How Abortion Restrictions Impact People Who Miscarry

Few headlines have felt more like a sucker-punch than "Roe v. Wade Overturned" and yet here we are. On Friday, June 24, the Supreme Court struck down the decades-old decision that protected abortion rights. And while many are (rightfully) concerned about how this decision will affect their access to safe abortions, few are speaking about how the landmark ruling will impact other areas of reproductive health. That may be what inspired one doctor on Instagram to speak up about a subject that is still taboo: miscarriage.

In a now-viral video, Dr. Marta Perez explains in plain and simple to follow terms exactly how losing access to abortion services will harm patients experiencing a miscarriage. Dr. Perez explains how during a miscarriage, there are three main ways to manage the experience, and they can include using an abortion pill, a miscarriage pill, or an abortion surgery.

Natural Miscarriage

The first of the three miscarriage management options Dr. Perez points to is a natural miscarriage; this is when the uterus naturally expels its contents without the aid of medication or surgery. This process is usually fairly quick; however, there can be problems. If there is an incomplete miscarriage, which is when some but not all of the material is passed, then this process may take a few days. If there is a missed miscarriage (when the fetus is no longer growing but has not passed), then it could take several weeks and a person may need medical intervention.

"What the physician is referring to is what we in the medical community call 'expectant management.' We do this in some cases where it appears that most of the products of conception have already passed and there may only be bleeding similar to a period," Dr. Nicole Williams, M.D., FACOG, FACS, owner of Gynecology Institute of Chicago, and author of This Is How You Vagina, tells Parents. "When you're talking about access to care, it can be dangerous if the patient does not have quick access to an ER or their own doctor. If there are still products remaining, it could lead to a resurgence in bleeding or infection. So, knowledge and access are key when you are talking about expectant management."

Medical Management of Miscarriage

Dr. Perez's video explains what medical management is and how abortion pills play a crucial role in helping a patient remain safe during a miscarriage.

"The most effective regimen is to use two medications, mifepristone, also known as the abortion pill, and misoprostol, also known as the miscarriage pill. Mifepristone has restrictions on its use for the sole reason of its use in elective abortion and political interference in the FDA. Therefore many prescribers may not be licensed to prescribe mifepristone, meaning that many patients do not have access to the most effective regimen and use misoprostol alone," Dr. Perez wrote in the video caption.

According to the Guttmacher Institute, as of 2020 more than half of all abortions in the United States are medication abortions. The FDA has approved mifepristone for use up to 10 weeks of pregnancy, although research shows that it remains safe to use beyond that timeline. Patients who elect for a medication abortion will start by taking mifepristone, which stops the pregnancy, followed by misoprostol, which helps the body pass the material.

"Mifepristone and misoprostol is the most common combination for induction of miscarriage. Mifepristone effectively blocks the hormone progesterone that supports pregnancy, while misoprostol induces contractions," Dr. Williams tells Parents. "While misoprostol is easy to obtain since it was originally designed for GI indications, mifepristone is notoriously difficult to obtain, even in a safe state where I live, Illinois. This is because mifepristone is heavily regulated by the FDA and is unavailable in traditional retail pharmacies."

Mifepsristone versus Plan B

Mifepristone is heavily regulated because of its role in elected abortions. Some folks may confuse that for Plan B, which is an FDA-approved emergency contraceptive that is available over-the-counter. Plan B is an emergency contraceptive medication given to prevent a pregnancy from happening within 72 hours of intercourse, and it is up to 89 percent effective, but that is only if it is used correctly and if the patient weighs under 165 pounds. Mifepristone, however, is a medication that stops a pregnancy that has already begun.

The safety of medication management options

Using medication to aid in miscarriage management is safe. But that doesn't mean that the option should be undertaken without the guidance of a trained medical provider. And that is the terrifying crux of this political moment for patients who experience miscarriage: If abortion services that include mifepristone, misoprostol, and surgery are banned, then patients who need medical help may ultimately be harmed.

"The use of medication for abortion is incredibly safe. In a study from Planned Parenthood, which looked at 200,000 women, there was only one death, and this patient had an ectopic pregnancy," Dr. Williams shares.

Dr. Williams goes on to explain that in the past, a person seeking an abortion had to go to a clinic in person to receive the medication. But since the pandemic, that has changed. Patients can now have their abortion pills mailed directly to them.

"The federal government approved sending mifepristone by mail during that time, and now those changes will be permanent. The biggest barrier to care now is knowing that the medication is now available safely through the mail, and how one goes about doing so. This is where I believe we need to expand our reach," Dr. Williams says.

Surgical Management of Miscarriage

The third option for miscarriage management is surgical. This procedure is called a dilation and curettage (D&C), which is when a doctor dilates the cervix and then surgically removes the lining of the uterus, including its contents, by scraping or scooping.

"A D&C can be done in the operating room under general anesthesia," Dr. Perez wrote in the Instagram video caption. "There is also a device called a manual vacuum aspirator (MVA) that allows the same treatment but does not need [operating room] equipment; it can be done bedside under regional anesthesia in an outpatient medical office. A MVA is commonly used for early first trimester abortions. Because abortion care is siloed outside routine OB-GYN care and training, many OB-GYNs are not familiar with using MVAs, so the only option may be a D&C; operating room scheduling is more complex and may take a few days or a week, delaying care."

A surgical management option is safe, common, and relatively simple. According to Planned Parenthood, the procedure is one of the safest medical procedures you can get, and there is no link between surgical treatment and infertility. In other words, having an abortion procedure will not lower your future chances of becoming pregnant again.

It cannot be overstated enough that for a person experiencing a miscarriage, how it is managed is often the same as abortion care. By taking away access to safe, reproductive health care, birthing people who need medical help with a miscarriage will be put in harm's way.

"Miscarriage is an entirely different medical condition than pregnancy," Dr. Williams says. "Miscarriage indicates that the pregnancy is already breaking down. We don't always know why it happens, but it is incredibly common. Miscarriage can lead to prolonged bleeding, anemia, or infection, and we know that the use of mifepristone and misoprostol in combination helps patients heal much faster than expectant management. It is imperative that we do not limit access to these medications as we are limiting how we can care for our patients."