Abortion restrictions are affecting the care people receive for miscarriages, a new study suggests.
The same medications and procedures that induce abortion are used to treat miscarriage. The Supreme Court’s 2022 decision in Dobbs v. Jackson Women’s Health Organization, which ended constitutional protection for abortion, triggered bans in 14 states. Compared with states without abortion bans, states with bans were associated with a reduction in medication management for a miscarriage, researchers report May 18 in the Journal of the American Medical Association. In cases where medication management was pursued, states with bans were linked to less use of the most effective protocol.
“Miscarriage is the most common complication of pregnancy, and the finding from this analysis demonstrate how vulnerable the patients are to breaks in the system,” says obstetrician and gynecologist Courtney Schreiber at the University of Pennsylvania’s Perelman School of Medicine, who was not involved in the new research. People suffering pregnancy loss are “experiencing additional psychological and physical harm as a result of policies that restrict access to abortion care, even though those restrictions should not apply to this population.”
Around 15 to 20 percent of known pregnancies end in miscarriage, often due to genetic abnormalities or without an apparent cause. Early pregnancy loss affects approximately 1 million women in the United States each year. Miscarriage puts a person at risk of complications, including infection, and mental health conditions such as depression and posttraumatic stress disorder.
Bleeding, cramping or pain in early pregnancy could indicate a miscarriage, “and you want to reach out to your clinician right away,” says study coauthor Maria Rodriguez, an obstetrician and gynecologist at Oregon Health & Science University School of Medicine in Portland.
If a person is otherwise in good health, they have a choice in how to proceed. Some people want to give the body time to pass the pregnancy tissue, called expectant management. Others, upon learning the pregnancy has ended, want medication or a surgical procedure to finish the expulsion of tissue as quickly as possible, Rodriguez says. “We go by what patients prefer.”
In terms of medication management, the most effective protocol is to use both mifepristone —which blocks progesterone, a hormone that helps the pregnancy develop — and misoprostol, which induces contractions. Using both drugs results in complete expulsion of pregnancy tissue more often than misoprostol alone.
In January 2023, the U.S. Food and Drug Administration removed the in-person dispensing requirement for mifepristone and allowed the medication to be mailed and made available at pharmacies. But the agency kept other restrictions that can make acquiring and providing the drug challenging, even though mifepristone is safe and effective. Clinicians providing obstetric and gynecological care in states with abortion restrictions are less likely to offer mifepristone as part of miscarriage treatment, research has found.
The new study, which used data from a commercial insurance database, included almost 124,000 individuals aged 15 to 45 who had first trimester miscarriages. The research team analyzed miscarriage treatment before the Dobbs decision, from January 2018 to May 2022, and after the decision, from July 2022 to September 2024. Alabama, Arkansas, Georgia, Idaho, Kentucky, Louisiana, Mississippi, Missouri, North Dakota, Oklahoma, South Dakota, Tennessee, Texas and West Virginia, which ban abortion at six weeks or before that, had about 54,000 individuals who had miscarriages. The rest were in comparison states without abortion bans: Alaska, California, Colorado, Connecticut, Delaware, Illinois, Maine, Maryland, Michigan, Minnesota, Montana, New Jersey, New Mexico, New York, Oregon, Rhode Island and Washington.
There was a link between states with bans and a 2.8 percentage point rise in expectant management as well as a 2.2 percentage point drop in medication management, compared with states without bans. “There’s not an increase across the board in women requesting expectant management,” Rodriquez says. “It’s confined to those states where there is an abortion ban.” So a person wanting medication management in states with abortion bans may not be getting that option, she says. “That’s putting a person in a tough place.”
There was also a 13.8 percentage point increase in misoprostol-only protocols for those in states with bans who did receive medication, instead of following the most effective approach of using both medications.
“The findings from this study are important in that they document differences in clinical practice surrounding miscarriage care,” says obstetrician and gynecologist Daniel Grossman, director of Advancing New Standards in Reproductive Health at the University of California, San Francisco, who was not involved in the new research. “Taken together with anecdotal reports of patients facing barriers to evidence-based miscarriage care in states with abortion bans, this study highlights how these laws are having broad impact on pregnant people.”
The fact is, Rodriguez says, “you can’t just silo one aspect of pregnancy care” as all of that care is inextricably linked.
“Women’s health, in particular, is over-legislated,” she says. With laws written by people who are not physicians, midwives, nurses, or have any medical expertise, it’s “essentially practicing medicine without a license, and when that happens, that’s going to harm people.”
