A Sentinel Among Sentinels: The Importance of Maternal Mortality Review Committees in Post-Dobbs United States

Introduction

Maternal mortality and infant deaths, while rare, are sentinel events. They are indicators of larger health and inequality issues in a society. Monitoring, understanding, and preventing them is crucial in a world in which people’s access to resources, including health care, can vary so drastically based on income, race, gender, location, and their intersection. Because of this, they also represent a crucial justice issue.

Maternal and infant mortality in the United States is the highest among peers in high gross domestic product countries, and risks are not evenly distributed among the American population. ¹ Those most at risk are overrepresented in minoritized and disadvantaged populations. For example, infants of Black American mothers are more than twice as likely to die in their first year than those of White American mothers. ² When it comes to maternal deaths, not only is the trend going upward but also the difference between White and Black mothers is, in some places, as high as a factor of six. ^1,3

With both Roe v. Wade and Casey v. Planned Parenthood overturned, the risks of maternal mortality have not only been projected to increase as people are forced to either carry on with high-risk pregnancies or seek out potentially unmonitored and dangerous abortions, ^4,5 but also this decision will exacerbate the existing abortion provider shortage. ⁶ Additionally, while the main targets of the laws triggered by the repeal of Roe and Casey appear to be medical providers or individuals seeking to obtain an abortion, those who participate in public health surveillance may also be impacted. Indeed, as these legal frameworks impede access to comprehensive reproductive health care, access to high-quality abortion data, which is necessary for capturing and interpreting data on cause, timing, and preventability of maternal deaths, ⁷ will inherently diminish.

Until recently, all 50 states, the District of Columbia, and Puerto Rico had active Maternal Mortality Review Committees (MMRCs) or a legal requirement to review pregnancy-related deaths. ⁸ These committees provide an interdisciplinary understanding of individual maternal deaths and make clinical care and public health recommendations to health practitioners and policymakers. This is achieved through triangulation of a broad variety of data sources, not just the examination of vital statistics, and it provides a uniquely clear picture of the deaths under review. ^9,10

In 2023, Idaho was the first state to disband its MMRC. ¹¹ This legislation was lobbied by the far-right political group Freedom Foundation, which argued that the committee was an expansion of government surveillance, in addition to being a financial burden. ¹² Other proponents of the legislation similarly contended that the committee costs did not warrant its benefits. It is worth noting that Idaho also had a trigger abortion ban come into effect following the Dobbs v. Jackson Women’s Health Organization ruling in 2022. Idaho currently prohibits abortion at all stages of pregnancy, with exceptions for pregnant people with life-threatening circumstances and for survivors of rape and incest who have reported the incident to law enforcement. ¹³ The Supreme Court of the United States ruled on this ban in June 2024 to affirm the need for Idaho to comply with the federal requirements as laid out in the Emergency Medical Treatment and Active Labor Act. This means that exceptions must include not just life-threatening but also health-threatening circumstances. ¹⁴

Just as maternal mortality should be considered a sentinel event, we consider the disbanding of the Idaho MMRC a sentinel event, an early indicator of what we fear may be to come in other states where the Dobbs ruling also triggered abortion bans. Henceforth, in this research note, we will discuss how maternal mortality statistics are limited and how MMRCs provide much-needed triangulation to improve our knowledge about this important issue. We will conclude on the importance of this topic at this moment in time in the United States, especially when it comes to issues of justice, be it reproductive or otherwise.

The Problem with Maternal Mortality Statistics

There are two main sources of maternal mortality surveillance in the United States: The National Center for Health Statistics (NCHS) and the Pregnancy Mortality Surveillance System (PMSS). ¹⁵ The former uses pregnancy-related International Classification of Diseases (ICD-10) codes (A34, O00-O95, and O98-O99) ¹⁶ extracted from death certificates for deaths that occurred during pregnancy or within 42 days postpartum. The result is the maternal mortality rate (MMR) per 100,000 live births. The MMR is based on the World Health Organization’s definition and, therefore, standardized for international comparisons. The PMSS produces a pregnancy-related mortality ratio (PRMR) per 100,000 live births. Compared with the MMR, the PMSS and resulting PRMR provide a longer follow-up period on death certificates postpartum (1 year) and include an added layer of review by medical epidemiologists at the state level. ^17,18 These data are submitted by states to the Centers for Disease Control and Prevention (CDC) experts, who categorize them to create the PRMR.

Several issues have arisen over time when looking at the reliability and validity of MMRs. First, some changes in reporting practices highlight historically rampant underreporting. For example, the release of the ICD-10 in 1999 was followed by a 13% increase in maternal mortality. While maternal mortality fluctuates from year to year, much of this increase was attributed to a lack of identification of maternal deaths before the introduction of the ICD-10. ¹⁹ The implementation of the 2003 revision of the U.S. Standard Death Certificate, which introduced a pregnancy checkbox to address underreporting, was followed by similar yet lagged increases in maternal mortality due to the multi-year implementation of the new death certificate. ²⁰ It was not until 2018 that all 50 states implemented it. ^{20 –23} This lagged implementation has been hypothesized to explain as much as 31% of the maternal mortality increase between 1997 and 2012. ²³ Other studies acknowledge an underreporting of maternal deaths in the National Vital Statistics System (NVSS). ^24,25 Some states, such as Georgia, have begun to match maternal death certificates to birth and fetal death certificates, ²⁶ although relying on death certificates and/or obstetric codes alone is insufficient for accurate maternal mortality reporting, as underestimates can still occur. ^27,28

Second, and paradoxically, there are also issues of overreporting. While the pregnancy checkbox did improve underreporting in maternal mortality, studies have also shown that it led to overestimates, especially for women over 40 years old, ^18,29,30 and that as much as 21% of the cases in which the pregnancy checkbox was checked were false positives. ²² The NCHS also confirmed that checkbox errors increase with maternal age and that more than half of all checkbox errors occur on death certificates of women over the age of 45. In response, the NCHS made changes to coding rules and reporting to ensure that when the deceased is 45 or older, only death certificates that mention pregnancy or a pregnancy-related condition in the cause of death fields are coded as maternal deaths, regardless of how the pregnancy checkbox is marked. This is known as the 2018 method. ²⁰ Although there is some indication that the 2018 method did correct errors introduced by the use of the pregnancy checkbox for women aged 45 and older, some scholars have questioned whether it provides wholly accurate maternal mortality figures. ^31,32

Third, and finally, a major problem with MMRs as an indicator of maternal health is that they are limited to pregnancy-related deaths, and thus deaths that are pregnancy-associated, such as those resulting from trauma (e.g., motor vehicle accidents), as well as those resulting from homicide, suicide, and drug overdoses, may be excluded. For reference, pregnancy-associated deaths refer to the death of pregnant or recently pregnant individuals, regardless of the cause. ³³ Pregnancy-related deaths, a subset of pregnancy-associated deaths, refer to the death of pregnant or recently pregnant individuals caused by the pregnancy or its management. ³¹ The exclusion of pregnancy-associated deaths, such as those resulting from homicide, is problematic considering it is a leading cause of death among pregnant and recently pregnant individuals, ^{34 –36} and that pregnant and recently pregnant women are at higher risk of death by homicide than nonpregnant/nonpostpartum women. ³⁷ This issue is also racialized, as pregnant Black women have long held an elevated risk for intimate partner homicide. ^{37 –39} This creates equity gaps in maternal death data. Moreover, one study based in Philadelphia found that almost 50% of maternal mortality was nonpregnancy related, including overdoses, motor vehicle accidents, suicides, and homicides, ⁴⁰ while another study based in Colorado found that 30% of maternal deaths over 9 years were related to self-harm. ⁴¹ As such, pregnancy-associated deaths are important for maternal death data because they can be indicators not only of the quality of a health system(s), but of the cumulative risks to individuals, mostly women, who become pregnant.

PRMRs have yielded similar critiques. Studies explain that errors in the pregnancy status reported on death certificates can potentially lead to an overestimation or underestimation of PRMRs. ⁴² Also, often the pregnancy-relatedness cannot be determined in PRMRs for drug overdoses, suicides, homicides, or cancer-related deaths, because of limited information available to the PMSS concerning death circumstances. ^25,42 Additionally, as recent reports have indicated an increase in maternal mortality in the United States, Joseph and colleagues caution that PRMRs cannot account for the effects of enhanced surveillance or inaccurate cause of death reporting. ¹⁸ Alas, while PRMRs are a more comprehensive measure than MMRs, they can be affected by data quality and data availability issues.

Despite the issues created by reporting practices and instruments, the increased rates of maternal mortality in the United States are not entirely explained by these occurrences. Other factors include the historical lack of standardized education and response protocols in hospitals for addressing common complications of pregnancy/childbirth, such as hemorrhage, hypertension, as well as cardiac and coronary conditions. ²⁴ Based on a review of pregnancy-related deaths, these are some of the most preventable causes of maternal mortality. ⁴³ Further, rising cesarean delivery rates may play a role. The United States has one of the highest cesarean rates in the world. ⁴⁴ While cesarean delivery is a useful intervention for mothers and newborns in some situations, studies have determined that a woman’s health or the health of the baby are not the primary predictors of cesarean deliveries, ⁴⁴ and that rates of cesarean deliveries differ by hospital. ⁴⁵ Cesarean deliveries, and more specifically multiple successive cesarean deliveries, are associated with a higher risk of severe acute maternal morbidity than vaginal deliveries. ^46,47 Furthermore, the increased prevalence of chronic conditions in the general population, the growing proportion of pregnant individuals of advanced maternal age, the opioid epidemic, ⁴⁸ structural racism, ²⁴ and, of course, the COVID-19 pandemic, ⁴⁹ all contribute to increased maternal mortality. Now, in our post-Dobbs era, these numbers are likely to keep increasing. ⁴

Maternal Mortality Review Committees

As outlined above, MMRs and PRMRs can be used for surveillance of trends and large-scale patterns, but it is difficult to capture the complexity of rare events such as maternal deaths without the granular details afforded by MMRCs. Indeed, MMRCs represent the most accurate maternal mortality data system in the United States, due to their unique ability to combine multiple data sources and examine cases individually. ^9,10 While the data coming out of MMRCs might not be uniformly reported to the CDC by all states through the Maternal Mortality Review Information Application (MMRIA), at the MMRC level, these data are of the highest quality compared with MMRs and PRMRs, and this is because they are not aggregate-level data, but rather incident-based. Of course, MMRC data are not just used for surveillance, they are above everything else tasked with making clinical care and public health recommendations. ⁵⁰

MMRCs are multidisciplinary teams assembled at the state or local level to periodically review maternal deaths. In addition to vital records, MMRCs have access to a varied range of other records of the cases they review, including medical and social records. Committee members include a broad range of health-related personnel and forensic experts, but also social workers and sometimes patient advocates and community members. ⁵¹

MMRCs work collaboratively with state and/or local vital records offices, as well as epidemiologists, to identify the population of cases they are to review: the deaths that happened either during pregnancy or within a year of the end of a pregnancy. These cases are identified not simply through the pregnancy checkbox, but rather by linking all deaths of women of childbearing age with records of either live births or fetal deaths, within a year of the birth. Matching records are those included in the review. Additional information is compiled by MMRC abstractors, including but not limited to hospital and medical records, prenatal care records, informant interviews, social service and environmental health records, etc. MMRCs then review each case with a set of questions to guide their inquiries (which also correspond to the CDC’s MMRIA): ⁵¹ 1.

“Was the death pregnancy-related?

As such, the main goal of MMRCs is to assess which deaths were preventable and make recommendations as per interventions that may prevent similar deaths from occurring in the future. MMRCs can vary widely in the proportion of preventable deaths they identify, depending on the type of information available to them. The proportion of deaths identified as preventable grows with the availability of data beyond just clinical information and with the multidisciplinary nature of the team. ^51,52 This illustrates the importance of viewing health and health equity from a larger framework than a medical one alone.

According to the CDC’s Maternal Mortality Review Committee Logic Model, ⁵¹ a key component to establishing successful MMRCs is leadership buy-in and a legislative mandate with associated protection. MMRCs must be given access to restricted data, which includes health records, and be protected from subpoenas to accomplish their mission. Protection and confidentiality safeguard members from civil and criminal liability and grant the necessary authority for the committee to collect data for accurate and thorough case review. ⁵³ When the Idaho Legislature let the MMRC founding statute sunset in June of 2023, they effectively withdrew their protection to the committee and rendered it useless.

MMRCs as a Justice Apparatus

While Idaho’s MMR, as reported in the MMRC’s final report, remains below the national MMR (22.3 per 100,000 live births versus 32.9 per 100,000 live births in 2021), it has (1) been increasing over the last 4 years the Idaho MMRC was active, which follows the national trend, and (2) the increase has disproportionately affected Black, Native American, and Alaska Native women, which is noteworthy, as the state has predominantly White residents. ⁵⁴ It is gaps like this that make women’s reproductive health a justice issue. Alas, MMRCs are crucial in righting such wrongs and, therefore, central to reproductive justice in the following ways.

First, MMRCs can play an important role in identifying causes of pregnancy-associated deaths. While it is noted that MMRCs are tasked with reviewing pregnancy-related deaths, some MMRCs do review pregnancy-associated deaths, including homicides. ³⁸ As stated earlier, homicide is a leading cause of maternal death; pregnant women are at higher risk of homicide than nonpregnant women, and this is aggravated for pregnant Black women in the context of intimate partner homicide. ^{34 –39} As such, MMRCs’ recommendations can play a critical role in maternal homicide prevention efforts, ⁵⁵ and we argue that this role should be bolstered.

Second, MMRCs are beneficial to programs, policy efforts, and data initiatives addressing the health needs of justice-involved women. The mass incarceration of women has significantly worsened maternal health in the United States. ^56,57 Further, studies have found that justice-involved Black women are at risk for severe maternal morbidity. ^58,59 As a response, the Black Maternal Health Momnibus Act was introduced in 2021, comprising 13 individual bills, including the Justice for Incarcerated Moms Act. This bill aims to improve health care and reproductive dignity in jails and prisons, particularly acknowledging the need for policies that target maternal morbidity and mortality. ⁶⁰ In a review of this bill, Shlafer and colleagues ⁶¹ reflect on crucial tenets, such as data collection and evaluation of pregnancy-associated deaths, rates of preterm births, and low-birthweight births among incarcerated people. The authors further highlight the importance of interdisciplinary responses to mortality and maternal care. Noting that many health care trainees are not exposed to issues of mass incarceration and carcerality, they especially call for expanding partnerships between academic health centers and jails and prisons. MMRCs are an avenue for such a partnership. Concerning our sentinel event in Idaho, the disbanding of the state MMRC in 2023, as the state has one of the highest female incarceration rates in the country, ⁶² we suggest that such a partnership is particularly relevant.

Furthermore, a recent study by the Bureau of Justice Statistics (BJS) reviewed the feasibility of collecting maternal and pregnancy outcomes in prisons and jails. The study acknowledged various resource, legal, and technical challenges impacting facilities’ ability to review information on different pregnancy complications, off-site maternal health care, and postpartum health. Constraints in the areas of time and staffing were emphasized. ⁶³ MMRCs can review justice-related data, including arrest records and incarceration records, within 1 year of a death. While this is contingent on data sharing, the collaborative nature and training of MMRCs render them uniquely capable to enhance public health for incarcerated populations and address a substantial gap in justice statistics.

Finally, when it comes to promoting justice, we would be remiss if we did not mention the potentially difficult situation in which MMRCs in states with abortion bans could find themselves. MMRCs help identify and address inequities in maternal mortality, including harmful legislation that undermines maternal well-being. This is particularly pertinent as the Dobbs decision has wide-reaching global impacts for many sociodemographic groups, ⁶⁴ including women of color, immigrant women, and women who suffer from economic inequalities. Yeniifer Alvarez-Estrada Glick of Luling, Texas, a woman who died in July of 2022, provides the perfect illustration. By the age of 26, Alvarez-Estrada Glick, a Latina who immigrated from Mexico, developed health conditions that are found in higher prevalence in economically marginalized populations, including hypertension, diabetes, and cardiopulmonary complications. She also lacked health insurance. When she became pregnant, her pregnancy was high risk by default. Some women with the same conditions end up safely delivering healthy babies. However, in her seventh week of pregnancy, she started bleeding and struggling to breathe. She would go on to be hospitalized multiple times for severe pregnancy complications, including preeclampsia. As the months wore on, her pregnancy became more dangerous, and she became sicker. Then, at 31 weeks, both she and her fetus died. While the manner of death in this case is still pending, pregnancy is considered to be a contributing factor. ⁶⁵

Medical professionals who reviewed her file explained that had a therapeutic abortion been offered and had she accepted, it probably would have saved her life. However, she was never offered a therapeutic abortion, nor was the possibility of a therapeutic abortion ever discussed with her in a health care setting. This includes when she was initially hospitalized with breathing problems, when she visited an OBGYN who determined that she was at risk of having a heart attack and stroke, and when she had to be transferred to a larger hospital where records state that she was at “high risk for clinical decompensation/death.” ⁶⁵ Furthermore, though she may have qualified for a legal abortion, there is much confusion over the wording of Texas’s strict abortion law (known as S.B. 8), especially as it relates to medical exemptions. This leaves many pregnant women vulnerable to health complications, including mortality. ⁶⁶ Accordingly, a maternal-fetal expert concluded that Alverez-Estrada Glick’s death was a consequence of both S.B. 8 and Texas’s inadequate funding of the medical needs of disenfranchised communities. ⁶⁵

This case is an illustration, as it is not an isolated incident. Many of the trigger bans set in place across half of the country include provisions targeting health care workers. The Idaho ban makes it a crime punishable by up to 5 years in prison to perform or assist in an abortion. Moreover, as states with trigger bans tend to have the poorest maternal health outcomes, ⁶⁷ these policies are especially fraught. As such, deaths such as Alverez-Estrada Glick’s will become more common, and moving forward, MMRCs might find themselves playing a critical role in outlining the impact of abortion access on maternal deaths.

About the justice-related role of MMRCs, we can identify three missions made more difficult by the Dobbs decision and associated abortion bans. First, identifying deaths resulting from an unsafe abortion or attempt is challenging for MMRCs, even in states with legal access to abortion. In such cases, the cause of death may be listed as hemorrhage, sepsis, bowel injury, or uterine perforation. While MMRCs could attempt to learn whether the pregnancy was desired or not from interviews with personal contacts and social service records and speculate that legal/access to safe abortion might have prevented the death, there is no guarantee the deceased would have discussed their pregnancy and/or efforts to terminate with friends, family, or service providers. Abortions are a deeply private matter, and criminalizing them will only further obfuscate open discussions. All this said, in recent years, the CDC has not shied away from asking MMRCs to collect information about complex and difficult to ascertain factors. In 2020, a checkbox was added to the MMRIA model form to indicate if discrimination contributed to a pregnancy-related death. Yet, at the time of writing, the CDC has not asked states to track deaths linked to abortion bans. In a recent press release, maternal health researchers and experts noted that because of the absence of a checkbox or tracking model, MMRCs have no standard way to consider the role of abortion bans in maternal deaths, ⁶⁸ which makes it harder to study deaths related to restrictions comparatively and create informed recommendations.

Second, as seen in the case of Yeniifer Alvarez-Estrada Glick, health care providers may delay necessary interventions until patients face life-threatening conditions due to fear of legal repercussions or misinterpretation of state laws regarding abortion exceptions. ⁶⁹ In identifying those missed interventions, MMRCs would position themselves both against the law and against the health care workers attempting to navigate it. These committees are set up to investigate the broad causes of maternal health failures, not to assign individual blame. Certainly, doing so in official committee conclusion reports could seriously disrupt strategies and actions to improve maternal health care.

Third, and related to the second point, MMRCs may find themselves in the unenviable role of calling out state legislations for their deleterious effects on women’s health. While commenting directly on current legislation is not one of the outlined tasks of MMRCs, ⁵¹ this commentary is not outside of their purview. For reference, in Georgia, a state with a 6-week abortion ban, an internal MMRC report implied that two women’s deaths were preventable and possibly linked to abortion restrictions. After the leak of this internal report, the Georgia Department of Public Health announced its plans to dismiss all members of the state’s MMRC. ⁷⁰ While this decision is a partial consequence of the leak itself, as committee members are prohibited from sharing confidential information with the public, activists and data scientists have alleged this was also politically motivated and an attempt to suppress important information on abortion bans and maternal mortality outcomes. ^71,72

Furthermore, while MMRCs are often funded by the CDC’s Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) project, at least some MMRC team members are likely to be state employees and therefore may be subject to political pressures. Therein, there are concerns that MMRC reports of maternal deaths associated with abortion care, or lack thereof, might be censored. Moreover, some states may altogether prohibit MMRCs from reviewing any maternal deaths following an abortion (legal or otherwise). For reference, Texas state legislators are threatening not to permit their MMRC to share its data with the CDC’s ERASE MM project. ⁷³ The changes in state abortion policies and their associated pressures will undoubtedly make advocating for necessary changes based on MMRC findings more difficult.

In summary, the Dobbs decision creates a more challenging environment for MMRCs by introducing increased risks associated with obstetric emergencies due to delayed care, difficulties in tracking the impact of abortion access on maternal health outcomes, and potential political interference. Committees must navigate these challenges while upholding their ethical obligations toward data transparency and advocacy in maternal health. Indeed, maintaining MMRCs in states with abortion bans is vital to document the public health outcomes of these policies, but the bans themselves render the work of the MMRCs all the more difficult and potentially untenable. In a world in which attempting to protect women’s lives beyond their reproductive roles is political, the work of MMRCs becomes political work.

Conclusion

We find ourselves at a crucial moment in time, when we arguably have the best maternal mortality data we have ever had as a country. They are still far from perfect, but systems have steadily been put in place to improve them. Nevertheless, we have not managed to use the data effectively to turn around the increasing MMRs. To make matters worse, we are now entering a new era (or maybe returning to past times) in women’s health, one in which Roe v. Wade and Casey v. Planned Parenthood no longer stand. As past studies have observed higher maternal death rates in areas with restricted access to safe abortion and/or hostile abortion legislation, ^{74 –77} it is imperative to understand the complete dynamics of maternal mortality within this new/old context.

MMRCs are the public health arm of a state or region when it comes to clinical care and putting forward recommendations to influence preventable maternal deaths. As we have outlined above, this work simply cannot be done without the level of granular details uniquely available to MMRCs. Further, when MMRC reviews can be aligned with data reporting to the NCHS and PMSS, more accurate national maternal mortality statistics will be possible. ⁷⁸ In the current landscape, MMRCs’ mission has been made more difficult, and the impact of their work is likely to be undermined. The discontinuation of the Idaho MMRC in 2023 indicates either a lack of understanding of the importance of such committees for the amelioration of public health or simply a lack of regard for the health of a specific population, in this case, women of childbearing age. Two bills were introduced during the 2024 Idaho legislative session aiming at reconstituting some sort of MMRC, and as of March 18, 2024, one, HB399, had been signed into law by the Idaho Governor. ⁷⁹ While it is somewhat reassuring that the aberration of the 2023 sunset was not left unchecked, it is important to note that the statute as passed by the Idaho Legislature moves the MMRC-like structure from the Department of Health and Welfare to the Idaho Board of Medicine without specifying appointments to a committee or any sort of immunity or confidentiality conferred to the members. Further, this administrative relocation has implications for the ability of the hypothetical MMRC to receive federal funding. ⁸⁰ Per se, the statute simply states that the Idaho Board of Medicine will have the responsibility to provide the legislature with a yearly report on maternal deaths in the state. ⁸¹ As such, it seems that until proven otherwise, this piece of legislation does nothing significant to bring back the Idaho MMRC.

While the situation in Idaho represents a single MMRC, it is our goal to mobilize clinicians for action as if what happened in Idaho were a sentinel event for MMRCs nationwide. The focus right now is understandably on ensuring access to reproductive health for women, having been cut off from it in states with trigger bans, as well as helping clinicians in those states navigate new legal landscapes. Nevertheless, all should also be concerned about ensuring local and state MMRCs can continue their work unimpeded and independent of political pressure. Further, this conversation should also include considering all pregnancy-associated deaths in our surveillance and review systems, as they are indicators of larger social equity gaps in women’s and maternal health. This is work that should happen at the local level, in legislatures, as well as through national organizations such as the American Medical Association (AMA) and the American College of Obstetricians and Gynecologists (ACOG). Both the AMA and ACOG have worked collaboratively with innovative partners across the field of maternal health to identify preventable deaths and have been champions of quality maternal death data and MMRCs.

In closing, just as maternal and infant mortality are seen as sentinel events, telling a larger story about a population’s health, the discontinuation of one of our 50 MMRCs nationwide ⁸ must be seen as a sentinel event in this new post-Dobbs women’s health landscape. Idaho’s situation foreshadows what is to come. Already, Georgia is in the process of restructuring their MMRC following a leak of sensitive case information related to maternal mortality and abortion access. ⁷⁰ The new Georgia MMRC’s work will likely be more complex as a result. While it is difficult to ascertain the scale of impact of abortion restrictions on the work of MMRCs, it seems clear at this point that even just maintaining MMRCs in existence is not a given. The consequences on women’s health of the demise of MMRCs would be dire, including increased maternal mortality, gaps in maternal death data, sociodemographic disparities, and missed opportunities to improve women’s health. Acknowledgment, action, and advocacy are crucial now more than ever. If it happened in Idaho, it can, and will, happen elsewhere

Authors' Contributions

The research idea, literature search, analysis, and synthesis of information were performed by B.M.P. and M.-A.N. The first draft of the manuscript was written by B.M.P. and M.-A.N. and both authors commented on revision versions of the manuscript. Both authors read and approved the final manuscript.