How Do Abortion Bans Affect Miscarriage Treatment? What to Know — ProPublica

We heard the same story again and again this year:

The women were having miscarriages. They were bleeding and in pain.

They needed a medical procedure to clear their uterus, but their doctors delayed it or didn’t even counsel them about it. Our yearlong investigation found that abortion laws are affecting how physicians treat pregnancy loss and other complications because the procedures used in these cases are also used for abortions.

We spoke to women who survived terrifying experiences, and we interviewed family members of those who died without care. They all felt unprepared as they entered emergency rooms, unaware of how abortion laws were reaching into pregnancy care.

They wished they had known what to expect and how to advocate for themselves and their loved ones.

We created this guide for them and anyone who finds themselves in the same position.

We wrote it in consultation with dozens of doctors, including those who hold positions at leading medical organizations and those who regularly treat patients who are miscarrying.

This guide does not provide medical or legal advice. We encourage you to seek out other reliable resources and consult with experts you trust.

What Is a Miscarriage?

When a pregnancy has stopped developing before 20 weeks, that is considered a miscarriage.

This is common — it happens in up to 1 out of every 4 known pregnancies. The medical term for miscarriage is “spontaneous abortion.”

During a pregnancy loss, someone might experience symptoms like bleeding and cramping and pass pregnancy tissue. Or an ultrasound might show that there’s no fetal cardiac activity even if the patient had no miscarriage symptoms.

While most miscarriages resolve on their own, some lead to dangerous complications, including hemorrhage and infection.

Eight in 10 miscarriages occur in the first trimester. A pregnancy that ends after 20 weeks is considered a stillbirth, but sometimes it is still referred to as a miscarriage.

Other rare complications, like premature rupture of membranes (when the water breaks too early) or preeclampsia (life-threatening high blood pressure), can develop in the second trimester of pregnancy and endanger both the pregnant patient and the fetus. Choosing not to intervene may mean there is some chance the fetus could survive, but it also may put the patient at risk of developing life-threatening complications.

Each situation is unique. In these circumstances, doctors should talk to patients about the risks and benefits of continuing the pregnancy and the option of ending it to protect their health, experts said. Sometimes these cases are referred to as a miscarriage.

What Are the Treatment Options?

When a patient is having a miscarriage or is at high risk for one, they should be offered three choices, according to major medical organizations like the American College of Obstetricians and Gynecologists:

1. Expectant management: Waiting to see if the body will pass the pregnancy on its own.
2. Medication: Taking medicine to help the body clear the tissue. This can include misoprostol or mifepristone with misoprostol, which causes the uterus to contract and can speed up the process
3. Procedure: Getting a dilation and curettage (D&C) in the first trimester or a dilation and evacuation (D&E) in the second trimester to empty the uterus.

All of these can be safe choices for an uncomplicated miscarriage, and a first trimester-miscarriage is rarely an emergency. The standard of care is for doctors to explain all options along with their risks and benefits, and then let their patients choose what they prefer. All major medical societies say that patients should be given that choice.

If a patient is bleeding heavily or showing signs of infection, doctors should recommend a procedure (D&C or D&E) to protect their health, medical experts say.

What Is a D&C?

A D&C is a procedure to empty the uterus and is one of several safe ways to navigate pregnancy loss.

The term D&C stands for dilation and curettage and the procedure is often called “surgical” — but that’s a bit of a misnomer. It is more accurately called “uterine aspiration.” Doctors don’t need to make incisions or use sharp tools. They insert a straw-like tube into the uterus and use suction to gently draw out pregnancy tissue. The patient can be awake, sedated or asleep. It only takes a few minutes and typically ends the bleeding quickly.

When this suction procedure was popularized in the 1970s, after abortion became legal nationwide, “it was a real awakening” in maternal health care, said Dr. Philip Darney, a reproductive health care expert at the University of California, San Francisco. It made emptying the uterus faster, safer and more accessible, he said, saving countless lives.

Today, the simple procedure is usually used for pregnancies up to 12 weeks. Some prefer it as a quick and thorough way to complete a miscarriage and minimize ongoing pain and bleeding, as well as infection risks. For patients with heavy bleeding or infections in the first trimester, a D&C could be lifesaving, doctors told us.

What Is a D&E?

A D&E, or dilation and evacuation, is a procedure used in the second trimester to empty the uterus. The doctor uses suction and tools like forceps. The patient is sedated or asleep in an operating room. It takes less time than an induction, allows the patient to avoid a labor experience and generally is associated with less blood loss and infection risk than other options. For patients with heavy bleeding or infections in the second trimester, a D&E could be lifesaving, doctors told us.

How Have D&Cs and D&Es Been Affected by Abortion Bans?

The same procedures are used for both abortions and miscarriages; whether they’re used to remove pregnancy tissue because of a complication or because the patient has decided to end the pregnancy for another reason, there’s no difference in how the procedures are carried out, and most state abortion bans aren’t clear about when physicians are legally allowed to perform them. The American College of Obstetricians and Gynecologists, the leading organization representing OB-GYNs, calls the language these laws use to describe exceptions “unclear” and “inherently vague.”

This can create confusion and fear around the procedures. For example, a patient can be in the process of miscarrying, but there might still be fetal cardiac activity. Some doctors consider intervening to be a risk because managing the miscarriage in that situation could be defined as an abortion.

The laws attach criminal penalties to a violation — in Texas, for example, doctors can face up to 99 years in prison for performing an abortion. State laws usually include exceptions for “medical emergencies.” (Patients can check their state law and discuss it with their doctors.)

Many physicians have told us, however, that the exceptions do not account for how quickly emergencies can develop or how medical decisions are made. While many miscarriages resolve on their own, infections and other complications like heavy bleeding can rapidly become life-threatening, leaving doctors little time to intervene.

While some OB-GYNs who work in abortion-ban states interpret these laws as allowing them to offer all options for a miscarriage, sticking to longstanding medical best practices, our reporting has found that confusion around the grey areas in the laws and the need for extra documentation have caused some doctors to change their approach to counseling and treating miscarriages, even in cases where there is no fetal cardiac activity.

We have found that sometimes doctors didn’t talk about any procedures or medication management options with patients and only told them about the “watch and wait” approach. We’ve heard from doctors who say that it can be difficult to get these procedures approved by their hospitals and that sometimes other medical staff such as OB-GYNs, anesthesiologists or nurses don’t feel comfortable participating. In still other cases, we have reported on doctors delaying care while they take extra steps to document that there is no fetal heartbeat.

At least five women — Amber Thurman, Candi Miller, Josseli Barnica, Nevaeh Crain and Porsha Ngumezi — died after they didn’t receive these procedures in time, we found.

How to Find Doctors Who Will Offer All Options

Talk to people and organizations you trust for recommendations. This can include local doulas, midwives, nurses who work on labor and delivery wards, and reproductive health organizations.

Medical experts suggested asking physicians direct questions like: I’ve seen stories about patients who were unable to get care for miscarriage or pregnancy complications because of state abortion laws. Can you explain to me how the law in our state could affect my care?

They suggested following up with questions like:

• Considering the law in our state, are there options you would not be able to offer?
• If I were having a miscarriage, would you do a D&C if I wanted one? Would you do a D&C if I needed one for medical safety?
• If I were having a miscarriage in the second trimester, would you perform a D&E?
• Are you allowed to tell me my options or give me information in the event of a miscarriage?
• If you can’t provide these services, where should I go?

How to Prepare for Emergencies

Experts told us patients can talk to their doctors early about what to do if something goes wrong.

Here are some questions they recommend asking:

• If I think I’m miscarrying, can I receive care at your office, or do I need to go to the ER?
• Do you do D&Cs and D&Es? How often and where?
• If my water breaks in the second trimester, do you offer the option of abortion care or do you wait until there are signs of infection?
• Which hospital do you recommend if I need emergency care?

How to Choose a Hospital

Here are some things doctors and patients told us you can do:

• Ask to see the hospital’s miscarriage management guidelines.
• Ask whether doctors are expected to counsel patients on all three treatment options and provide whichever the patient chooses.
• Ask if the hospital has any physicians who have expertise in D&Es. One sign that a doctor may be well-qualified to perform this procedure is if they have done a Complex Family Planning fellowship.
• Check what organizations a hospital is affiliated with. Hospitals with religious affiliations sometimes don’t perform procedures to empty the uterus. Hospitals affiliated with universities tend to provide more comprehensive care and are more likely to have doctors with extra training in D&Es.
• Don’t delay seeking emergency care, even if it’s difficult to find an ideal hospital.

What to Do if You’re Experiencing Signs of a Miscarriage

Cramping and bleeding can be signs of miscarriage, but not always. Call your doctor or midwife to discuss symptoms first.

• You may be advised to wait and monitor your symptoms. Most miscarriages resolve without intervention within two weeks.
• If a doctor says to go to a hospital or a clinic, experts suggest asking for:
  • An ultrasound to guide your care
  • An OB-GYN to be involved in your care
  • Information about all three treatment options
  • The treatment option you prefer to get
• Be on the lookout for symptoms like high pulse and feeling faint, which could mean you have a serious complication. Bleeding heavily, such as soaking a pad in 30 minutes or less, is a reason to ask doctors if it’s necessary to empty the uterus, experts told us.

What to Do if You Aren’t Getting Care You Need

Medical experts recommend the following:

• Documenting the care.
• Asking directly for the desired treatment.
• Asking why care is being denied.
• Asking to see another doctor if the one assigned to the case is not providing the desired care.
• Requesting a transfer to another hospital if the one you’re at will not provide the care. Patients can cite EMTALA, the Emergency Medical Treatment and Labor Act, and remind physicians that federal law requires hospitals to stabilize anyone experiencing an emergency. If they can’t, they must transfer the patient to another hospital that will.
• Showing doctors evidence-based standards of care from professional medical organizations to explain that you should be offered these options. Here are guidelines from the American College of Obstetricians and Gynecologists.
• Asking to speak with patient advocates, who work at hospitals to help patients understand their rights and answer questions about their care. Or asking to speak to the hospital’s legal team. Hospitals have processes for escalating concerns.
• Asking for an ethics consult if you still aren’t getting straight answers or are being denied a procedure. Another option is an interdisciplinary meeting with your doctors and nurses, nursing leaders and hospital administrators.
• Reminding doctors that you are being denied the standard of care, which could mean the providers are committing malpractice.
• Filing complaints with the state survey agency, if you think EMTALA was violated, and with the state medical board.
• Calling your state representatives or contacting legal advocacy groups that can advocate for patients’ rights, including the Repro Legal Helpline at If/When/How (844-868-2812), the Center for Reproductive Rights (917-637-3600), the American Civil Liberties Union or the National Women’s Law Center.
• You can also reach out to journalists at ProPublica at [email protected]. We are continuing to investigate cases of denied care.