Abortion restrictions in the US have made it more difficult to access care for miscarriages, a new study stays.

The new research found that since the June 2022 Dobbs v Jackson Women’s Health Organization decision overturning Roe v Wade, pregnancy care has fractured along state lines; it’s getting increasingly harder to access healthcare for miscarriages in US states with abortion restrictions.

In states where abortion bans went into effect following Dobbs, miscarriage management is shifting away from medications, especially mifepristone, and toward a wait-and-see approach, restricting the options for patients experiencing miscarriages and falling beneath standards of care in the US.

“We wanted to understand how, when you restrict access to abortion, that might affect people who are having a pregnancy loss or an early miscarriage,” said Maria Rodriguez, lead author of the study, professor of obstetrics and gynecology, and director for the Center for Women’s Health at Oregon Health & Science University. “What we found was that people had fewer choices to the type of care they got, and they were receiving lower-quality care as well.”

The study, published by the Journal of the American Medical Association on 18 May, looked at a total of 123,598 people with private insurance. Some 54,181 of the patients lived in states with restrictions on abortion after six weeks that were triggered by the Dobbs decision, while 69,417 lived in comparison states.

States with trigger bans saw a 2.8 percentage point increase in expectant management – meaning more patients were sent home to wait and see what would happen with their miscarriages – and a 2.2 percentage point decrease in medication management – meaning fewer people were prescribed standard-of-care medications for managing miscarriages. Patients who were prescribed medication, but lived in ban states saw a 13.8 percentage point increase in misoprostol-only treatment, which is safe but is not the standard of care in the US and may take longer, resulting in more discomfort.

​​Spontaneous abortion – the medical term for miscarriage – is “the most common complication of early pregnancy and requires the same treatment options as induced abortion”, the authors write.

“We use the same medications, it’s the same procedure,” said Rodriguez.

The study is probably an under-estimate, because it only looked at people with private insurance, Rodriguez noted. “This is among privately insured people who are generally wealthier and have a lot more resources than people who don’t have health insurance or are on Medicaid, so the fact that we’re seeing this big of a difference in this population means that the population at the highest risk for maternal mortality and severe maternal morbidity – people on Medicaid – it’s going to be worse.”

More than a million people experience pregnancy loss each year in the US, and at least 400,000 miscarriages are happening in states with abortion bans, according to a September 2024 study in Health Affairs.

“We need to have medical capacity in place to support people, because mismanaged miscarriage care can be extremely dangerous,” said Jenna Nobles, lead author of the 2024 study and a professor of demography at University of California, Berkeley.

About 25% to 30% of recognized pregnancies – when a test turns positive or pregnancy is confirmed in other ways – end in miscarriage, she said. “It’s enormous. It’s absolutely enormous.” And, she added, “miscarriage is something that affects all of us” – not just patients but also partners, families and friends.

Rodriguez has been an obstetrician-gynecologist for 20 years. “I’ve had a miscarriage myself. I’ve taken care of, at this point, thousands of women that have had them, and for each person, it’s really different,” she said. “But what people want, when they’re in that kind of pain, is to be able to pick how they’re taken care of.”

Miscarriage management usually involves three choices that are all medically appropriate, Rodriguez said. Expectant management involves waiting to see if the pregnancy loss passes on its own. There are usually two medications taken in the US, mifepristone followed by misoprostol, a combination recommended by the American College of Obstetricians and Gynecologists (ACOG). And a procedure can clear the pregnancy quickly.

Not treating miscarriages according to medical standards can lead to life-threatening infections, decrease fertility and cause deep pain and trauma, Nobles said. And “anything that constrains standard forms of medical care has spillover effects”, she added.

Making it harder for miscarrying patients to access mifepristone, for instance, increases the risk of complications, Nobles said. Yet “because there are increasing penalties or sanctions on providers, on insurers, on pharmacists, people may be less likely to prescribe mifepristone, people may be less likely to cover it, people may be less likely to fill prescriptions. And as a result, a smaller fraction of people who need miscarriage care are getting the ACOG-recommended miscarriage care.”

Restrictions on reproductive healthcare have made it harder for some patients to access fertility treatment and it’s made it significantly more difficult for obstetrician-gynecologists to practice – leading to healthcare deserts.

Even though one in four American women have an abortion by the age of 45 – a rate approaching cesarean births – it’s still silenced and stigmatized, Rodriguez said.

Many people don’t realize that miscarriage management is the same kind of care as abortion, and that banning abortion makes it harder to treat miscarriages, Rodriguez said. “We have to get away from thinking about pregnancy care – it’s not abortion care, it’s not miscarriage care, it’s not ectopic care or live birth care, it’s pregnancy care, and it’s very much a continuum, and there’s a lot more gray and nuance in this than people realize.”