Trigger Abortion Bans Linked to Delayed, Less Effective Miscarriage Care

State-level abortion bans enacted after Roe v. Wade was overturned were associated with a shift in management of spontaneous abortion away from evidence-based care, a retrospective cross-sectional study found.

A difference-in-differences analysis of spontaneous abortion management found that bans were linked with a 2.8 percentage point increase in expectant management (95% CI 1.0-4.6) and a 2.2 percentage point decrease in medication management (95% CI -3.5 to -0.9) compared with the time before the bans in adjusted models; surgical management did not change significantly, reported Maria Rodriguez, MD, MPH, of Oregon Health & Science University in Portland, and colleagues.

For those who got medication, trigger bans were associated with a 13.8 percentage point increase in less-effective misoprostol-only regimens relative to the evidence-based mifepristone-misoprostol combination (95% CI 9.0-18.6). Use of the mifepristone-misoprostol regimen nearly doubled in comparison states from 15.9% to 31.5% and barely moved in ban states (1.9% to 3.1%), the authors wrote in JAMA.

“To date, these findings provide the first large-scale, national claims-based evidence that abortion restrictions have altered the clinical management of spontaneous abortion in the United States,” the authors wrote. They suggested that the shift in management may be affected by legal ambiguity, workforce changes post-Roe, and barriers to getting mifepristone.

Spontaneous abortion — usually referred to as miscarriage — is the most common complication of early pregnancy and often involves similar clinical care as induced abortion. This overlap has led to an unintended consequence of abortion restrictions where patients experiencing pregnancy loss may face delayed or denied treatment. More spontaneous abortion diagnoses happened in emergency departments in the post-policy period (going from 21% to 26.4% in ban states and 14.8% to 18.7% in comparators), which Rodriguez said suggests that access to care was affected.

“Abortion bans resulted in not only delays in obtaining care for miscarriage, but lower quality miscarriage care,” Rodriguez told MedPage Today.

“We cannot silo abortion care from pregnancy care,” Rodriguez said. “It is a continuum, and legislating access to one type of care during pregnancy impacts miscarriage management and may impact other pregnancy outcomes.”

The authors concluded that shifts in management “have direct clinical implications for the hundreds of thousands of individuals experiencing miscarriage annually in states with abortion restrictions and for the ongoing maternal mortality crisis in the United States.”

Daniel Grossman, MD, of the Advancing New Standards in Reproductive Health research group at the University of California San Francisco, who was not involved in the research, told MedPage Today that the increased use of misoprostol-only regimens for miscarriage management in ban states compared to states without bans is notable and that “it’s concerning that patients in these states are being offered a less effective regimen.” Grossman noted that previous research had already found that physicians in states with abortion restrictions were less likely to offer the combined mifepristone-misoprostol regimen for miscarriage management.

“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,” he said.

For this retrospective cross-sectional study, the researchers used the Merative MarketScan Commercial Claims database, which has deidentified longitudinal claims data from people with commercial insurance. They looked at patients between the ages of 15 and 45 who had a spontaneous abortion at 77 days’ gestation or earlier and had continuous insurance enrollment for 60 days before and 60 days after. This resulted in a cohort of 123,598 people.

Using a difference-in-differences framework, they assessed spontaneous abortion management in 14 states with abortion trigger bans and 17 comparison states before the Dobbs v. Jackson Women’s Health Organization ruling (January 2018 to May 2022) and after, when trigger bans took effect (July 2022 to September 2024); June 2022 was excluded.

The primary outcome was spontaneous abortion management type (expectant, medication, or surgical), and for those who received medication, receipt of mifepristone plus misoprostol or misoprostol alone.

In all, 43.8% of patients in the sample lived in states with trigger bans and 56.2% lived in comparison states. Trigger ban state patients skewed younger (mean 30.17 vs 32.45) and were more likely to live in rural areas and receive their diagnosis in the emergency department.

Study limitations included that patient preferences were not captured by claims data, longer term effects were not captured by the post-policy time period, and the reliance on ICD-10 codes. Also, uninsured or Medicaid-enrolled patients, who often face more financial barriers, were not included, so findings may underestimate the magnitude of disparities.

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