In September 2021, Texas passed Senate Bill 8, or SB8, which banned abortions as early as five weeks after the start of a patient’s last menstrual cycle. The measure effectively banned abortion in the state—where previously abortions up to 22 weeks gestation were permitted.
When 2022 birth data became available, demographic researcher Suzanne Bell, PhD ’18, MPH, an assistant professor in Population, Family and Reproductive Health, and her colleagues Allison Gemmill and Elizabeth Stuart began to assess the impacts of SB8—specifically on the number of births in Texas.
Bell spoke with Lindsay Smith Rogers on the August 31 episode of Public Health On Call about a new report quantifying SB8’s impacts, as well as her and her colleagues’ plans to dive deeper into the data to illuminate the effects of abortion bans on women, children, and families.
Background on the study
Other research has shown that abortion bans and restrictions have led to reductions in facility-based abortions and increases in requests for medication abortion pills from online vendors.
What we didn’t know: whether or to what extent abortion bans would influence the number of births. Our study was the first to look at this question in relation to Texas’ 2021 ban on abortion in early pregnancy, known as Senate Bill 8, or SB8, which was the most severe abortion ban at the time.
How we answered the question and what we found
My colleagues Allison Gemmill and Elizabeth Stuart and I used birth certificate data for all 50 states and Washington, D.C., to examine monthly live birth counts from January 2016 through December 2022. We [used this data] to create a synthetic version of Texas in the period prior to the implementation of SB8.
Then we compared monthly live birth counts in this synthetic version of Texas to what actually happened in Texas from April 2022 through December 2022. We observed nearly 9,800 births above expectation in Texas—equivalent to a 3% increase in births during this nine-month period.
These findings suggest that many pregnant people in Texas were unable to overcome barriers to accessing abortion services and instead were forced to continue an unwanted or unsafe pregnancy to term. These results were specific to Texas only. We did not observe a similar pattern in monthly live births during this period and other states.
Unanswered question: Who was most hurt by SB8?
We were not able to look at who might have been most hurt by this policy change. The impacts of abortion bans and restrictions are not uniformly felt by people in the U.S. Many people seeking abortion care experience intersecting barriers—poverty, structural racism, their migrant status, or their status as a minor—that make accessing safe abortion incredibly difficult. The provisional birth certificate data didn't allow us to disaggregate changes in monthly live births by the birthing individuals’ characteristics.
Potential long-term impacts on women and families
We were unable to examine the short- and long-term impacts on women and their families who had an unintended birth during this period. But findings from UCSF’s Turnaway Study, which I was not involved in, indicate that women denied an abortion are more likely to experience economic hardship lasting years after the birth and more likely to stay in contact with a violent partner. They're also more likely to have worse health, and their children have slower development and are more likely to live in poverty.
We know that the majority of people who seek abortions live below or close to the poverty line, so it’s likely that many of these birthing people and their families in Texas were struggling financially even before the recent birth.
Compounding this problem: States that banned or restricted abortion access following the Dobbs decision and following SB8 in Texas have not implemented corresponding programs to improve maternal and child health or to support families in need. These states have among the worst indicators of well-being for women and children.
Not yet measured: Impacts of Dobbs
SB8 passed in September 2021, and data for 2022 just became available a few months ago. Dobbs happened nearly a year later, so those births are occurring in 2023, and that data won't be available until next year. Any impacts of Dobbs and subsequent policy changes in Texas or elsewhere would not be reflected in these data given the timing of the policy changes.
We may see even larger impacts on the number of live births to Texans, given that nearly all abortions in the state are prohibited and most of the neighboring states have since banned abortion as well. And we've seen results from the Society of Family Planning’s WeCount study, suggesting pregnant people are now traveling much more and much further to obtain abortion services post-Dobbs, so it's becoming more difficult for people to overcome barriers to access timely abortion care.
Self-managed medication abortion may fill gaps
Many people are learning about and using medication abortion pills obtained from online sellers, so self-managed medication abortion will likely become an increasingly large share of abortions occurring in the U.S. as more people learn about this option.
Where those two things balance out—the increased bans and further barriers to care, in conjunction with the self-managed safe medication abortion option—will determine the ultimate impacts on live births.
Still, it’s important to recognize that options for terminating a pregnancy outside of a facility in one's home state are not equally accessible to everyone. There will always be people who can't travel, who do not have access to online information about medication abortion, or don’t have the funds to purchase those pills online. These people will face the greatest consequences of these recent abortion bans and restrictions following Dobbs.
Is Texas an outlier?
Texas is unique in a lot of ways. It's a huge state and has a lot of births. And before these bans, Texas had a number of abortion providers, as opposed to some states where there might be one provider in the entire state. So, there was a higher abortion rate in Texas than in other states that have since banned abortion.
In a state like Missouri, where there were fewer abortions happening even pre-Dobbs, the total impact of an abortion ban might be less substantial than the 9,800 births above expectation that we observed in Texas. I think the number will be much smaller in states that were abortion-hostile before Dobbs and have since passed restrictions.
Next steps in our research
My colleagues and I intend to explore the potential differential impacts of SB8 once the disaggregated 2022 birth data become available. I think it’s important to understand which populations might be most hurt by these restrictions on reproductive autonomy and might be in most need of additional support following an unintended live birth.
We're also working on exploring changes in infant health in Texas following SB8. Those same birth certificate data give us information about pregnancy outcomes—preterm birth, low birth weight, stillbirth—and we hope to bring some rigorous methodological analyses to an examination of abortion restrictions’ impact on infant health.
When data become available, we intend to examine the impact of Dobbs and the subsequent associated state level abortion restrictions on fertility and maternal and infant health outcomes to look at what is happening broadly in the U.S. post-Roe.
Suzanne Bell, PhD ’18, MPH, is an assistant professor in Population, Family and Reproductive Health. Bell studies patterns of contraceptive use and abortion, particularly in the context of population-based surveys.