The Supreme Court is poised to overturn Roe v. Wade this summer, as revealed by a leaked draft opinion released early last week by Politico. If the Supreme Court moves forward with its original opinion, access to abortion care will be curtailed in the U.S., but what many people may not realize is that people going through a miscarriage will also be affected.
When a pregnancy ends in miscarriage and the fetus is not expelled naturally, the pregnant person has three options: wait for their body to expel the pregnancy on its own (called “expectant management”); take medication, typically mifepristone and misoprostol (commonly called the abortion pill); or use surgical management, including dilation and curettage (D&C) and aspiration to remove the tissue from the uterus.
Some states could implement abortion bans that take the latter two options away from people experiencing miscarriage, as the medication and surgical procedures used are the same as those used for abortions.
“This places them at grave risk,” said Dr. Jen Villavicencio, the lead for equity transformation at the American College of Obstetricians and Gynecologists and an OB-GYN with a specialty in complex family planning. “No one facing a medical crisis should have to fear their physician pausing, or even halting, when in the midst of doing what the patient needs in order to resolve or avoid the threat of prosecution.”
One state that could feel the impact is Louisiana, which recently introduced HB 813, known as the Abolition of Abortion in Louisiana Act of 2022, criminalizing abortion. The bill doesn’t specify pregnancy loss, but the ACLU of Louisiana has confirmed the law would extend to people who experience a miscarriage. Georgia’s abortion ban, however, contains an exception for miscarriage.
The Center for Reproductive Rights has estimated that if Roe is overturned, roughly half of the states will enact restrictive laws or seek to enforce currently unconstitutional laws that ban abortion.
“The individuals writing these laws are not medical experts,” Villavicencio said. “Laws like abortion restrictions and bans are not based in science or evidence and, therefore, the language does not coincide within the practice of the highest quality, evidence-based care. The language is often incorrect, not clinically meaningful, and therefore confusing to those practicing medicine … Pregnancy, complications of pregnancy, and the treatment of those complexities require nuanced, individualized care—something that is very difficult when faced with unscientific, non-medical laws.”
Between one-third and one-half of all pregnancies end in miscarriage before the person knows they are pregnant, and about 10-20% of people who know they are pregnant miscarry.
For people who miscarry and choose to go the expectant management route, one issue they run into is not knowing when it will happen.
“[Expectant management] can take two days, it can take two weeks, it can take over a month,” said Dr. Meera Shah, a health care provider and chief medical officer of Planned Parenthood Hudson Peconic in New York. “Some people choose expectant management, but many people want to plan for when exactly they’re going to start cramping and bleeding and expelling the pregnancy.”
The process can be painful and messy, and it can take time, so some patients choose surgical management to avoid enduring the physically and emotionally difficult process of cramping and bleeding.
“It’s more patient-centered and compassionate to be able to offer the full menu of management options for a patient who may be experiencing a miscarriage, especially if it’s a desired pregnancy,” Shah said. “Some people just want it to be over with.”
Sometimes, patients who miscarry bleed excessively and “need to have procedural management to prevent hemorrhage. And these options need to be readily available for managing patients for these reasons,” Shah said.
Miscarriage can be traumatic, even when the person’s chosen option to manage it goes as planned. Nearly 20% of women who experience a miscarriage become symptomatic for depression or anxiety, and in most of those cases, symptoms persist for one to three years, affecting quality of life.
A 2021 study of 275 women who miscarried found that about one-quarter of women who experience an early pregnancy loss are at an increased risk of major depression, and this risk was significantly higher for Black women than it was non-Black women.
Even if abortion bans don’t explicitly ban miscarriage management options, they may have the practical effect of reducing the number of providers willing to use them, therefore limiting access to people who miscarry.
“That is a possibility, because what the anti-abortion movement has done is that they like to instill fear among abortion providers to prevent them from managing our patients in a way that’s founded in science and centered around the patient,” Shah said. “It’s the same reason that there are fewer providers in hostile states—because they’ve just created this atmosphere of fear.”
Restricting care for miscarriage may instill fear in patients as well. “People may fear criminalization if they go to the emergency room for hemorrhage, if they go to their doctor’s office for a miscarriage,” Shah said. “Patients get really confused by the headlines and the laws and what all the restrictions actually mean, and they actually may not seek care.”
Under Texas’ SB 8, which bans abortions after about six weeks, pharmacies have reportedly declined to fill prescriptions for misoprostol.
“We are hearing anecdotally that obstetrician-gynecologists and other involved specialists are already facing questions and uncertainty about whether the care they are providing to their patients is exposing them to potential legal action,” Villavicencio said. “This is not in the best interests of patients, and it’s an affront to the patient-physician relationship.”
Restricting care for miscarriage may be especially harmful to BIPOC and low-income people who are disproportionately likely to lack access to medical care in general. Black women are also twice as likely as white women to have a miscarriage in weeks 10-20 of pregnancy, and they are three times more likely to die from a pregnancy-related cause than white women.
“The impact of bans and other restrictions will be felt by countless people, but we cannot forget that the greatest harm will fall on communities of color, people without robust financial resources, and people who live in rural areas where ready access to care is already limited,” Villavicencio said.
Barring patients and providers from certain care is one thing, but criminalizing them is another.
“It’s heart-wrenching, intensely frustrating, and a violation of my oath and duty to care,” Villavicencio said. “I worry so much that instead of being able to dedicate all of my expertise, mental energy, and attention to treating my patient in front of me, I have to also think about whether or not I will face consequences, some criminal, for offering the most appropriate, individualized, and evidence-based care.”