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. Author manuscript; available in PMC: 2024 Nov 26.
Published in final edited form as: Health Aff (Millwood). 2024 Sep;43(9):1219–1224. doi: 10.1377/hlthaff.2023.00982

Abortion Restrictions Threaten Miscarriage Management in The United States

Jenna Nobles 1,3,4, Sungsik Hwang 1,3, Eliza Bennett 2,4, Laura Jacques 2,4
PMCID: PMC11596537  NIHMSID: NIHMS2028348  PMID: 39226500

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.

Exhibit 1. Estimated annual first- and second-trimester miscarriages in the US, by method of management.

Exhibit 1.

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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.

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 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 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

Exhibit 2. Estimated annual first- and second-trimester miscarriages in US states that had abortion bans as of April 2024* by method of management.

Exhibit 2.

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*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.

Exhibit 3. Estimated annual first- and second-trimester miscarriages in US states without current abortion bans as of April 2024* by method of management.

Exhibit 3.

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*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.

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.

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