Management of Spontaneous Abortion Among Commercially Insured Individuals in the United States After <i>Dobbs v Jackson</i>

Importance Spontaneous abortion is the most common complication of early pregnancy and requires the same treatment options as induced abortion. Limited data on the influence of abortion bans on spontaneous abortion management in the United States exist. Objective To assess the association of state-level abortion bans with spontaneous abortion management and receipt of the evidence-based medication regimen mifepristone plus misoprostol among commercially insured individuals in the United States. Design, Setting, and Participants Retrospective cross-sectional study using the Merative MarketScan Commercial Claims database to identify 123 598 individuals aged 15 to 45 years with spontaneous abortion at fewer than 77 days’ gestation from January 1, 2018, through September 30, 2024. A difference-in-differences framework compared management changes from prepolicy (January 2018 to May 2022) to postpolicy (July 2022 to September 2024) in 14 states with trigger bans vs 17 comparison states. Exposures State-level abortion bans restricting abortion to fewer than 6 weeks’ gestation, triggered by the Dobbs v Jackson Women’s Health Organization decision on June 24, 2022. Main Outcomes and Measures Spontaneous abortion management type (expectant, medication, or surgical) and, among individuals receiving medication, receipt of mifepristone plus misoprostol vs misoprostol alone. Results The study included 123 598 individuals (54 181 in trigger ban states; 69 417 in comparison states) with a mean age of 30.17 years (SD, 6.25 years). In adjusted models, trigger bans were associated with a 2.8 percentage point increase in expectant management (95% CI, 1.0-4.6; baseline to postpolicy change: 26 260 of 35 855 [73.2%] to 14 048 of 18 326 [76.7%] in trigger ban states vs 32 927 of 47 232 [69.7%] to 15 617 of 22 185 [70.4%] in comparison states), a 2.2 percentage point decrease in medication management (95% CI, −3.5 to −0.9; 3183 of 35 855 [8.9%] to 1446 of 18 326 [7.9%] vs 5054 of 47 232 [10.7%] to 2687 of 22 185 [12.1%]), and no significant change in surgical management. Among individuals receiving medication, trigger bans were associated with a relative 13.8 percentage point increase in misoprostol-only regimens (95% CI, 9.0-18.6; 3124 of 3183 [98.1%] to 1401 of 1446 [96.9%] in trigger ban states vs 4250 of 5054 [84.1%] to 1840 of 2687 [68.5%] in comparison states). Conclusions and Relevance State-level abortion bans were associated with a shift in spontaneous abortion management away from medication and toward expectant approaches, with persistent reliance on suboptimal misoprostol-only regimens in ban states, suggesting a decrease in management options for individuals with spontaneous abortion in ban states.