Post-Dobbs policies shift spontaneous abortion care management

State-level abortion bans enacted following the Dobbs v. Jackson Women’s Health Organization decision were associated with measurable changes in how spontaneous abortion was managed in the United States, according to a study published in JAMA.¹ The analysis found a shift away from medication management toward expectant approaches, alongside reduced use of the evidence-based mifepristone–misoprostol regimen, potentially impacting “hundreds of thousands of individuals experiencing miscarriage annually in affected states,” according to the study authors.

Spontaneous abortion, commonly referred to as miscarriage, remained the most frequent complication of early pregnancy in the United States. Management options for uncomplicated cases in the first trimester typically included expectant management, medication treatment, or procedural intervention. Medication management often relied on the same drugs used in induced abortion care, most notably mifepristone and misoprostol, creating an overlap that became increasingly consequential following changes in abortion policy.

After the Dobbs ruling eliminated federal constitutional protections for abortion in June 2022, multiple states enacted “trigger bans” restricting abortion access to fewer than 6 weeks’ gestation.

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“Emerging evidence suggests these restrictions are associated with adverse clinical outcomes,” the authors wrote. “In Texas, where the first post–Roe v Wade abortion ban took effect in September 2021, blood transfusions among patients hospitalized for pregnancy loss increased 15% above expected levels after the total ban.”

To evaluate the impact of these policies, researchers conducted a retrospective cross-sectional study using the Merative MarketScan Commercial Claims database. The study included 123,598 individuals aged 15 to 45 years diagnosed with spontaneous abortion at fewer than 77 days’ gestation between January 2018 and September 2024. Of these, 54,181 individuals resided in 14 states with trigger bans, whereas 69,417 were in 17 comparison states without such restrictions.

Using a difference-in-differences framework, investigators compared management patterns before policy implementation (January 2018 to May 2022) and after (July 2022 to September 2024). The results demonstrated statistically significant shifts in care delivery associated with abortion bans.

Medication use declines

In trigger-ban states, expectant management increased by 2.8% (95% CI; 1.0-4.6), rising from 73.2% before policy implementation to 76.7% afterward. In contrast, comparison states saw only a modest increase from 69.7% to 70.4%. At the same time, medication management declined by 2.2% (95% CI; −3.5 to −0.9) in ban states, decreasing from 8.9% to 7.9%, whereas it increased in comparison states from 10.7% to 12.1%. Surgical management rates did not significantly change in either group.

Among patients who did receive medication management, the study identified a notable divergence in treatment regimens. In trigger-ban states, clinicians continued to rely heavily on misoprostol-only protocols, with minimal uptake of the more effective combination therapy. The analysis found a relative 13.8% increase in the use of misoprostol alone in these states compared with those without bans (95% CI; 9.0-18.6). By contrast, comparison states showed increasing adoption of the combined mifepristone–misoprostol regimen, which has been shown to improve treatment efficacy and reduce the need for additional procedures.

These findings underscored how legal and regulatory changes influenced clinical practice patterns, even for conditions unrelated to elective abortion. The reduced use of mifepristone in ban states likely reflected institutional restrictions, supply limitations, and clinician concerns about legal exposure, despite the medication’s established role in evidence-based miscarriage care.

Policy shapes clinical care

The observed shift toward expectant management may have important consequences for patient experience and outcomes. Expectant management can be appropriate in select cases but may prolong symptom duration and increase patients' uncertainty. Similarly, reliance on less effective medication regimens may increase the likelihood of incomplete treatment, necessitating additional interventions.

The study’s authors emphasized that these changes occurred in a population of commercially insured individuals, suggesting that even patients with relatively stable access to health care experienced altered care patterns under restrictive abortion policies.

“These management changes 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,” the authors wrote. “Efforts to clarify that spontaneous abortion management is legally distinct from induced abortion to protect formulary access to mifepristone for pregnancy loss indications and to sustain the outpatient reproductive health infrastructure necessary for evidence-based care are needed.”

References

1. Rodriguez MI, Fuerst M, Schrote K. Management of spontaneous abortion among commercially insured individuals in the United States after Dobbs v Jackson. JAMA. Published online May 18, 2026. doi:10.1001/jama.2026.6344