Growth of uncertainty: how fragmented abortion legislation associates with maternal healthcare engagement and outcomes- an ecological cross-sectional analysis of secondary state-level data

Abstract Background Following Dobbs v. Jackson Women’s Health Organization , abortion policy in the United States has become increasingly fragmented across states. This study examined whether legislative restrictiveness is associated with differences in maternal and perinatal health at the population level. Methods This ecological cross-sectional study assessed state-level associations between abortion-policy restrictiveness and maternal age distribution, intended pregnancy, prenatal care timing and adequacy, gestational age, birth weight, infant mortality subcategories, insurance coverage, neonatal intensive care unit admission, and obstetric service access across the 50 states and the District of Columbia. Policy data from the Guttmacher Institute and the Center for Reproductive Rights were harmonized into a five-point restrictiveness scale. Health indicators were obtained primarily from March of Dimes PeriStats (2020–2025) and supplemented with national datasets. State values were standardized as Z-scores and analyzed using Spearman rank correlations, Kruskal–Wallis tests, and Bonferroni-adjusted post hoc comparisons. Results Increasing legislative restrictiveness was statistically associated with lower intended pregnancy prevalence, reduced early prenatal care, higher rates of moderate preterm birth, and increased moderate and very low birth weight. More restrictive states also demonstrated younger maternal age distributions. Observed associations ranged from moderate to strong in magnitude. Conclusions Although causal inference is limited by the ecological cross-sectional design, findings suggest that abortion-policy fragmentation is associated with broader patterns of reproductive health disadvantage in the post- Dobbs United States, with potential implications for maternal and perinatal outcomes.