State abortion laws linked to higher maternal morbidity in high-risk pregnancies

State abortion laws linked to higher maternal morbidity in high-risk pregnancies | Image Credit: © pressmaster - © pressmaster - stock.adobe.com.

Maternal morbidity is significantly increased by legislation changes leading to universal expectant management of life-limiting fetal conditions, according to a recent study published in JAMA Network Open.¹

Patients managing pregnancy can balance their values and safety through comprehensive counseling and shared decision-making, including choices about pregnancy duration. When continuing pregnancy because of expectant management, patients may be at increased risk of complications such as hemorrhage, infection, and hypertension.

“However, limited data exist to aid decision-making,” wrote investigators. The cohort study was conducted to assess perinatal outcomes before and after state legislation limited management options for life-limiting fetal conditions. Data was obtained from a single institution, with uninsured or Medicaid-insured patients comprising most patients.

Options before and after legislation changes

Participants included women with a singleton pregnancy diagnosed with a life-limiting fetal condition at under 22 weeks’ gestation. Pregnancies from January 2017 to December 2018 were considered before changes in state legislation, while those from January 2022 to December 2023 were considered after changes in legislation.

In the before group, patients with life-limiting fetal conditions were offered expectant management or previable termination of pregnancy. These conditions included trisomy 13 and 18, which are linked to limited postnatal life expectancy and major structural anomalies.

Following the implementation of state legislation, only expectant management was offered except for cases of a maternal life-threatening condition. Investigators compared maternal morbidity and neonatal outcomes before and after state legislation.

Maternal and neonatal outcomes

Maternal morbidity outcomes included endometritis, hysterotomy, chorioamnionitis, transfusion, hemorrhage, abruption, preeclampsia, death, and postpartum readmission. Neonatal outcomes included stillbirth and infant or neonatal death.

There were 53 patients diagnosed with a life-limiting fetal condition at a mean 17.4-weeks’ gestation before legislation changes and 34 diagnosed at a mean 18.4-weeks’ gestation after legislation changes were included in the final analysis. Of the former group, 55% chose to terminate pregnancy, and 45% chose to undergo expectant management.

In the latter group, 4 patients were lost to follow-up, and 26 underwent expectant management. Pregnancy was terminated at an out-of-state facility by the remaining 4.

Stillbirth or neonatal death was reported in all pregnancies with expectant management, with the latter increasing from 46% before legislation to 69% after legislation. An increase in preeclampsia rates was also reported, occurring only in patients receiving expectant management.

Increased risks from expectant management

Expectant management led to a significantly higher maternal morbidity rate vs pregnancy termination, at 72% vs 15%, respectively. Additionally, the prevalence of composite maternal morbidity significantly increased following state legislation, at 35% before vs 72% after.

This data highlighted a significant rise in maternal morbidity from expectant management of life-limiting fetal conditions because of legislation changes. The study was limited by a small sample size and the retrospective nature of data collection.

“Further research is warranted to examine the impact of reproductive legislation on subsequent pregnancies and long-term health outcomes for this population,” wrote investigators.

Broader impacts of restrictive reproductive policies

Policies restricting pregnancy termination have also been linked to adverse infant outcomes, including an increased risk of heart disease.² The data highlighted a difference of 9.6 babies with cyanotic congenital heart disease in states with abortion restrictions vs abortion protections.

When observing differences over time vs the expected rates based on trends before legislation was implemented, a higher degree of difference was reported. This indicated a need to perform a long-term evaluation of these trends.

References

1. Nambiar A, Duryea EL, Thiele LR, et al. Maternal morbidity with expectant management of life-limiting fetal conditions. JAMA Netw Open. 2025;8(7):e2521883. doi:10.1001/jamanetworkopen.2025.21883
2. Krewson C. Restrictive abortion laws linked to offspring heart disease. Contemporary OB/GYN. March 19, 2025. Accessed June 23, 2025. https://www.contemporaryobgyn.net/view/restrictive-abortion-laws-linked-to-offspring-heart-disease.