reductions in contraceptive services and unintended pregnancy.
Take Gregg County in East Texas for example. The federally qualified health center in the county lost more than 60 percent of its family planning funding and, as a result, served fewer clients than in previous years. In 2012, there were 59 abortions among Gregg County residents. In 2014, there were 172, a whopping 191 percent increase.
Neighboring counties such as Harrison and Upshur also had considerable increases during the same period. There were also sharp increases in Bowie and Nacogdoches, as well as bordering counties.
The increase in the number of abortions in these East Texas counties is in contrast to the overall trend in abortion for the state as a whole. According to the 2014 statistics, the number of abortions in Texas decreased by 14 percent since 2013. But this decline was uneven across the state. For instance, in Lubbock and Hidalgo counties, where women had to travel more than 100 miles to reach the nearest health facility, the number of abortions dropped by more than 50 percent between 2012 and 2014.
The changes in abortion in these selected counties illustrate the competing forces shaping women’s reproductive health in Texas. On one hand, the decrease in access to family planning services increased unintended pregnancy and women’s demand for abortion. On the other, women had significantly reduced access to abortion. This was the dominant force operating in the majority of Texas counties where either abortion clinics closed or the distance to the nearest clinic dramatically increased.
There is reason to believe that the impact of decreased access to reproductive care on the total number of abortions in Texas would have been considerably larger had there not been a simultaneous increase in demand for abortion.
Since 2013, the Legislature, the Department of State Health Services and the Health and Human Services Commission have attempted to rebuild the safety net for family planning services. Some of the major changes include increasing state funding for services, reorganizing the Family Planning Program, launching the new Healthy Texas Women program, and expanding access to highly effective contraception immediately after delivery for low-income women. These are good steps, but their effectiveness has been limited by excluding Planned Parenthood clinics and politically motivated grants to less than fully qualified providers.
But the statewide increase in maternal mortality and likely increases in unintended pregnancy — as evidenced by increase in the number of abortions in some counties – point a bright light on the harm done by the 2011 cuts to the reproductive health care safety net.
Moving forward, the Texas Legislature must make a long-term and comprehensive investment to restore the family planning infrastructure, and public health leaders need to be committed to ensuring women have timely access to high-quality preventive reproductive health care regardless of their income and where they reside in the state. Given the damage that has been done and the program limitations now in place, it may be a long time before we see the results from these commitments.
Potter is a professor of sociology at The University of Texas at Austin. White is an assistant professor of health care organization and policy in the School of Public Health at the University of Alabama at Birmingham. Both are associated with the Texas Policy Evaluation Project.