SMFM: Managing high-risk pregnancies amid abortion care restrictions

Despite judicial, legislative, and institutional barriers that exist, a new Special Statement from the Society of Maternal-Fetal Medicine (SMFM) noted that abortion care is a “core component of practice for MFM subspecialists nationwide, both to reduce the burden of maternal morbidity and mortality and to operationalize reproductive justice for pregnancy-capable people.”¹

The statement was published September 15, 2026, in Pregnancy and endorsed by the Society of Family Planning.^1,2

The statement addresses actions that MFM subspecialists and institutions can take to build consensus and create systems that ensure patients receive optimal, evidence-based reproductive healthcare, including abortion care, particularly in states where abortion is legally restricted.^1,2

Following the Supreme Court’s 2022 decision in Dobbs v. Jackson Women’s Health Organization, many states increased abortion restrictions, forcing more patients to travel out of state for care and creating confusion and uncertainty among physicians and institutions managing high-risk pregnancies.²

“As high-risk pregnancy physicians, we know first-hand that restrictions on abortion care hinder our ability to provide compassionate, evidence-based healthcare for our patients,” said Justin R. Lappen, MD, chair of the SMFM Reproductive Health Committee. “This new guidance helps MFMs use their expertise, experience, and leadership to build reliable and collaborative systems so that pregnant patients receive the very best care without unnecessary delay.”²

Evidence about abortion restrictions and maternal outcomes

In a case series at 2 Texas hospitals, “demonstrated that state-mandated expectant management of periviable preterm prelabor rupture of membranes resulted in significant morbidity for the majority of patients (57%),” the statement authors noted. “This rate of maternal morbidity is higher than the rate observed in published cohorts of patients declining expectant management under similar clinical circumstances in states without restrictive legislation (33%). Furthermore, perinatal outcomes were poor, with 27 of 28 patients (96%) in this series having a stillbirth or neonatal death.”¹

In a separate study examining pregnancies with severe life-limiting fetal anomalies diagnosed before 22 weeks, composite maternal morbidity doubled after Texas abortion restrictions took effect (35% vs. 72%), with higher rates of cesarean delivery and preeclampsia, and all expectantly managed pregnancies ending in stillbirth or infant death.

Abortion restrictions disproportionately affect pregnant people who experience systemic racism and economic injustice and will likely exacerbate existing disparities in severe maternal morbidity and mortality. The statement acknowledged that hospitals and clinicians have had diverse interpretations of the laws’ narrow exceptions, resulting in inequitable outcomes and access to care.

What steps can be taken?

SMFM calls for interdisciplinary discussions among institutional, community, regional, and state-level stakeholders to achieve consensus on the legal interpretation of abortion restrictions and minimize uncertainty about legally permissible healthcare in medical emergencies or legal “grey zones.”^1,2 Specific institutional actions recommended include:

• Creating an advisory group to address access to abortion care, contraception, management of early pregnancy loss, and educational and training needs across specialties and disciplines
• Establishing a task force to address unpredictable clinical scenarios as they arise
• Developing legal partnerships including criminal legal representation options given state laws
• Building referral networks within and between institutions and states to ensure patient access
• Expanding access to abortion care to the legal limit allowed by state law

“Collaborative partnerships with institutions and clinics in surrounding states that provide abortion care should be developed so that patients can be quickly and safely transferred for care,” said Lappen.² The statement also highlights the Illinois Complex Abortion Regional Line for Access (CARLA) program as a model for coordinated care that facilitates abortion care for medically complex patients from freestanding abortion clinics to hospital-based care.¹

How should clinicians counsel high-risk patients and those with fetal anomalies?

SMFM recommends that all patients with an increased risk of medical complications during pregnancy be provided with accurate, evidence-based information about health risks, all treatment options, and their availability, including abortion care.^1,2 Counseling about abortion should be included among the options for pregnancy management.

“Providing information and referrals about lawful abortion care enjoys strong First Amendment protections,” the authors wrote in Pregnancy.¹

Considering abortion care as a core for MFM

The Special Statement raises significant workforce concerns, as at least 40% of obstetrics and gynecology resident trainees will have limited experience in abortion care given the current legal landscape. While surveys of MFM fellows demonstrate high interest in providing procedural abortion care, a minority of MFM faculty endorse the need for training in and provision of abortion care as part of fellowship training.

Comprehensive pregnancy options counseling, including abortion care counseling, should be considered a core competency of MFM training and formally incorporated into fellowship training through institutional and accrediting mechanisms. The authors of the Special Statement also cited preliminary data that documented experiences of moral injury among MFM subspecialists practicing in abortion-restrictive states following the Dobbs decision.

Given this data, paired with the potential downstream impacts of moral injury on the reproductive workforce, “future attention should be directed to evaluating moral distress among MFM subspecialists as well as methods of combating this distress, including psychosocial and behavioral health support networks,” said the statement authors.

More research is needed on the impact of abortion restrictions on patient outcomes with severe obstetrical complications, maternal and fetal morbidity and mortality, MFM training competencies, and patient volume and transport patterns.^1,2

“The practice of MFM includes navigating complex clinical scenarios at the intersection of high-risk pregnancy and abortion care,” the statement authors concluded. “MFM subspecialists should harness their clinical expertise and institutional leadership to optimize patient safety and work to create approaches that maximize the provision of reproductive healthcare under state restrictions.”

View the full statement via SMFM here.

References:

1. Society for Maternal-Fetal Medicine; Dukhovny S, Crosland A, Ramdaney A, et al. Society for Maternal-Fetal Medicine Special Statement: Considerations for management of high-risk pregnancies when abortion care is restricted. Pregnancy. Published September 15, 2026. doi:10.1002/pmf2.70376
2. Society for Maternal-Fetal Medicine. Abortion care and counseling is core to the practice of maternal-fetal medicine, says new SMFM guidance. Society for Maternal-Fetal Medicine. Press release. Published September 15, 2026. https://www.eurekalert.org/news-releases/1143334?