The publication of this essay was supported by the Trans Journalists Association.

Every year, hundreds of people in the United States die from pregnancy-related complications. In most states, maternal mortality review committees work to understand why and prevent it from happening again. But in Texas, at least 80 percent of those deaths are preventable—yet the state's maternal mortality review committee has become a battleground for anti-abortion and anti-trans politics rather than a vehicle for saving lives.

A two-pronged assault on public perinatal health infrastructure is currently underway. The first prong is anti-abortion: Texas has stacked its maternal mortality review committee with advocates hostile to its public health mission while restricting the data the committee can access. The second is anti-trans: the state is passing laws that restrict who counts as a pregnant person, erasing transgender people from public health data entirely. Both prongs serve the same purpose: to obscure the harmful, and at times deadly, consequences of the state's policy choices.

Over the past several months, I have sought to understand how transgender people are erased from maternal mortality reporting and data collection in Texas. State health officials have not responded to requests for comment. Public records offer no insight into how the Texas Maternal Mortality and Morbidity Review Committee (MMMRC)  is navigating these questions—whether it considers gender identity at all, whether it is aware of the gaps in its data, or whether anyone within the Committee is raising these questions themselves. 

The work of the MMMRC has become deeply entangled in the state's increasingly repressive political landscape, raising questions about its ability to fulfill its mission—and the fate of pregnant and parenting Texans of all genders if it can't.

Understanding The Architecture of Trans+ Erasure in Texas

The Texas Maternal Mortality and Morbidity Review Committee does not publish statistics on pregnancy-related deaths for transgender decedents. Even federally, no large-scale data collection effort on perinatal and infant mortality and morbidity accounts for gender identity—either as an identity held by pregnant people or as a factor in perinatal health outcomes more broadly.

In Texas, this erasure operates at every level of the process. It starts with the statute. The law that creates the MMMRC defines pregnancy-related death as "the death of a woman while pregnant or within one year of delivery or end of pregnancy." The language reflects a legal architecture incompatible with gender variance.

From there, the identification method determines which deaths enter the system. The "standard method" for identifying maternal deaths relies solely on obstetric cause-of-death codes–a death with one of these codes is automatically counted. Texas adopted an "enhanced method" in 2012, using a two-step process: First, linking death records to fetal birth or fetal death certificates created within one year of the person's death; second, reviewing medical records for deaths where pregnancy is indicated on the death certificate. 

But what happens when our data sources–like birth certificates, death certificates, and medical records–lose their integrity to comply with anti-trans state laws?

In 2025, the Texas Legislature passed SB 1188, which requires electronic health records to reflect the "biological sex at birth" of all patients. That same year, the Texas Legislature also passed House Bill 229, which defines "female" as "an individual whose biological reproductive system is developed to produce ova" and "male" as "an individual whose biological reproductive system is developed to fertilize the ova of a female." This definition applies across all state government records. 

House Bill 229 closely aligns with the decision by the Texas Department of State Health Services to no longer permit Texans to update the sex listed on various legal documents–including birth certificates and driver's licenses–by court order. Proposed legislation would further entrench this: Senate Bills 1696 and 1953 would eliminate the possibility of altering biological sex on all government documents—birth certificates, death certificates, and identification cards—except for clerical errors. This means that even if the law defining pregnancy-related deaths can be read flexibly to include non-women's deaths, the records that feed into the state's data systems are not.

This erasure has defined the career of Verniss McFarland III (they/she), founder and executive director of The Mahogany Project, a Houston-based nonprofit that provides education and support services for queer and trans people navigating reproductive healthcare.

"The data is obscured. People aren't classifying trans people how we should be classified and haven't for as long as I've been in this work. I'm sure people have always been classifying [trans people] as their assigned gender at birth or what they could check off the easiest on a piece of paper. So [when it comes to pregnancy outcomes] I know trans people are either being misgendered actively or they're just being excluded."

But the gap between data and lived reality is not merely statistical. Andie McCoy-O'Neil (they/he), a transmasculine person currently pregnant in Texas, described the dissonance of navigating a system that categorizes them as an intruder rather than a patient in need of care:

"I understand that I am, in some ways, literally taking up [what are labeled] women's spaces. But I don't get to experience the kind of deep and intentional affirmation that many women receive as part of pregnancy and delivery, even though we know that the overall standard of care and support many women receive is still not where it needs to be."

Houston Birth Workers Respond to the Black Maternal Health Crisis

Panelists emphasized the need to decrease our dependency on carceral systems and solutions like the family policing system, which is also destroying the ability for Black people and Black birthgivers to live lives free of surveillance—which has been masked as a way to achieve "safety"—and violence.

by Aarohi Sheth

Typically, when these issues are discussed, they begin and end with that first sentence—reinforced by the false idea that to support trans people is to support cisgender women less, or that the support of transgender people comes at cisgender women's expense. That couldn't be further from the truth. As Texas communities grapple with the shuttering of rural maternity wards and high rates of maternal and infant mortality, it's clear that the absence of culturally responsive healthcare takes a toll on all of us, regardless of who is ultimately reflected in the state's calculus.

"I'm constantly looking for sign posts, anything to signal that I'm welcome and safe here," McCoy-O'Neil said, "[P]roviders set the tone; if they treat me like an outlier, it changes the entire culture of care for everyone like me. I care deeply about maternal health outcomes, and these things also have the potential to increase the stress on my body and of my delivery."

Verniss underscored what happens when this erasure goes unchecked—when trans people are left without the data, resources, or support they need:

"When trans people navigate pregnancy, abortion, or birth, the system sends them home with nothing—no resources, no follow-up, no education. And then we're left to figure it out on our own, often with providers who don't know our bodies and don't bother to learn. We're paying for healthcare and still having to be our own experts. That's not care. That's abandonment."

Untangling this web of ambiguity—first to understand what we do know, then to chart a path toward knowing more and doing better by pregnant Texans—is no simple feat. It would require Texas to concede that queer and trans people deserve dignity, which is contrary to the core ideological tenets of the dominant political forces in the state.

The Role of Anti-Abortion Extremism in the Data Gap

The erasure of trans people from maternal health data is not happening in isolation. At the same time, researchers have documented increased maternal and infant mortality in U.S. states where abortion is either heavily restricted or totally banned, including in Texas. Data analysis by ProPublica revealed that the rate of sepsis for women hospitalized during second-trimester pregnancy loss spiked by more than 50 percent since Texas' total abortion ban went into effect in 2021. This revelation came after ProPublica reported on two separate maternal deaths resulting from the denial of abortion care: Nevaeh Crain and Josseli Barnica. Yet, Texas's state government has been actively working to ensure that the sweeping policy change necessary to prevent maternal death never happens.

In September 2022, the Texas Department of State Health Services delayed the publication of the MMMRC's biennial report, releasing it only after significant public pressure, including the threat of a lawsuit from the Society for Maternal-Fetal Medicine.  Nakeenya Wilson, who served as the MMMRC's community advocate—a role created to bring grassroots, lived experience into the review process—had been a leading voice in the public pressure campaign demanding its release. 

In 2023, the Texas Legislature passed HB 852, which functionally eliminated Wilson's role. The law required that two new community seats be filled by individuals with "experience in a relevant health care field, including a field involving the analysis of health care data". The new members appointed to these roles underscored the shift: the rural position went to Dr. Ingrid Skop, a San Antonio OB/GYN who is vice president and medical director at the Charlotte Lozier Institute, the research arm of the anti-abortion advocacy group Susan B. Anthony Pro-Life America. The appointment of an anti-abortion advocate to a committee tasked with saving pregnant people's lives signals a fundamental shift in the committee's purpose: it is no longer primarily a public health body, but an authoritarian one.

Adding another layer of complexity, the legislation that created the MMMRC contains a restriction that has proven dangerous in the post-Dobbs landscape: the MMMRC is prohibited from reviewing abortion-related deaths. To add insult to injury, the Committee announced in December 2024 that it would skip reviewing pregnancy-related deaths from 2022 and 2023—the first two years since Texas banned nearly all abortions. This month, advocates shared that the MMMRC will again delay its report ahead of the 2026 midterms.

Several years of political interference, composition changes, and data gaps have eroded the Committee's credibility and left many Texans hungry for change. Though justified, those concerns have had to take a backseat while the Committee undergoes Sunset Review—a routine process that will determine whether Texas renews the Committee or retires it altogether. 

Jasmine Roussell (she/her), a member of the Maternal Health Equity Collaborative (MHEC) and the Houston Birth Collaborative, is among the reproductive justice advocates currently witnessing the Committee's erosion. In her opinion, a sunset of the MMMRC is unlikely, and the MMMRC's reform is what is most pressing for advocates.

"Realistically, we don't need a sunset review; we need a review of its effectiveness", said Roussell, "We need reform, but [this political moment and] the nature of sunset review means there isn't even space to interject to say so."

For all the ways that the MMMRC continues to fail Texans, this Committee remains the only mechanism available to monitor pregnancy-related deaths at scale. Eliminating it—in a state as large, populous, and politically fractured as Texas—would be like sending ships home through treacherous waters without a lighthouse. Wreckage is not a possibility. It is a guarantee.

But even if the Committee survives, Jasmine cautioned against placing too much faith in institutions that have repeatedly proven themselves unworthy of it:

"We will always have to think about and monitor perinatal and infant health outcomes, just as our ancestors always have. The measure of whether we're doing right by pregnant people is not going to be that we can stop monitoring and researching [this issue]. We're seeing that [public health] institutions are not stable, so we have to remember that we are experts of our own care and we will be the reason why our communities can move past these systems that harm us. And all of this is interconnected. We need leadership, services, and resources designed to meet everybody's, including queer and trans folks' needs, with intentionality and full investment."

While many of the questions at the heart of this investigation have gone unanswered, one thing is clearer than ever: the liberation of transgender people and the ability of all Texans to expand their families on their own terms are inextricably linked. The state's maternal mortality review process was designed to answer a straightforward question—how institutions, communities, and individuals can collaborate to prevent pregnancy-related deaths—but in Texas, that mission has been overtaken by another: how to do just enough to avoid accountability while pursuing policies that actively harm pregnant people. Anti-abortion and anti-trans legislation are not separate assaults; they are two fronts of the same war, waged by a state that does not care who lives or dies, only that its vision of personhood goes unchallenged.

Ja'Loni Owens is a Black Muslim feminist lawyer, writer and full-spectrum birth worker based in the Greater Atlanta Metro area. Ja'Loni’s legal and policy background is primarily in eliminating patriarchal violence, family policing abolition, international human rights, and bodily autonomy.