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by Andrea Suozzo, Sophie Chou and Lizzie Presser

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A first-of-its-kind analysis by ProPublica found that the sepsis rate in second-trimester pregnancy loss hospitalizations increased by more than 50% after Texas’ near-total abortion ban went into effect in September 2021. The analysis also identified at least 120 in-hospital deaths of pregnant or postpartum women in 2022 and 2023 — an increase of dozens of deaths from a comparable period before the COVID-19 pandemic.

Neither the CDC nor states are investigating deaths or severe maternal complications related to abortion bans. And although the federal government and many states track severe complications in birth events using a federally established methodology, far less is known about complications that arise during a pregnancy loss. There is no federal methodology for doing this, so we consulted with experts to craft one.

We acquired Texas hospitalization data from 2017 through 2023, giving us more than two years of data after the implementation of the state’s six-week abortion ban in September 2021, and more than a year of data following its full abortion ban, which went into effect in August 2022.

We spoke with dozens of researchers and clinicians to adapt the federal algorithm for birth complications to focus on severe complications in early pregnancy, before fetal viability.

This methodology lays out the steps we took to complete this analysis, to help experts and interested readers understand our approach and its limitations.

Identifying Second-Trimester Hospitalizations

We purchased seven years of inpatient discharge records for all hospitals from the Texas Department of State Health Services. These records contain de-identified data for all hospital stays longer than a day, with information about the stay, including diagnoses recorded and procedures performed during the stay, as well as some patient demographic information and billing data.

Within this dataset, we opted to focus on second-trimester pregnancy loss, because first-trimester miscarriage management often occurs in an outpatient setting. In the future, we plan to look at outpatient data as well.

To examine outcomes in the second trimester, we first identified hospitalizations where a pregnancy ended. We used a methodology to identify severe complications in birth events developed by the Health Resources and Services Administration, the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, and the Alliance for Innovation on Maternal Health, an initiative of the American College of Obstetricians and Gynecologists. The method is outlined in statistical code published by HRSA, and it first identifies every hospitalization with a live birth, stillbirth or an “abortive outcome” (which refers to an intended or unintended pregnancy loss before 20 weeks). Rather than excluding those abortive outcomes to focus on birth, as the HRSA code directs, we included them to look at all hospitalizations where a pregnancy ended. This narrowed our list of hospitalizations to an average of 370,000 per year.

The HRSA methodology further filters hospitalizations to only patients who are female and between the ages of 12 and 54. Our dataset had five-year age ranges, so we filtered to ages between 10 and 54. This brought our hospitalization list to 364,000 each year, on average.

For each hospitalization where a pregnancy ended, we looked for a diagnosis code recording the gestational age of the fetus. In cases where a long hospitalization had multiple gestational week codes recorded over the course of the stay, we took the latest one.

We excluded pregnancy-end hospitalizations without a gestational week code from our analysis — removing about 49,500 hospitalizations, or 1.9% of our dataset. More than two-thirds had coding that indicated a birth, likely to have occurred after 20 weeks.

Based on conversations with doctors and researchers, we narrowed our focus to hospitalizations where a pregnancy ended in the second trimester before fetal viability, from the start of the 13th week through 21 weeks and six days. While pregnancies that end at 20 and 21 weeks are often coded as births, rather than abortive outcomes, we included those weeks in our definition of pregnancy loss because experts told us it’s extremely unlikely that a baby born at 21 weeks could survive. This brought our list of hospitalizations to 15,188.

The number of second trimester hospitalizations, and characteristics of the women hospitalized, was largely stable from 2017 through 2023, the years of our analysis. In 2023, however, as the number of births in the state increased, the number of hospitalizations in our window declined to 2,036, below the yearly average of 2,169.

The race and ethnicity of patients each year, as well as the proportion of these hospitalizations in which the patients were covered by Medicaid or uninsured, did not change significantly after the state’s 2021 abortion ban, known as SB 8, went into effect.

Determining Sepsis Rates

Within these hospitalizations, we looked for diagnoses of sepsis, a life-threatening complication that can follow delays in emptying the uterus. The CDC defines a list of sepsis codes associated with severe maternal complications, which formed the basis of our definition. However, that list of codes is developed to look at sepsis in birth events, the vast majority of which occur much later in a pregnancy than our hospitalizations. We identified five sepsis codes associated with early pregnancy events like ectopic pregnancy and miscarriage, adding them to the existing list of sepsis codes to develop a definition that more fully captured early pregnancy complications.

To compare rates before and after the implementation of SB 8, we grouped the nine quarters of data we had after the implementation of the ban (October 2021 through December 2023) and compared it with the nine quarters immediately before (July 2019 through September 2021). Our dataset gives us the quarter in which a patient was discharged from the hospital but not the exact date, so the “before” group contains one month of data from after SB 8 went into effect on Sept. 1, 2021.

Identifying Fetal Demise

The standard of care for second-trimester miscarriage or rupture of membranes prior to fetal viability is to offer patients a dilation and evacuation or an induction to end the pregnancy — even if there is still a fetal heartbeat. In our reporting, we’d heard that because of the language of Texas’ abortion law, some hospitals and doctors were waiting for the fetal heartbeat to stop or the mother to develop a life-threatening illness, whichever occurred first. To look into this, we wanted to separate hospitalizations in which doctors would have theoretically been able to offer a termination immediately under the law — ones where the patient had a diagnosis indicating that there was no fetal heartbeat at the time of admission to the hospital — from ones where doctors may have waited to provide care.

We determined that about half of our second-trimester hospitalizations did not have a fetal heartbeat on admission. We identified these cases by focusing on two sets of diagnosis codes: Prior to 20 weeks gestation, a diagnosis of “missed abortion” refers to a miscarriage where the fetus has stopped developing, but the body has not yet expelled the tissue. After 20 weeks, a diagnosis of “intrauterine death” indicates that the fetus has died. For both diagnoses, we included only those that were marked as “present on admission.”

Sepsis Rate Findings

Our analysis found that the sepsis rate in second-trimester pregnancy loss hospitalizations increased after the state’s ban went into effect, and the surge was most pronounced in cases in which the fetus may still have had a heartbeat when the patient arrived at the hospital.

In the nine quarters before SB 8 went into effect, the sepsis rate in second-trimester pregnancy loss hospitalizations was 2.9%. In the nine quarters after SB 8 went into effect, the sepsis rate was 4.5%, an increase of 55%.

Since our total number of sepsis cases was relatively small, we measured whether the two groups of data were significantly different using a t-test. We calculated sepsis rates for second-trimester hospitalizations in the nine quarters after SB 8 went into effect and compared that with sepsis rates during the nine quarters immediately prior. We found that increase to be statistically significant (p-value < 0.05).

Sepsis Rate Increased Over 50% for Second-Trimester Pregnancy Loss Hospitalizations After SB 8

We compared the nine quarters after SB 8 went into effect — from October 2021 through December 2023 — to the nine quarters before the ban went into effect — July 2019 to September 2021.

Note: For hospitalizations involving a pregnancy loss between 13 weeks’ gestation and the end of the 21st week.

Sepsis is a reaction to an infection, and the most common additional infection diagnosis in sepsis hospitalizations was chorioamnionitis, an infection of the amniotic fluid that can also cause early rupture of membranes. Rates of chorioamnionitis in sepsis cases remained stable before and after SB 8.

Our analysis also showed that patients admitted while their fetus was still believed to have a heartbeat were far more likely to contract sepsis.

Sepsis Rates Spiked for Patients Whose Initial Diagnosis Didn’t Include Fetal Death

For patients in Texas hospitals who lost a pregnancy, about half were not diagnosed with fetal demise when they were admitted, meaning that their fetus may still have had a heartbeat at that time. Those patients saw a dramatic increase in sepsis after the state banned abortion.

Note: For hospitalizations involving a pregnancy loss between 13 weeks’ gestation and the end of the 21st week. We identified patients whose fetus had no heartbeat when they were admitted by looking for a diagnosis of “intrauterine death” or “missed abortion.” Rates are annual. (Lucas Waldron/ProPublica)

In the nine quarters prior to the implementation of SB 8, the rate of sepsis was nearly twice as high for those with no fetal demise diagnosis on admission compared with those with a fetal demise diagnosis on admission. After SB 8, the rate increased in both groups, and the gap between them widened.

Again, since the number of total sepsis cases was relatively small, we used a t-test to see if there was a statistically significant difference before and after SB 8 in both groups. We found the increase in rates to be significant on both counts (p < 0.05).

Sepsis Rates for Hospitalizations With Fetal Demise on Admission Sepsis Rates for Hospitalizations Without Fetal Demise on Admission Notes: For hospitalizations involving a pregnancy loss between 13 weeks’ gestation and the end of the 21st week. We compared the nine quarters after SB 8 went into effect to the nine quarters before the ban went into effect. Sepsis Rate Analysis Limitations

Maternal health experts noted that discharge data offers a limited window into the details of patient care. Changes in the frequency of a diagnosis code can signal a change in patient health but also a change in coding practices. Our analysis can’t isolate changes in outcomes from changes in sepsis coding practices over time or doctors taking additional documentation steps to show they’ve complied with the law. And billing records offer no detail into a patient’s history and medical wishes or the decisions that medical staff make in the course of care.

Our analysis also does not account for changes in health care outside of hospitals. Though births typically take place in a hospital, other early pregnancy care often occurs in an outpatient setting and does not require a hospitalization, so we can only see a small subset of this type of care — specifically, the most severe cases. We also can’t account for how closures of reproductive health care clinics in the wake of Texas’ abortion ban changed the role hospitals play in miscarriage care.

We cannot see when hospitals turn patients away rather than admitting them. And if a patient who is miscarrying has an inpatient stay at one hospital and is then transferred to another hospital for another inpatient stay, that patient would be double-counted in our analysis, since we can’t connect patients across visits. This could potentially inflate the number of hospitalizations in our dataset, artificially pushing the sepsis rate down.

Our dataset is missing a handful of records from the fourth quarter of 2023; in a small number of cases — about 300 per quarter, or 0.04% of records — providers submit data on a hospitalization late, and that record is released in the dataset for the following quarter.

Billing data is widely used by researchers to study maternal health. While it will never tell the whole story, in aggregate, particularly in a state with a large population, it can paint a picture of changing health outcomes. Our analysis gives us a broad view of care at Texas hospitals before and after a major policy change.

More than a dozen maternal health experts reviewed ProPublica’s findings and said our analysis adds to mounting evidence that the state’s abortion ban is likely leading to dangerous delays in care. Many said the ban is the only explanation they could see for the sudden jump in sepsis cases.

Pregnancy-Associated Hospital Deaths

We found 120 women who died while hospitalized during pregnancy or up to six weeks postpartum in 2022 and 2023 in the inpatient billing data. The Texas Maternal Mortality and Morbidity Review Committee will not review deaths from these years, stating that they will skip to 2024 in an effort to get a more “contemporary” view of deaths, a choice that faced widespread criticism. (The committee chair said there was “absolutely no nefarious intent” behind the decision.)

To identify inpatient deaths in the Texas hospital discharge data, we included all records with a “patient status” of “expired” and with a diagnosis or procedure code indicating that the patient was pregnant or up to six weeks postpartum, with a specific postpartum complication based on the “Identifying Pregnant and Postpartum Medicaid and CHIP Beneficiaries” code list by the Centers for Medicare & Medicaid Services. The CDC looks at deaths up to within one year of a pregnancy’s end, but our dataset doesn’t explicitly identify pregnant or recently pregnant patients, so we were limited in the hospitalizations we could identify through codes.

Our tally does not include those who died in a hospitalization that took place separately from the end of a pregnancy, unless the patient was diagnosed with a specific postpartum complication. We did not filter for age and gender for our death records, as that data was less reliably filled out than the diagnosis and procedure codes.

Our count of inpatient deaths does not attempt to determine what role a person’s pregnancy or the state’s abortion ban played in their death. That type of analysis would require access to medical records. Our tally would include, for example, a person who was hospitalized after a car crash but who was also pregnant. Experts advised us to leave these cases in, because without investigation by the maternal mortality committee, it’s impossible to know, for example, if there was any relationship between the patient’s pregnancy and the cause of the accident, or if there were any delays in maternal care after the accident.

We found that deaths increased sharply during the height of the COVID-19 pandemic and peaked in 2021, and that many cases in 2020 and afterward included COVID-19 diagnostic codes. More than 60% of the deaths that we analyzed had a diagnosis of COVID-19 in 2021, and 27% had a COVID-19 diagnosis in 2022. The COVID-19 diagnostic code was not introduced until October 2020, several months after the pandemic began, and was updated in January 2021. The coding changes, combined with changes in hospital protocols around identifying COVID-19 cases, make it impossible to filter out all COVID-19 related deaths during this time period.

Texas and National Rates of Maternal Mortality

The hospital billing data only includes information about Texas, so to compare with national rates, we used data from the CDC’s WONDER portal, which is based on birth and death certificates. For this analysis, we used a definition of maternal death recommended by CDC research guidelines for this data source. Our denominator includes all live births. For statewide rates, we use the state of residence of the mother in both the numerator and denominator. Rates are reported per 100,000 births.

Between 2019 and 2023, we found a 33% increase in maternal mortality rates in Texas, compared with a decrease of 7.5% nationally during the same time.

While both nationally and in Texas rates of maternal mortality peaked in 2021 during the COVID-19 pandemic and have dropped since, rates in Texas remain higher than before the pandemic.

Missing Documents

The federal methodology we used as a basis for our analysis of severe complications in pregnancy hospitalizations was outlined in a document available for download from HRSA’s Maternal and Child Health Bureau. The instructions included statistical code that we adapted to do our own analysis, and they were accompanied by a spreadsheet of maternal and child outcome measures over time for all 50 states and nationally.

As of early February, both the instructions and the spreadsheet had been replaced by documents noting that the files were “currently under construction and not available.”

Lucas Waldron contributed graphics.

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FOR IMMEDIATE RELEASE:

A judge yesterday granted the City of Clarksdale, Mississippi’s request to order a newspaper, The Clarksdale Press Register, to delete an editorial criticizing city officials. The order blatantly disregards the constitutional prohibition on “prior restraints” censoring the press.

The following statement can be attributed to Seth Stern, director of advocacy at Freedom of the Press Foundation (FPF):

It's hard to imagine a more unconstitutional order than one compelling a newspaper to take down an editorial critical of the government. And it's particularly ironic when the editorial in question is about government secrecy undermining the public trust. If anyone previously trusted the secretive officials involved in this censorship campaign, they shouldn't now.

“The underlying lawsuit here appears frivolous for any number of reasons. But even in constitutionally permissible defamation lawsuits, it's been well-established law for decades that the remedy for plaintiffs is monetary damages, not censorship orders.

“This case should not be viewed in isolation — it's part of a nationwide increase in baseless censorship orders, known as ‘prior restraints.’ But this one is uniquely egregious. City Attorney Melvin D. Miller II and all other lawyers involved in asking a court to silence the press should face real consequences, as should Judge Crystal Wise Martin, who rubber-stamped their request. Judge Martin shouldn’t be adjudicating parking tickets, let alone First Amendment cases.

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by Lomi Kriel, ProPublica and The Texas Tribune

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This article is co-published with The Texas Tribune, a nonprofit, nonpartisan local newsroom that informs and engages with Texans. Sign up for The Brief Weekly to get up to speed on their essential coverage of Texas issues.

The Afghan brothers worked closely with the American military for years, fighting the Taliban alongside U.S. troops, including the Special Forces, and facing gunfire and near misses from roadside bombs while watching their friends die.

They escaped Afghanistan in 2021 when the Taliban seized control of the country. One brother is now an elite U.S. Army paratrooper at Fort Liberty in North Carolina. The other serves in the Army Reserve in Houston. Their eldest sister and her husband, however, were stranded in Afghanistan, forced into hiding as they waited for the U.S. government to green-light their refugee applications. Finally, after three years, they received those approvals in December and, according to the family, were slated to reunite with their brothers this month.

But weeks before the couple was due to arrive, President Donald Trump issued an executive order indefinitely suspending the admission of refugees. The order was the first in a series of sweeping actions that blocked the arrival of more than 10,000 refugees who already had flights booked for the U.S. and that froze funding for national and international resettlement organizations.

A top former government official who worked on refugee issues told ProPublica and The Texas Tribune that another 100,000 refugees who had already been vetted by the Department of Homeland Security have also been blocked from entering the country. The official, who declined to be identified for fear of retribution, said the Trump administration is “moving so swiftly that there might not be much of a refugee program left to recover.”

Taken together, Trump’s actions are effectively dismantling the U.S. refugee system and eroding the country’s historic commitment to legal immigration, according to refugee resettlement and U.S. military experts, who say the most egregious examples include denying entrance to thousands of Afghans who worked with the U.S. military and their relatives.

The refugees “have been going through the process, which is very slow and very detailed and offers extreme scrutiny on each and every individual, and now, all of a sudden, that too is no longer acceptable,” said Erol Kekic, senior vice president with Church World Service, one of 10 national programs that work with the U.S. government to resettle refugees.

“We’re basically abandoning humanity at this moment in time, and America has been known for being that shining star and guiding countries in the world when it comes to doing the right thing for people in need,” Kekic said. “Now we’re not.”

The orders halting aid to international groups also indirectly affected a separate visa program for Afghan translators who worked with the U.S. military, closing off yet another avenue by which thousands hoped to enter the country. Together, the Trump administration’s actions have likely shuttered pathways to the U.S. for about 200,000 Afghans and their relatives whose refugee and military visa applications are currently being reviewed, including tens of thousands who have been vetted, the former U.S. government official said.

Abandoning Afghan allies whose work with the U.S. has them facing threats of retribution and death imperils the country’s standing abroad and makes the military’s job exceedingly difficult, said Ryan Crocker, a former U.S. ambassador to Afghanistan and onetime dean of Texas A&M University’s George Bush School of Government and Public Service.

If the Trump administration does not quickly exempt Afghans from the refugee-related orders, “good luck signing up the next bunch of recruits to help us in our endeavors in the future,” said Crocker, who is now a fellow with the Carnegie Endowment for International Peace, a nonpartisan international think tank in Washington, D.C.

“The entire world sees what we do and don’t do to support those who supported us,” Crocker said.

Spokespeople for the White House, the U.S. State Department, Secretary of State Marco Rubio and Homeland Security Secretary Kristi Noem did not respond to requests for comment about the escalated actions by Trump, who slashed refugee admissions to a record low of 15,000 in the final year of his first term.

Refugees and a coalition of resettlement groups filed the first refugee-related lawsuit against the administration last week, seeking to reverse the executive orders. It argues that the recent actions violate Congress’ authority to make immigration laws and that the administration did not follow federal regulations in implementing them. Another resettlement group, the U.S. Conference of Catholic Bishops, also sued the Trump administration over its refugee actions this week, arguing that they were unlawful.

The executive orders promise a review in 90 days and say that the State Department and DHS could grant exemptions “on a case-by-case basis,” but refugee groups said that neither agency has explained who is eligible or how to request such a waiver.

The Afghan brothers, who asked to be identified by an abbreviation of their last name, Mojo, are hoping the answers come quickly. They are among at least 200 Afghan Americans currently serving in the U.S. military whose family members applied for refugee status, only to be suddenly denied entrance.

“We feel betrayed,” the brother in Houston said. “We serve this country because it protected us, but now it is abandoning my sister, who is in danger because of our work with America.”

The Army Reserve member shows a letter written by his American military supervisor attesting to his years of risks and service for the U.S. government in fighting the Taliban. The letter argues that the man and his family were in danger as a result of his service and that the U.S. would “benefit” from his presence. (Annie Mulligan for ProPublica and The Texas Tribune) “A Community Issue”

The U.S. Refugee Admissions Program, which Congress created in 1980 following the Vietnam War, allows legal immigration for people fleeing their countries if they meet the narrow definition of being persecuted.

To qualify, refugees must prove that they have been targeted for political, racial or religious reasons or because they are part of a threatened social or ethnic group.

The vetting, which requires multiple security screenings and medical examinations, takes an average of about two years, according to experts.

Those who had made it through the process and are now unable to come because of Trump’s recent actions include the children of a former U.S. military translator living in Massachusetts with his wife. The Afghan couple waited three years to reunite with their children, who were separated from their parents at the Kabul airport on the day of the Taliban takeover and have been living in Qatar during the yearslong vetting process.

The kids, ages six to 17, were about to board their flights in Doha last month when the executive orders suddenly blocked their travel, leaving them in Qatar, where they had been supported by international refugee agencies that were funded, in part, by the U.S. government.

It’s uncertain how much longer they can stay in Qatar, said their father, Gul, who asked that his last name not be published to protect his family.

“When my wife heard this news, she fell on the ground and lost consciousness,” Gul said. “We have waited years for them to come and in a few hours, everything changed.”

A former Texas National Guard member was beside himself when he talked about how his plans to be reunited with his wife later this month had been upended. She is a member of the Hazara minority group, which has historically been the target of widespread attacks and abuses including from the Islamic State’s affiliate in Afghanistan, according to a 2022 report by Human Rights Watch, an international advocacy group.

His work for the U.S. military, he said, put her in even more danger.

“I don’t know what we’re going to do,” he sobbed into the phone.

The actions have also blocked the arrival of persecuted Christians, whom Trump had previously vowed to protect. That includes an Afghan family whose conversion led to violent attacks from conservative Muslims, according to refugee organizations.

Word of their persecution spurred a church in the conservative East Texas community of Tyler to sponsor the family’s refugee resettlement applications. Justin Reese, a 42-year-old software developer in Tyler who volunteers to help resettle refugees, said telling the family that it could no longer come was heartbreaking.

“You went from this level of commitment and certainty to none at all, literally in the space of a couple of minutes,” he said.

Aside from halting arrivals, Trump’s orders have blocked funding to U.S. nonprofit resettlement organizations, which caused them to lay off or furlough hundreds of employees and hindered their ability to help refugees already in the country.

In Houston, for example, the YMCA is currently restricted from offering about 400 new refugees basic services such as housing and health screening to help set them up for self-sufficiency, said Jeff Watkins, the organization’s chief international initiatives officer.

The nonprofit is temporarily relying on private funds and other programs to ensure that refugees’ housing and food needs are met and that they are not stranded, but Watkins said that is not sustainable for the long term.

“This becomes a community issue if those needs aren’t addressed,” Watkins said.

The Afghan Army reservist in Houston hopes the Trump administration will ultimately do right by his family after their previous and continuing service to the U.S. government. (Annie Mulligan for ProPublica and The Texas Tribune) “Live Up to Our Word”

The Afghan brothers in Houston and North Carolina said that their sister and her husband were forced to flee their home three years ago after the Taliban published photos of the brothers working with American troops and interrogated neighbors about their whereabouts.

The couple, who are both physicians, could no longer work. They moved every few months, relying on wire transfers sent by the brothers as they waited for the U.S. government to approve their refugee applications.

Now they are forced to continue hiding, but this time the path toward safety feels more nebulous.

Each day with no action increases the danger for stranded Afghans like them, said Shawn VanDiver, a U.S. Navy veteran who leads AfghanEvac, an organization that he began to help those left behind after the withdrawal.

“The Taliban is routinely harassing and torturing folks associated with us,” he said.

For years, Republicans criticized Biden for his handling of the withdrawal. “Now is the time for them to stand with our Afghan allies and fix this,” VanDiver said.

A Taliban spokesperson disputed in a text that it targeted those who worked with the U.S. military. The United Nations Assistance Mission in Afghanistan, however, in 2023 documented more than 200 killings of former officials and members of the armed forces after the takeover, but international human rights officials have said the true number is likely far higher.

U.S. Rep. Michael McCaul of Texas, one of Biden’s critics on Afghanistan, said in a recent interview with CBS News that the U.S. needed to “live up to our word” to protect Afghan allies.

“Otherwise, down the road, in another conflict, no one’s going to trust us,” he said.

But McCaul avoided criticizing Trump in a statement to ProPublica and the Tribune, saying that he believed the president would listen to veterans who have called for an exemption for Afghan allies.

The Houston brother said that he hopes that Trump will ultimately do the right thing for the families of servicemen like him and his brother, who have sacrificed so much for America.

His brother in North Carolina has written to his congressman to request an exemption for Afghans who “have been doing everything legally, following the law.”

“We don’t want to be worried about our loved ones being left behind in Afghanistan, and that will help boost our morale and our confidence in serving the American people with integrity,” he said.

That service, according to the North Carolina brother, will soon include a deployment to the Texas border with Mexico, where his unit would be ordered to aid the curtailing of illegal immigration.

Anjeanette Damon and Jeremy Kohler contributed reporting.

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