June 30, 2022 12:25 PM EDT

The United States is a surprisingly dangerous place to be pregnant. The U.S. maternal mortality rate—nearly 24 deaths per 100,000 live births, as of 2020—is far higher than in comparable developed nations, and research shows it has gotten worse in recent years, not better. Maternal death rates are particularly high among Black women, at 55 deaths per 100,000 births compared to 19 deaths per 100,000 births among white women.

Experts fear these numbers will only get worse now that Roe v. Wade has been overturned, eliminating the constitutional right to abortion and triggering an array of state-level bans that place limits on reproductive health care.

“Even a low-risk pregnancy and birth has higher risks to a mother than a termination,” says Michelle Drew, a family nurse practitioner and midwife who is the executive director of the Ubuntu Black Family Wellness Collective, a Delaware-based nonprofit. When you consider “forced gestation and forced birth, with a pregnancy that may not be well-timed or desired or that may be high-risk,” Drew says, the stakes only grow higher.

One 2021 study estimated that, if the U.S. banned abortion outright, the overall number of pregnancy-related deaths would rise by more than 20% in subsequent years, with a 33% increase among Black women. That estimate doesn’t apply exactly to the present day, since abortion is expected to remain available in about half of U.S. states even without Roe. But research clearly suggests that when abortion access increases, maternal deaths go down—and vice versa.

That said, in the U.S., the impacts differ significantly between demographics. After abortion was legalized in the U.S., culminating with the Supreme Court’s original Roe v. Wade decision in 1973, maternal mortality among women of color in the U.S. dropped by more than 30%, while there was a limited effect among white women, according to a study posted as a preprint last year. Almost all of the decline was due to fewer abortion-related deaths among women of color, says co-author Lauren Hoehn-Velasco, an assistant professor of economics at Georgia State University—suggesting that, before abortion was broadly legal in the U.S., many women of color resorted to unsafe methods for ending an unwanted pregnancy.

“I don’t know that we can say exactly how things will look going forward,” Hoehn-Velasco says, noting that advances like abortion pills can now help provide safe access even in states where abortion is restricted.

Even with advances like medication abortion available, there is still a link between abortion access and maternal mortality in the U.S. As of 2017, states with restrictive abortion policies, such as gestational age limitations or pre-procedure waiting periods, had an average maternal mortality rate of 28.5 deaths per 100,000 births, compared to an average rate of 15.7 in states that protected abortion access, according to a 2021 study published in the journal Contraception. A separate study from the same year, published in the American Journal of Public Health, found a similar trend: states with significant restrictions on abortion care recorded a 7% increase in total maternal mortality from 2015 to 2018.

There are a number of possible reasons for this dynamic. States with strict abortion policies tend to also be those that have not expanded Medicaid and have lower numbers of practicing medical professionals, both of which can make it harder for people to access good health care. “Incidentally, they also happen to be states that have large populations of families living in poverty and especially large populations who are people of color, who are earning low wages,” Drew says.

Socioeconomic factors like these are closely linked to risk factors, like having underlying health conditions and inadequate access to prenatal care, that increase the chances of pregnancy complications. A 2020 report from health insurer Blue Cross Blue Shield found that rates of pregnancy and birth complications among commercially insured women in the U.S. rose from 2014 to 2018, in part because more people entered pregnancy with pre-existing health problems. The report also found that a third of women had fewer than the 10 recommended prenatal medical appointments during pregnancy—and of those who didn’t, nearly a quarter had childbirth complications.

Dr. Mark Hoofnagle, a trauma surgeon at the Washington University School of Medicine in St. Louis and a co-author on the Contraception study, notes that abortion clinics often provide many forms of reproductive health care, so policies that make it harder for these facilities to survive can have trickle-down effects. “Planned Parenthood does way more than just abortions,” Hoofnagle says. “When you attack the clinics in general, you’re aggravating an existing inequity.”

The vast majority of people who undergo a pregnancy do not experience life-threatening issues; there were 861 maternal deaths in the U.S. in 2020 and about 3.6 million births. But particularly for people who enter pregnancy with existing health problems, “carrying a pregnancy to term is so much riskier than having an abortion in this country,” says Dovile Vilda, a research assistant professor who studies maternal and child health at the Tulane University School of Public Health and Tropical Medicine and a co-author of the American Journal of Public Health study. Without Roe, and with many people unable to travel out of state to get an abortion, more individuals “will be forced to carry unwanted and high-risk pregnancies to term even if their health and lives are in danger,” she says.

The risks of that situation aren’t hypothetical. For a 2015 study, researchers tracked a group of about 850 women who sought abortions at U.S. facilities. Some were turned away because they were past gestational age limits in their states, which ranged from as few as 10 weeks to more than 20 weeks of pregnancy. About 6% of the individuals who were denied abortions and gave birth went on to report a potentially life-threatening complication, such as hemorrhaging or eclampsia, compared to about 1% of people who got an abortion near their state’s gestational age limit and about 0.4% of those who got a first-trimester abortion. One woman died after being turned away by an abortion clinic and giving birth.

At this point, Vilda says, the research is clear: making abortions harder to get means more women and babies will get sick and die. “We have enough data and we have enough research and we have enough evidence,” she says. “What we truly need now is political will.”

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Write to Jamie Ducharme at jamie.ducharme@time.com.

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