Texas, like Flor-i-daaaaaaa but stupider...

Texas Is Letting a Maternal-Mortality Skeptic Investigate Maternal Mortality

Dr. Ingrid Skop thinks 9-year-olds can have safe pregnancies and “abortion regret” is deadlier than abortion bans.

NINA MARTIN

Just a few years ago, maternal mortality was the rare reproductive justice issue that seemed to transcend partisan politics. In late 2018, Republicans and Democrats in Congress even came together to approve $60 million for state maternal mortality review committees (MMRCs) to study why so many American women die from causes related to pregnancy and childbirth. Donald Trump—not exactly famous for his respect toward pregnant women and new mothers in his personal life—signed the bill.

But some Republicans’ enthusiasm for these committees began to wane at around the same time abortion rights advocates began warning that draconian restrictions on reproductive care would only push the shamefully high US maternal mortality rate—the worst among affluent countries—even higher. Nor did conservatives, like Idaho lawmakers, appreciate the policy recommendations that came out of many MMRCs.

Texas, whose record on maternal mortality (and maternal health more broadly) has been an embarrassment since long before Dobbs, has a history of controversial attempts to play down potentially unwelcome findings from its MMRC. After the Dobbs decision, when the state committee was working on its report examining maternal deaths in 2019, Texas officials decided to slow-roll its release until mid-2023—too late for lawmakers to act on its recommendations. “When we bury data, we are dishonorably burying each and every woman that we lost,” one furious committee member told the Texas Tribune. Ultimately, officials released the report three months late, in December 2022. Soon afterward, the Legislature reconfigured the MMRC, increasing its size—but also ejected one of its most outspoken members. 

Now Texas officials have stirred up the biggest furor yet, appointing a leading anti-abortion activist to the panel. Dr. Ingrid Skop, an OB-GYN who practiced in San Antonio for 25 years, will join the MMRC as a community member representing rural areas (even though she is from the seventh-largest city in the US). But she also represents a largely overlooked segment of the anti-abortion movement: researchers who seek to discredit the idea that abortion restrictions are putting women’s lives in danger. To the contrary, Skop and her allies argue that abortions are the real, hidden cause of many maternal deaths—and that abortion restrictions actually save mothers’ lives.

One of several doctors suing to revoke the Food and Drug Administration’s approval of mifepristone, the medication abortion drug at the center of one of this term’s blockbuster Supreme Court cases, Skop has been a familiar face on the anti-abortion expert-witness circuit for more than a decade. She has frequently testified in favor of strict abortion bans in court cases, state legislatures, and before Congress. In a high-profile case this winter, she submitted an affidavit stating that a Dallas woman named Kate Cox— who was seeking a judge’s permission to terminate a nonviable pregnancy—did not qualify for an abortion under Texas’s medical exception. The Texas Supreme Court rejected Cox’s petition, and to get medical care, the 31-year-old mother of two had to flee the state. Apparently, Skop’s hard-line stance against abortion-ban exemptions extends to children. At a 2021 congressional hearing, she testified that rape or incest victims as young as 9 or 10 could potentially carry pregnancies to term. “If she is developed enough to be menstruating and become pregnant, and reached sexual maturity,” Skop said, “she can safely give birth to a baby.”

Skop’s relatively new role as vice president and director of medical affairs for the Charlotte Lozier Institute, the research arm of Susan B. Anthony Pro-Life America, has solidified her standing in the anti-abortion firmament. Lozier, which has positioned itself as the anti-abortion alternative to the Guttmacher Institute, described Skop’s role as “coordinat[ing] the work of Lozier’s network of physicians and medical researchers who counter the abortion industry’s blizzard of misinformation with science and statistics for life.” Elsewhere on its website, Lozier notes that Skop’s “research on maternal mortality, abortion, and women’s health has been published in multiple peer-reviewed journals.”

What her Lozier bio doesn’t mention is that three of the studies Skop co-authored about the purported risks of abortion were retracted by their publisher this February. Attorneys representing Skop and her fellow anti-abortion doctors had cited the studies in the FDA-mifepristone case. As my colleague Madison Pauly reported, an independent review of the papers found “fundamental problems,” “incorrect factual assumptions,” “material errors,” “misleading presentations,” and undisclosed conflicts of interest between the studies’ authors (including Skop) and anti-abortion advocacy groups (including Lozier). In a rebuttal on its website, Lozier called the publisher’s move “meritless,” adding, “There is no legitimate reason for [the] retractions.”

Skop has argued repeatedly that abortions are directly and indirectly behind the rise in maternal mortality in the US. In a 53-page “Handbook of Maternal Mortality” she wrote for Lozier last year, she says that CDC maternal mortality data can’t be trusted in part because “there is much unreported maternal mortality and morbidity associated with legal, induced abortion, often obscured due to the political nature of the issue.” She claims that a history of abortions puts women at risk in pregnancy, childbirth, or during the postpartum period—whether from maternal complications she contends are linked to prior abortions, or from mental health problems, such as drug addiction and suicide, purportedly caused by abortion regret. 

In another paper co-written with some of the same co-authors as in her retracted studies, Skop and her colleagues call for an overhaul of how states and the CDC collect maternal mortality data, urging the inclusion of “mandatory certification of all fetal losses,” including abortions.

And whereas the vast majority of public health experts predict that maternal deaths and near-deaths will increase in states with abortion bans, Skop takes the opposite view. In yet another Lozier paper, she lists 12 reasons why states with abortion bans will have fewer maternal deaths. For instance, she argues, because of abortion restrictions, women will have fewer later-term abortions, which tend to be more dangerous to women than first-trimester procedures. (In fact, researchers report, that state bans have led to an increase in second-trimester abortions.) She claims that since women who don’t have abortions won’t have mental health problems supposedly associated with pregnancy loss, their alleged risk of postpartum suicide would be reduced. (In fact, the idea that abortion regret is widespread and dangerous has been thoroughly debunked.) Skop makes a similar argument about abortion’s purported (and disproven) link to breast cancer, arguing that fewer abortions will mean fewer women dying of malignant tumors.

Much of Skop’s advocacy work has been done in collaboration with colleagues who share her strong ideological views. MMRCs, by contrast, have a public health role that is supposed to transcend politics—their focus is on analyzing the deaths of expectant and new mothers that occur within a year of the end of the pregnancy. Typically, committee members come from a wide range of professional backgrounds: In Texas, these include OB-GYNs, high-risk pregnancy specialists, nurses, mental health providers, public health researchers, and community advocates. Panels also aim to be racially and geographically diverse, the better to understand the communities—Black, Indigenous, rural, poor—where mothers are at disproportionate risk of dying. In a country that hasn’t prioritized maternal health, MMRCs are uniquely positioned to identify system failures and guide policy changes that can save lives.

Texas’s most recent maternal mortality report found that 90 percent of maternal deaths were preventable, racial disparities in maternal outcomes weren’t improving, and severe childbirth complications were up 23 percent—all before the state’s abortion bans took effect.

It remains to be seen how someone with Skop’s background and agenda will fit in with her new colleagues, especially at this dire moment for women in the state. Maternal health advocates aren’t optimistic: “This appointment speaks volumes about how seriously certain state leaders are taking the issue of maternal mortality,” Kamyon Conner, executive director of the Texas Equal Access Fund, told the Guardian. “It is another sign that the state is more interested in furthering their anti-abortion agenda than protecting the lives of pregnant Texans.”

Skop, contacted through Lozier, didn’t respond to a request for comment. In a statement to the Texas Tribune, Skop said she was joining the Texas MMRC because questions about maternal mortality data deserve “rigorous discourse.” “There are complex reasons for these statistics, including chronic illnesses, poverty, and difficulty obtaining prenatal care, and I have long been motivated to identify ways women’s care can be improved,” she said. “For over 30 years, I have advocated for both of my patients, a pregnant woman and her unborn child, and excellent medicine shouldn’t require I pit one against the other.”

Meanwhile, the American College of Obstetricians and Gynecologists criticized Skop’s appointment, asserting that members of any maternal mortality review committee should be “unbiased, free of conflicts of interest and focused on the appropriate standards of care.”

“The importance of the work done by MMRCs to inform how we respond to the maternal mortality crisis cannot be overstated,” the group said in a statement. “It is crucial that MMRC members be clinical experts whose work is informed by data, not ideology and bias.”