us

Abortion Restrictions Threaten Miscarriage Management in The United States

Jenna Nobles1,3,4, Sungsik Hwang1,3, Eliza Bennett2,4, Laura Jacques2,4

1Department of Sociology, University of Wisconsin-Madison

2Department of Obstetrics and Gynecology, University of Wisconsin-Madison

3Center for Demography and Ecology, University of Wisconsin-Madison

4Collaborative for Reproductive Equity, University of Wisconsin-Madison

Abstract

Miscarriage and abortion require similar clinical management. Restrictions placed on abortion

threaten the quality of miscarriage care, a policy spillover that affects many Americans. We

combined vital statistics with lifetable parameters to estimate that 1,034,000 miscarriages

occur annually, including nearly 400,000 in US states with abortion bans. Attempts to restrict

mifepristone access further threaten miscarriage management.

Miscarriage is a common pregnancy outcome, which results in health, economic, and

emotional costs for families.1,2 In Exhibit 1, we display estimates of the annual count of

first- and second- trimester miscarriages in the US, based on vital statistics data from the

period 2018–21. We further estimated the number of miscarriages managed medically3 (that

is, with medication), because the treatment of these miscarriages benefits from medications

that are facing multiple legal attempts at restriction, most notably in a June 2024 United

States Supreme Court case, FDA v. Alliance for Hippocratic Medicine. We generated these

estimates by combining prenatal lifetables4,5 with counts of fetal deaths and live births

for U.S. states from the National Center for Health Statistics (NCHS).6 The number of

miscarriages in the US is large: Our research suggests that an average of 1,034,000 first- and

second-trimester pregnancy losses occur each year in the US. This is more than one-fourth

the number of people giving birth.

Restrictions on induced abortion in the US have created mounting challenges for patients

requiring miscarriage care.7 Because miscarriage management and abortion management

involve similar medications and procedures, physicians have expressed concern about

oversight and sanctions for providing miscarriage support.8 Indeed, in states where abortion

provision is criminalized, patients have experienced reduced willingness among some

institutions and some clinicians to provide care, resulting in painful, traumatic, or even

life- threatening experiences as people navigate miscarriages and miscarriage complications

on their own.9–13 The impact of these restrictions is likely to grow over time, as the scope

[email protected]. 1180 Observatory Drive, Madison WI 53705.

HHS Public Access Author manuscript Health Aff (Millwood). Author manuscript; available in PMC 2024 November 26.

Published in final edited form as: Health Aff (Millwood). 2024 September ; 43(9): 1219–1224. doi:10.1377/hlthaff.2023.00982.

A uthor M

anuscript A

uthor M anuscript

A uthor M

anuscript A

uthor M anuscript

and quality of medical training is affected. Scientific studies demonstrate that providers’

comfort in managing routine miscarriage increases with exposure to abortion care training,14

and nearly half of obstetrics and gynecology residents now train in states with significant

abortion restrictions.15 Evidence suggests that medical residency programs in these states

are less likely to provide training in comprehensive miscarriage care.16

The availability of mifepristone is another pressing example of the spillover effects of

abortion policy. Mifepristone is a synthetic steroid that when combined with a second

medication, misoprostol, is the most effective17 and the most cost-effective18 regimen for

medical miscarriage management. Mifepristone is the focus of multiple legal efforts to

restrict access to abortion, including FDA v. Alliance for Hippocratic Medicine, in which the

Court did not uphold a 2023 Court of Appeals decision limiting mifepristone access. Had the

Court upheld this decision, the ruling would have restricted the prescription of mifepristone

through telemedicine and would have banned noncertified prescribers (including most

emergency department clinicians), banned mail delivery of the medication, and banned use

of the medication for pregnancies beyond seven weeks’ gestation. The Supreme Court ruling

is consequential; these restrictions would have significantly limited mifepristone availability.

Although the restrictions were not upheld, this case is one of many ongoing efforts to limit

mifepristone availability, and further legal challenges are expected.19

Often described as an “abortion pill,” mifepristone is part of the medical regimen for

miscarriage management recommended by the American College of Obstetricians and

Gynecologists.20 For patients seeking medical management of first-trimester miscarriages,

the combination of mifepristone with misoprostol results in a higher success rate of

pregnancy tissue expulsion and a substantial reduction of the need for vacuum aspiration

compared with misoprostol alone.17,18,21 Mifepristone use is also recommended17 for

second-trimester medication abortions after miscarriage and stillbirth; it reduces time

to delivery and decreases the need for surgical management of the placenta.22–24 In

other words, patients who undergo medical management of pregnancy loss have more

rapid resolution, require less surgical intervention, and incur fewer medical costs when

mifepristone is included in their care.

Given how common miscarriage is and the overlap in management protocols with abortion

care, the number of Americans experiencing miscarriage whose health care is potentially

compromised by legal challenges to abortion access is large. The aim of this study is to shed

light on the number of people in the U.S. who stand to be affected by the spillover effects of

abortion policy, including restrictions on mifepristone prescription and distribution.

Study Data and Methods

To generate estimates of annual miscarriage counts for the U.S. and by state, we used

multidecrement lifetable (that is, competing-risk lifetable) parameters multiplied by state-

specific birth counts. Average annual live birth counts for U.S. states during 2018–21 came

from the NCHS.6 Lifetable parameters came from two sources: gestation week–specific

pregnancy loss rates and live birth rates for weeks 21–43, which are estimated from

fetal death records, and live birth counts, also from the NCHS. Gestation week–specific

Nobles et al. Page 2

Health Aff (Millwood). Author manuscript; available in PMC 2024 November 26.

A uthor M

anuscript A

uthor M anuscript

A uthor M

anuscript A

uthor M anuscript

pregnancy loss estimates from weeks 5–20 are far more difficult to ascertain because first-

trimester miscarriage is not tracked. We used prenatal lifetable values from De-Kun Li and

colleagues,5 determined by a review study4 to be of the highest quality among available

estimates. Although they are older, these lifetables generated a cumulative probability of

spontaneous pregnancy termination by week 20 (22 percent) that aligned with recently

published research from contemporary high-quality preconception cohorts in the U.S.: 19

percent in a study by Jennifer Yland and colleagues25 and 23 percent in research by Amelia

Wesselink and colleagues.26

We initiated the lifetables at the beginning of gestation week 5, when pregnancies can be

recognized in urine and blood. We estimated the count of week 5 pregnancies in each

state by dividing the count of live births in each state by the probability of survival

from gestation week 5 to live birth. This, multiplied by the cumulative probability of

miscarriage by gestational age, produced an estimate of the count of first- and second-

trimester miscarriages. Given early pregnancy estimate uncertainty, we used 95% confidence

intervals4 to visually depict a range of miscarriage counts for each state.

To understand the potential impact of mifepristone restrictions, we also estimated the count

of first-trimester miscarriages that are managed medically. Although evidence on the rate

of medical management is sparse, studies indicate proportions ranging from 10.2 percent

to 35 percent.3,27 Exhibit 1 displays the result of applying the lower bound of this range

(10.2 percent) to the count of first-trimester miscarriages during 2018–21, resulting in an

estimate of the minimum number of people in the US who undergo medical management of

miscarriage each year.

Lifetables can also account for the competing risk for induced abortion. The life-table

parameters used here came from cohorts with minimal induced abortion (fewer than 4

percent of pregnancies),5 and as a result, the addition of induced abortions to the lifetables

negligibly changed estimated miscarriage counts.28

We acknowledge limitations. To generate these estimates, we used a single set of life-table

parameters for all states because further regional disaggregation before week 20 of gestation

does not exist. This approach may have overstated miscarriage counts in places with the

lowest levels of perinatal mortality (for example, Minnesota) and may have understated it in

places with the highest levels of perinatal mortality (for example, Mississippi). However,

under reasonable assumptions, these deviations fell within our calculated confidence

intervals. Despite the imprecision of miscarriage measurement early in pregnancy, the

evidence makes clear a large and potentially consequential effect of restrictions on abortion

care and management.

Results and Discussion

Exhibit 1 displays miscarriage estimates for the US. Exhibits 2 and 3 display estimates for

each US state by status of abortion restriction legislation as of April 30, 2024, as reported by

the Guttmacher Institute.29

Nobles et al. Page 3

Health Aff (Millwood). Author manuscript; available in PMC 2024 November 26.

A uthor M

anuscript A

uthor M anuscript

A uthor M

anuscript A

uthor M anuscript

As illustrated by exhibit 1, we estimated that approximately 1,034,000 first- and second-

trimester miscarriages (95% CI: 517,834, 2,073,895) occur in the United States each year.

About 87 percent of this total, or approximately 900,000 miscarriages, occur in the first

trimester. We estimated that, at minimum, 92,000 first-trimester miscarriages are managed

medically each year, and they benefit from access to mifepristone and misoprostol.

Exhibit 2 plots miscarriage counts for US states with abortion bans (total or six-week bans)

as of April 2024. Exhibit 3 plots miscarriage counts for the remaining U.S. states; states

in this group include those with no abortion restrictions as well as those with pending

restrictions.

The estimates in Exhibit 2 underscore the large number of people in the U.S. who miscarry

in states where current abortion laws may already compromise care; we estimated that

317,552 miscarriages (95% CI: 159,026, 636,889) occur in these states each year. This

number has since grown; since these figures were created, for example, Florida and Iowa

have also instated six-week abortion bans. Combined, an additional 71,000 miscarriages

occur each year in these two states.30 More than 100,000 miscarriages occur annually in

Texas, where multiple reports of extreme complications from insufficient miscarriage care

have emerged.10 As a point of comparison on scale, roughly 390,000 live births occur

annually in Texas.

In addition to the impact on those seeking induced abortion care, legal restrictions on

abortion have the potential to affect health care for hundreds of thousands of pregnant

Americans who miscarry. Miscarriage is consequential. Suboptimal medical management,

for example, can result in prolongation or incomplete resolution of pregnancy loss, avoidable

procedural intervention, and additional health care costs.18,20,21 These experiences can have

physical and psychological consequences for patients.9,10 State and federal policies targeting

abortion will have consequences that extend far beyond abortion provision.

As legal challenges to the prescription and distribution of mifepristone and misoprostol

continue,19 attention to the potential broader effects of these challenges on reproductive

health is warranted. Restrictions that limit mifepristone access could result in, at a

minimum, 92,000 miscarriages, and potentially as many as 315,000 miscarriages (10.2–35.0

percent of first- trimester miscarriages) each year that are denied the medical management

recommended by the American College of Obstetricians and Gynecologists.

Notably, some of the highest-poverty US states are among those shown in Exhibit 2.

Reductions in the quality of miscarriage care and increases in adverse reproductive health

outcomes associated with suboptimal miscarriage management have the potential to further

widen reproductive health disparities that are already large.30

Acknowledgments

The authors gratefully acknowledge support from the Eunice Kennedy Shriver National Institute for Child Health and Human Development, National Institutes of Health (P2CHD047873, R01HD102207), and from the University of Wisconsin Collaborative for Reproductive Equity. The authors thank Elizabeth Wrigley- Field, Jenny Higgins, Jane Seymour, Amy Williamson, Nathan Jones, Li Hsu, and Allen Wilcox for discussions and feedback on this research and Don Metz for figure style recommendations. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Nobles et al. Page 4

Health Aff (Millwood). Author manuscript; available in PMC 2024 November 26.

A uthor M

anuscript A

uthor M anuscript

A uthor M

anuscript A

uthor M anuscript

References

1. Quenby S, Gallos ID, Dhillon-Smith RK, Podesek M, Stephenson MD, Fisher J, et al. Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss. Lancet. 2021;397(10285):1658–67. [PubMed: 33915094]

2. Farren J, Mitchell-Jones N, Verbakel JY, Timmerman D, Jalmbrant M, Bourne T. The psychological impact of early pregnancy loss. Hum Reprod Update. 2018;24(6):731–49. [PubMed: 30204882]

3. Benson LS, Holt SK, Gore JL, Callegari LS, Chipman AK, Kessler L, et al. Early pregnancy loss management in the emergency department vs outpatient setting. JAMA Netw Open. 2023;6(3):e232639–e232639. [PubMed: 36920395]

4. Ammon Avalos L, Galindo C, Li DK. A systematic review to calculate background miscarriage rates using life table analysis. Birth Defects Res A Clin Mol Teratol. 2012;94(6):417–23. [PubMed: 22511535]

5. Li DK, Odouli R, Wi S, Janevic T, Golditch I, Bracken TD, et al. A population-based prospective cohort study of personal exposure to magnetic fields during pregnancy and the risk of miscarriage. Epidemiology. 2002: 13(1): 9–20. [PubMed: 11805581]

6. National Center for Health Statistics. National Vital Statistics System. [Internet]. Hyattsville(MD): NCHS No date. 2024? [cited 2024 May 7]. Available from: https://www.cdc.gov/nchs/nvss/ index.htm

7. Manian M The Ripple Effects of Dobbs on Health Care Beyond Wanted Abortion. SMU Law Rev. 2023;76(1):77.

8. Rubin R How abortion bans could affect care for miscarriage and infertility. JAMA. 2022;328(4):31820.

9. Simmons-Duffin S Her miscarriage left hew bleeding profusely. An Ohio ER sent her home to wait. NPR [Serial on the Internet]. 2022 Nov 15.

10. Belluck P They had miscarriages, and new abortion laws obstructed treatment. New York Times [Serial on the Internet]. 2022 July 17. Available from: https://www.nytimes.com/2022/07/17/ health/abortion-miscarriage-treatment.html.

11. Tal E, Paul R, Dorsey M, Madden T. Comparison of early pregnancy loss management between states with restrictive and supportive abortion policies. Womens Health Issues. 2023;33(2):126–32. [PubMed: 36379879]

12. Méndez María. Texas laws say treatments for miscarriages, ectopic pregnancies remain legal but leave lots of space for confusion. Texas Tribune. [Serial on the Internet] 2022 July 20. https:// www.texastribune.org/2022/07/20/texas-abortion-law-miscarriages-ectopic-pregnancies/.

13. Méndez M Texas laws say treatments for miscarriages, ectopic pregnancies remain legal but leave lots of space for confusion. Texas Tribune [serial on the Internet]. 2022 Jul 20. Available from: https://www.texastribune.org/2022/07/20/texas-abortion-law-miscarriages-ectopic-pregnancies/.

14. Horvath S, Turk J, Steinauer J, Ogburn T, Zite N. Increase in obstetrics and gynecology resident self-assessed competence in early pregnancy loss management with routine abortion care training. Obstet Gynecol. 2022;139(1):116–9. [PubMed: 34856582]

15. Vinekar K, Karlapudi A, Nathan L, Turk JK, Rible R, Steinauer J. Projected implications of overturning Roe v Wade on abortion training in US obstetrics and gynecology residency programs. Obstet Gynecol. 2022;140(2):146–149. [PubMed: 35852261]

16. Phillips AM, Rachad S, Flink-Bochacki R. The association between abortion restrictions and patient-centered care for early pregnancy loss at US obstetrics-gynecology residency programs. Am J Obstet Gynecol.2023; 229(1):41.e1–41.e10.

17. Chu JJ, Devall AJ, Beeson LE, Hardy P, Cheed V, Sun Y, et al. Mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage (MifeMiso): a randomised, double-blind, placebo-controlled trial. Lancet. 2020;396(10253):770–8. [PubMed: 32853559]

18. Okeke Ogwulu C, Williams E, Chu J, Devall A, Beeson L, Hardy P, et al. Cost-effectiveness of mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage: an economic evaluation based on the MifeMiso trial. BJOG Int J Obstet Gynaecol. 2021;128(9):1534–45.

19. Cohen DS, Donley G, Rebouché R. Abortion Pills. Stanford Law Rev. 2024;76:317–402.

Nobles et al. Page 5

Health Aff (Millwood). Author manuscript; available in PMC 2024 November 26.

A uthor M

anuscript A

uthor M anuscript

A uthor M

anuscript A

uthor M anuscript

20. Hagey JM, Givens M, Bryant AG. Clinical Update on Uses for Mifepristone in Obstetrics and Gynecology. Obstet Gynecol Surv. 2022;77(10):611–623. [PubMed: 36242531]

21. Hamel C, Coppus S, van den Berg J, Hink E, van Seeters J, van Kesteren P, et al. Mifepristone followed by misoprostol compared with placebo followed by misoprostol as medical treatment for early pregnancy loss (the Triple M trial): A double-blind placebo-controlled randomised trial. EClinicalMedicine. 2021;32:100716. [PubMed: 33681738]

22. Bryant AG, Grimes DA, Garrett JM, Stuart GS. Second-trimester abortion for fetal anomalies or fetal death: labor induction compared with dilation and evacuation. Obstet Gynecol. 2011;117(4):788–92. [PubMed: 21422848]

23. Whitley KA, Trinchere K, Prutsman W, Quiñones JN, Rochon ML. Midtrimester dilation and evacuation versus prostaglandin induction: a comparison of composite outcomes. Am J Obstet Gynecol. 2011;205(4):386–e1.

24. Edlow AG, Hou MY, Maurer R, Benson C, Delli-Bovi L, Goldberg AB. Uterine evacuation for second-trimester fetal death and maternal morbidity. Obstet Gynecol. 2011;117(2 Part 1):307–316. [PubMed: 21252744]

25. Yland JJ, Crowe HM, Hatch EE, Willis SK, Wang TR, Mikkelsen EM, et al. A prospective study of preconception asthma and spontaneous abortion. Ann Epidemiol. 2022;69:27–33. [PubMed: 35235814]

26. Wesselink AK, Hatch EE, Rothman KJ, Wang TR, Willis MD, Yland J, et al. A prospective cohort study of COVID-19 vaccination, SARS-CoV-2 infection, and fertility. Am J Epidemiol. 2022;191(8):1383–95. [PubMed: 35051292]

27. Schreiber CA, Chavez V, Whittaker PG, Ratcliffe SJ, Easley E, Barg FK. Treatment decisions at the time of miscarriage diagnosis. Obstet Gynecol. 2016;128(6):1347. [PubMed: 27824749]

28. The source code for the analysis is available online at https://github.com/jen-nej/mifepristone.

29. Guttmacher Institute. State bans on abortion throughout pregnancy [Internet]. New York(NY): Guttmacher; 2024. Available from: https://www.guttmacher.org/state-policy/explore/state-policies- later-abortions

30. Kaiser Family Foundation. Maternal Deaths and Mortality Rates per 100,000 Live Births. [Internet]. San Francisco (CA): KFF; ND. Available from: https://www.kff.org/other/state- indicator/maternal-deaths-and-mortality-rates-per-100000-live-births

Nobles et al. Page 6

Health Aff (Millwood). Author manuscript; available in PMC 2024 November 26.

A uthor M

anuscript A

uthor M anuscript

A uthor M

anuscript A

uthor M anuscript

Exhibit 1. Estimated annual first- and second-trimester miscarriages in the US, by method of management Notes: Authors’ analysis of data from the National Center for Health Statistics, 2018–21.

On the left are annual US miscarriages (n = 1,034,000 for first and second trimesters

combined) by trimester of occurrence. On the right are first-trimester miscarriages (n =

900,000) by method of management. “Medically managed” is the lower-bound estimate of

US miscarriages currently man- aged with medication, for which mifepristone is part of

the most effective regimen recommended by the American College of Obstetricians and

Gynecologists. Second-trimester miscarriages requiring labor induction also benefit from

mifepristone access. “Expectant” refers to waiting and watching without treatment.

Nobles et al. Page 7

Health Aff (Millwood). Author manuscript; available in PMC 2024 November 26.

A uthor M

anuscript A

uthor M anuscript

A uthor M

anuscript A

uthor M anuscript

Exhibit 2. Estimated annual first- and second-trimester miscarriages in US states that had abortion bans as of April 2024* by method of management *Between May 2024 and September 2024, both Florida and Iowa initiated abortion bans.

Notes: Authors’ analysis of data from the National Center for Health Statistics, 2018–21.

Estimated annual first- and second- trimester miscarriage counts for US states with abortion

bans (total or six- week bans) as of April 2024.29 “First trimester medically managed” is the

minimum number (lower bound) of first-trimester miscarriages managed with medication.

“Expectant” refers to waiting and watching without treatment. The error bars represent 95%

confidence intervals.

Nobles et al. Page 8

Health Aff (Millwood). Author manuscript; available in PMC 2024 November 26.

A uthor M

anuscript A

uthor M anuscript

A uthor M

anuscript A

uthor M anuscript

Exhibit 3. Estimated annual first- and second-trimester miscarriages in US states without current abortion bans as of April 2024* by method of management *Between May 2024 and September 2024, both Florida and Iowa initiated abortion bans.

Notes: Authors’ analysis of data from the National Center for Health Statistics, 2018–21.

Estimated annual first- and second- trimester miscarriage counts for US states without

abortion bans (total or six-week bans) as of April 2024.29 “First trimester medically

managed” is the minimum number (lower bound) of first-trimester miscarriages managed

with medication. “Expectant” refers to waiting and watching without treatment. The error

bars represent 95% confidence intervals.

Nobles et al. Page 9

Health Aff (Millwood). Author manuscript; available in PMC 2024 November 26.

A uthor M

anuscript A

uthor M anuscript

A uthor M

anuscript A

uthor M anuscript