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2. New lawsuit challenges Georgia abortion ban  

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3. County tells churches they can't host homeschooled students

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Situational awareness: The CEO of Bryan County-based Daniel Defense will be on a panel testifying before the House Oversight Committee this morning about gun manufacturers' role in the country's gun violence. 

Daniel Defense produced the weapon used by the Uvalde shooter, and its marketing techniques have come under scrutiny.

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A daily look at the most significant and interesting stories affecting Atlanta. Written by Kristal Dixon and Thomas Wheatley.

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National

The worst drug shortage in a decade is disrupting gender-affirming care, as scarce supplies of injectable estrogen prevent some transgender women from obtaining hormone therapy. 

Why it matters: Shortages of cancer drugs and other life-saving medications have already forced doctors to develop workarounds. A lack of access to estrogen products can affect trans patients in different ways: putting some through early onset menopause, reversing certain physical changes from their transition or causing them to experience anxiety and depression. 

"If somebody is suddenly unable to take their hormones, then they certainly will be at risk of basically going through acute menopause: hot flashes, mood swings, low energy, low mood, migraines," said Maddie Deutsch, president of the U.S. Professional Association for Transgender Health. "It can precipitate serious mental health symptoms."

Patients who have had their genitalia surgically altered would be at risk of developing osteoporosis without long-term access to estrogen, Deutsch said. There's also the risk of testosterone levels going back up, which can cause masculinized features to develop, she added.

The big picture: Because injectable estrogen is seldom used outside of trans health care, "manufacturers have little incentive to produce this medicine," which leads to shortages, according to the University of California, San Francisco Gender-Affirming Health Program.

The American Society of Health-System Pharmacists (ASHP), which tracks current drug shortages, says that there is "insufficient supply" of estradiol cypionate, a type of injectable estrogen. 

Pfizer — the sole supplier — said that the disruption has been caused by a change in its manufacturing process. The product is on backorder at both CVS and Walgreens, and a Pfizer spokesperson said, "[W]e are currently awaiting regulatory approvals" to accelerate production.

An ASHP spokesperson said that estradiol valerate, an alternate form of injectable estrogen made by several companies, is not in shortage, "though there may be some intermittent, regional supply disruptions."

What we know: The Food and Drug Administration does not have either form of injectable estrogen on its drug shortage database.

Under federal law, manufacturers are required to notify to the FDA when there are changes in drug productions that could affect their availability. However, suppliers often don't.

What they're saying: "I cannot tell you how frustrating it has been," Heather Sheppard, a clinician for FOLX Health, a virtual health provider that caters to the LGBTQ community, said of the shortage.

Sheppard said that she has warned trans patients who chose to take injectable estrogen that there will "inevitably" be at least two times a year where they won't be able to get the medication: "It's part of my standard counseling."

Patients might need to switch pharmacies to one that has injectable estrogen available, but in some cases, a pharmacist could refuse to fill their prescription, Sheppard said.

Trans people may struggle to access health care, and those that do "have to call every pharmacy in town and just hope that they'll actually have the medication and fill it and not give them a hard time," she added.

Between the lines: It's possible for patients who cannot access injectable estrogen to switch to other alternatives — such as a tablet or patches — to get their hormones, but that comes with its own difficulties. For one thing, injections tend to have higher levels of estrogen, so some health providers might recommend them because they could decrease testosterone levels.

Prior medical history, cost, insurance coverage and how much change a patient desires, also are factors, said Jenny Wares, medical director at Plume.

In general, it's a trial-and-error practice, and a patient will need to consult with their physician on what alternative works best for them, Wares added.

Zoom in: Gender-affirming care providers told Axios that injectable estrogen is one of the most commonly prescribed hormone products among trans women.

Plume, which claims to be the world's largest virtual gender-affirming care provider, said that tablets are the most used, immediately followed by injections. Sheppard told Axios her personal experience led to the same conclusion.

Don't forget: Injectable estrogen is sometimes used in hormone replacement therapy to treat menopause, but the required doses are much smaller.

There's difficulty controlling the dosage levels, so patients could be "stuck with a potentially high level for long period of time," said Stephanie Faubion, medical director of the Menopause Society and director of the Mayo Clinic Center for Women's Health. 

The Menopause Society recommends the use of tablets, patches, sprays and gels.

What we're watching: Often, gender-affirming care providers will look to compounding pharmacies — where a licensed physician can prepare a drug when it's not available — to access injectable estrogen. However, compounded medications aren't always covered by insurance.

Drug shortages squeeze trans patients' access to hormone therapy

Transgender women struggle to access injectable estrogen as part of their gender-affirming hormone therapy.

Illustration of a hand reaching for a syringe.

Transgender

The <a class="gtmContentClick" data-vars-link-text="worst drug shortage" data-vars-click-url="https://www.axios.com/2023/05/22/americas-drug-shortages-reach-new-heights" data-vars-content-id="0dad7443-683b-4f68-a89f-728f04de3f6e" data-vars-headline="Drug shortages squeeze trans patients&#x27; access to hormone therapy" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://www.axios.com/2023/05/22/americas-drug-shortages-reach-new-heights" target="_self">worst drug shortage</a> in a decade is disrupting gender-affirming care, as scarce supplies of injectable estrogen prevent some transgender women from obtaining <a class="gtmContentClick" data-vars-link-text="hormone therapy" data-vars-click-url="https://www.axios.com/2023/03/03/gender-affirming-care-trans-youth-us" data-vars-content-id="0dad7443-683b-4f68-a89f-728f04de3f6e" data-vars-headline="Drug shortages squeeze trans patients&#x27; access to hormone therapy" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://www.axios.com/2023/03/03/gender-affirming-care-trans-youth-us" target="_self">hormone therapy</a>. Why it matters: Shortages of cancer drugs and other life-saving medications have already forced doctors to develop workarounds. A lack of access to estrogen products can affect trans patients in different ways: putting some through early onset menopause, reversing certain physical changes from their transition or causing them to experience anxiety and depression.

The U.S. faces a range of health care flashpoints — unaffordable drugs, opioids, vaping — as we debate whether to adopt universal care. For now, the Affordable Care Act is the law of the land, but Republicans want to issue it a final death blow.

Health

Portland

Axios Portland

Data: Institute for Health Metrics and Evaluation; Map: Tory Lysik/Axios Visuals

Maternal mortality rates nationwide have risen across racial and ethnic groups over the past 20 years, according to a recent study co-authored by researchers at the University of Washington.

By the numbers: The overall number of deaths per 100,000 live births in Oregon increased from 6.5 to 14 between 1999–2019.

Why it matters: Researchers say most maternal deaths are preventable, yet the U.S. has one of the highest rates of such deaths among high-income countries.

The big picture: Nationwide maternal mortality rates more than doubled between 1999 and 2019, with states in the Midwest, Great Plains and South accounting for significant increases.

Overall, there were an estimated 1,210 U.S. maternal deaths in 2019, compared to 505 in 1999.

Details: The study, published earlier this month in the Journal of the American Medical Association, provides the first state-by-state breakdowns of maternal mortality rates by ethnic group.

Zoom in: In Oregon, the maternal death rate among American Indians and Alaska Natives spiked by 168% from 1999 to 2019, rising from 9.2 deaths per 100,000 live births to 24.7 deaths per 100,000 live births.

Black women in the state saw an estimated 58% increase in maternal deaths over the same period, with the death rate rising from 17.4 per 100,000 to 27.6 per 100,000.

The intrigue: In 2019, Oregon was one of eight states where maternal death rates across all racial groups was lower than previous years, which suggested "prevention efforts have had some success in these locations," according to the study.

Meanwhile, the Oregon Maternal Mortality and Morbidity Review Committee, which includes health care professionals appointed by the governor, found that 53% of pregnancy-related deaths from 2018 to 2020 were preventable after reviewing case information.

In its 2023 report, the committee stressed the importance of including more doulas in health care settings and ensuring pregnant people with histories of substance use disorder receive proper medical treatment.

The committee found that 41% of pregnancy-related deaths included substance use disorder as an underlying cause of death.

Maternal deaths in Oregon increase

Researchers say most maternal deaths are preventable.

Maternal deaths

A visualization of a map of the United States with purple shades to depict the rate of maternal deaths.

Maternal mortality rates nationwide have risen across racial and ethnic groups over the past 20 years, according to <a class="gtmContentClick" data-vars-link-text="a recent study" data-vars-click-url="https://jamanetwork.com/journals/jama/article-abstract/2806661" data-vars-content-id="16920fd4-1b47-476d-a5f5-036850472b4c" data-vars-headline="Maternal deaths in Oregon increase" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://jamanetwork.com/journals/jama/article-abstract/2806661" target="_blank">a recent study</a> co-authored by researchers at the University of Washington.By the numbers: The overall number of deaths per 100,000 live births in Oregon increased from 6.5 to 14 between 1999–2019.

A total of 22 states have moved to ban or restrict abortion following the Supreme Court's decision to overturn Roe v. Wade and end all federal protections for abortion.

Why it matters: At least 24 U.S. states in total are expected to ban abortions or heavily restrict access to them, according to the Guttmacher Institute, an abortion-rights organization.

As more bans go into effect, people seeking abortions have been forced to either travel hundreds of miles to another state that allows abortions or order abortion pills that are prescribed online and delivered through the mail.

However, state lawmakers have already cracked down on abortion medications and may seek to prosecute people who cross state lines to get an abortion.

How it works: The Supreme Court's 1973 decision in Roe established the constitutional right to an abortion within the due process clause of the 14th Amendment.

The court's ruling in Dobbs v. Jackson, a case challenging a Mississippi law on the grounds that it violated Roe and other precedents, overturned Roe and granted states the legal authority to ban the procedure at any point in pregnancy — including at fertilization.

At least 22 states have banned or restricted abortion, as of Aug. 23: Alabama, Arizona, Arkansas, Florida, Georgia, Idaho, Indiana, Kentucky, Louisiana, Mississippi, Missouri, Nebraska, North Carolina, North Dakota, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, West Virginia and Wisconsin.

Near-total bans have been enacted in Alabama, Arkansas, Idaho, Indiana, Kentucky, Louisiana, Mississippi, Missouri, North Dakota, Oklahoma, South Dakota, Tennessee, Texas and West Virginia.

The unclear status of Wisconsin's pre-Roe ban has forced clinics to stop providing abortions.

Indiana's ban is expected to take effect in August.

A six-week ban is in effect in Georgia. States like Idaho, Kentucky, Tennessee and Texas also have six-week bans, but their near-total bans take precedence.

12-week bans are in place in Nebraska and North Carolina.

Arizona and Florida have 15-week bans in place. The latter recently enacted a six-week ban, but that law is not yet enforceable.

Abortion bans are currently blocked in seven states: Arizona, North Dakota, Ohio, Utah and Wyoming.

In Arizona, an appeals court blocked the enforcement of the state's pre-Roe ban. 

Iowa's six-week ban, which took effect in July 2023, was temporarily blocked just days after it took effect.

North Dakota's trigger ban was set to take effect following the Supreme Court's ruling. However, a judge temporarily blocked it on Aug. 25, 2022. 

In Ohio, a six-week abortion ban was allowed to take effect after Roe's fall, but it is indefinitely blocked.

The South Carolina state Supreme Court reversed course in August after striking down a six-week abortion ban in January.

Utah's trigger law took effect shortly after the Supreme Court released its ruling overturning Roe, but it has since been temporarily blocked.

A state judge temporarily blocked a Utah law that effectively bans abortion clinics in the state, arguing that it was discriminatory. 

While Wyoming's trigger law took effect a month after Dobbs, just hours after it became active, a state judge temporarily blocked the law.

Go deeper: Where abortion access is guaranteed without Roe v. Wade

Where abortion has been banned now that Roe v. Wade is overturned

At least 24 U.S. states in total are expected to ban abortions or heavily restrict access to them.

Abortion

Axios Explains: Abortion

A total of 22 states have moved to ban or restrict abortion following the <a class="gtmContentClick" data-vars-link-text="Supreme Court&#x27;s decision" data-vars-click-url="https://www.axios.com/2022/06/24/roe-wade-decision-abortion" data-vars-content-id="6294642c-0868-4c4e-b4bd-b46816c7ac83" data-vars-headline="Where abortion has been banned now that Roe v. Wade is overturned" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://www.axios.com/2022/06/24/roe-wade-decision-abortion" target="_self">Supreme Court&#x27;s decision</a> to overturn Roe v. Wade and end all federal protections for abortion.Why it matters: At least 24 U.S. states in total are expected to ban abortions or heavily restrict access to them, according to the <a class="gtmContentClick" data-vars-link-text="Guttmacher Institute" data-vars-click-url="https://www.guttmacher.org/2023/01/six-months-post-roe-24-us-states-have-banned-abortion-or-are-likely-do-so-roundup" data-vars-content-id="6294642c-0868-4c4e-b4bd-b46816c7ac83" data-vars-headline="Where abortion has been banned now that Roe v. Wade is overturned" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://www.guttmacher.org/2023/01/six-months-post-roe-24-us-states-have-banned-abortion-or-are-likely-do-so-roundup" target="_blank">Guttmacher Institute</a>, an abortion-rights organization.

Dallas

Data: Institute for Health Metrics and Evaluation; Map: Tory Lysik /Axios Visuals

Maternal mortality rates in Texas more than doubled between 1999 and 2019, per a new study.

Why it matters: The study — published in JAMA — provides the first state-level breakdowns by ethnic group, Axios' Oriana González reports.

The big picture: Nationally, maternal deaths more than doubled from 505 in 1999 to 1,210 in 2019.

States in the Midwest, the Great Plains and the South had significant increases during that time.

Zoom in: In Texas, the overall number of maternal deaths per 100,000 live births increased from around 10 in 1999 to around 22 in 2019, the study shows.

The state had one of the highest increases in deaths among Black individuals during that time period, the study shows.

Between the lines: The Texas Legislature this year extended Medicaid coverage to mothers for one year after childbirth, a recommendation of the state's Maternal Mortality and Morbidity Review Committee.

Lawmakers didn't pass several other bills addressing maternal mortality, however, including legislation that would have expanded medical education coursework in cultural competence and implicit bias.

Context: Maternal mortality is defined as a death that takes place during birth or up to a year later.

Common causes of maternal death include hemorrhages, blood clots, high blood pressure, and cardiac and coronary conditions, as well as mental health conditions like death by suicide and overdose related to substance use disorder.

The JAMA study looked at pregnant individuals aged 10 to 54.

Meanwhile: American Indians and Alaska Natives had the biggest increases in maternal mortality nationally, especially in states in the middle of the country where such inequities had not been previously highlighted, the researchers wrote.

"Often, states in the South are called out as having the worst maternal mortality rates in the nation, whereas California and Massachusetts have the best. But that doesn't tell the whole story," said Allison Bryant, one of the study's co-authors and a senior medical director at the Mass General Brigham system.

What's next: The Texas Maternal Mortality and Morbidity Review Committee is still examining pregnancy-related deaths during the COVID pandemic and how maternal health varies among different demographics in the state.

Go deeper: Maternal deaths widespread beyond the South

Maternal mortality rates rise in Texas

States in the Midwest, Great Plains and South had significant increases.

Maternal mortality rates in Texas more than doubled between 1999 and 2019, per a <a class="gtmContentClick" data-vars-link-text="new study" data-vars-click-url="https://jamanetwork.com/journals/jama/article-abstract/2806661" data-vars-content-id="f05634e5-445a-4b8f-ab13-d6db8364a2ce" data-vars-headline="Maternal mortality rates rise in Texas" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://jamanetwork.com/journals/jama/article-abstract/2806661" target="_blank">new study</a>.Why it matters: The study — published in JAMA — provides the first state-level breakdowns by ethnic group, Axios&#x27; Oriana González reports.

News

Des Moines

Axios Des Moines

Data: Institute for Health Metrics and Evaluation; Map: Tory Lysik/Axios

Maternal mortality rates in Iowa increased between 1999 and 2019, according to a JAMA study providing the first state-level breakdowns by ethnic group.

By the numbers: The overall number of deaths per 100,000 live births in Iowa increased from 10 to nearly 22 during the 20-year study period.

Details: Maternal mortality is defined as a death that takes place during birth or up to a year later.

The study looked at pregnant individuals ages 10 to 54.

Common causes of maternal death include mental health-related conditions and cardiac ailments.

Zoom in: The rate among Iowa's American Indian and Alaska Native populations rose from 26.5 to 139; from about 5.1 to 8.9 among Asian people, and 8.3 to 17.6 among white people, researchers found.

The rates among Black people decreased slightly from 26 to about 24.3, but it had spiked to as high as 63.2 during some years of the study.

State of play: Labor and delivery units have shuttered in multiple rural counties across the state in recent years.

Expectant mothers in those areas are less likely to access prenatal care, according to a study by the University of Iowa.

The big picture: Maternal mortality rates across the U.S. more than doubled between 1999 and 2019, with states in the Midwest, Great Plains and South accounting for significant increases.

Overall, there were an estimated 1,210 total U.S. maternal deaths in 2019, up dramatically from 505 in 1999.

Driving the news: American Indian and Alaska Native populations had the biggest increases, particularly in states in the middle of the country where such inequities "had not been previously highlighted," researchers wrote.

"Often, states in the South are called out as having the worst maternal mortality rates in the nation, whereas California and Massachusetts have the best," said Allison Bryant, co-first study author. "But that doesn't tell the whole story."

Iowa's maternal death rate rises as birthing units close

Labor and delivery units have shuttered in multiple rural counties.

Maternal mortality rates in Iowa increased between 1999 and 2019, according to a <a class="gtmContentClick" data-vars-link-text="JAMA study" data-vars-click-url="https://link.axios.com/click/32042682.18/aHR0cHM6Ly93d3cuYXhpb3MuY29tL2JyaWRnZT91cmw9aHR0cHM6Ly9qYW1hbmV0d29yay5jb20vam91cm5hbHMvamFtYS9hcnRpY2xlLWFic3RyYWN0LzI4MDY2NjEmcz0xMjQ0MDgmbj04MTZkYWJiMyZ0PTkxOGU3ZjRmNzc2ZDAzMzExZmRmMjRlN2M3ZDcyNzUxZjlhYTk2M2MmdXRtX3NvdXJjZT1uZXdzbGV0dGVyJnV0bV9tZWRpdW09ZW1haWwmdXRtX2NhbXBhaWduPXNlbmR0b19sb2NhbG5ld3NsZXR0ZXJ0ZXN0JnN0cmVhbT10b3A/6000782188cdd8159c5b680eB3af2a09c" data-vars-content-id="f50e6881-4fdb-4c32-b7d7-c33349bd25e8" data-vars-headline="Iowa&#x27;s maternal death rate rises as birthing units close" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://link.axios.com/click/32042682.18/aHR0cHM6Ly93d3cuYXhpb3MuY29tL2JyaWRnZT91cmw9aHR0cHM6Ly9qYW1hbmV0d29yay5jb20vam91cm5hbHMvamFtYS9hcnRpY2xlLWFic3RyYWN0LzI4MDY2NjEmcz0xMjQ0MDgmbj04MTZkYWJiMyZ0PTkxOGU3ZjRmNzc2ZDAzMzExZmRmMjRlN2M3ZDcyNzUxZjlhYTk2M2MmdXRtX3NvdXJjZT1uZXdzbGV0dGVyJnV0bV9tZWRpdW09ZW1haWwmdXRtX2NhbXBhaWduPXNlbmR0b19sb2NhbG5ld3NsZXR0ZXJ0ZXN0JnN0cmVhbT10b3A/6000782188cdd8159c5b680eB3af2a09c" target="_blank">JAMA study</a> providing the first state-level breakdowns by ethnic group.By the numbers: The overall number of deaths per 100,000 live births in Iowa increased from 10 to nearly 22 during the 20-year study period.

Axios Des Moines, anchored by Jason Clayworth and Linh Ta, is here to help readers get smarter, faster on the most consequential news and developments unfolding in their own backyard.

Oriana González

Stories

Where abortion has been banned now that Roe v. Wade is overturned

Maternal deaths in Oregon increase

Iowa's maternal death rate rises as birthing units close

Maternal mortality rates rise in Texas

Drug shortages squeeze trans patients' access to hormone therapy

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