Maternal Morbidity Increased in States Enacting TRAP Laws

With the decision in the 1992 Supreme Court ruling of Planned Parenthood v Casey, laws surrounding abortion have been allowed to stand in each individual state, leading to differences in the approach to abortion regulation in each state. A new study published in JAMA Health Forum found that these differences could have major effects on maternal morbidity,1 as those who lived in states with targeted regulation of abortion providers (TRAP) were at increased risk of morbidity compared with those who lived in states without such laws.

TRAP laws first became common after the 1992 Supreme Court ruling of Planned Parenthood v. Casey, which allowed for laws to be passed to restrict abortions that did not represent an “undue burden” to the mother. These could include facility structure requirements, such as specifying the size of the room for the procedure, or requiring arrangements with local hospitals, like admitting privileges, that abortion clinics cannot meet. There are 25 states with these laws enacted as of 2025,2 most of which were implemented between 2012 and 2018.1 This study aimed to assess how these TRAP laws could affect maternal and neonatal morbidity, specifically when it comes to in vitro fertilization (IVF) treatments through fertility clinics.

Women had higher maternal morbidity in states with TRAP laws | Image credit: Parilov - stock.adobe.com

The study was retrospective in nature and used data collected by the National Center of Health Statistics, which contained data collected between 2012 and 2021. States were separated into 2 groups based on those who had TRAP laws and those that did not. Maryland, Rhode Island, and Connecticut were excluded due to the minor nature of their restrictions. Patients who conceived without fertility treatments, had multiple gestations, had a gestational age of less than 23 weeks or greater than 42 weeks, or had births in the washout period were all excluded from the study. Births were considered conceived through fertility treatment if they were conceived through assisted reproductive technology, fertility-enhancing drugs, and/or infertility treatment.

The primary outcome was a collection of adverse outcomes that included intensive care unit (ICU) admission, uterine rupture, maternal blood transfusion, and unplanned hysterectomies. The rate of preterm birth and a neonatal collection of adverse outcomes acted as secondary outcomes of interest.

There were 416,019 conceptions through fertility treatment that were included in this analysis. The mean (SD) age of the mothers was 34.5 (5.3) years, and the mean gestational age was 38.3 (2.4) weeks. A total of 17 states had TRAP laws enacted during the study period, and 42.0% of conceptions were in states with TRAP laws. A total of 74.1% of the participants were White, 11.2% were non–Hispanic Asian, 8.5% were Hispanic, and 4.3% were non-Hispanic Black.

People who conceived in states with TRAP laws were more likely to be White (78.41% vs 68.07%) or non-Hispanic Black (4.55% vs 4.02%) compared with those who conceived in states without TRAP laws. These women were also more likely to have public insurance and less than a college education.

Proportions of the neonatal composite of adverse events were higher after TRAP laws were enacted compared with before their enactment (15.75% vs 13.61% in states without TRAP laws; 15.05% vs 12.85% in states with TRAP laws). There was not a significant difference between the states when it came to the change in neonatal composite (absolute adjusted difference-in-differences [DID], 0.13; 95% CI, –0.47 to 0.74).

A higher unadjusted proportion of preterm births was found in both states with (13.06% vs 14.24%) and without (12.36% vs 13.36%) TRAP laws in pregnant individuals. States without TRAP laws had an adjusted proportion of preterm births that decreased after TRAP law enactment (13.54% to 12.37%), and states with TRAP laws also saw this decrease (14.37% to 13.70%). The difference was not significant between the 2 groups of states (absolute adjusted DID, 0.49; 95% CI, –0.11 to 1.10).

The proportions of maternal composites of adverse events were higher in states with and without TRAP laws after TRAP law enactment compared with the baseline levels (1.33% vs 0.83% in states without; 1.08% vs 0.59% in states with TRAP laws). Pregnant individuals had a decrease in the maternal composite of adverse events in states without TRAP laws (1.30% to 1.20%), whereas an increase was found in states with TRAP laws (0.83% to 0.98%). This was found to be a significant increase (absolute adjusted DID, 0.25; 95% CI, 0.00-0.50).

There were some limitations to this study. Birth certificates were used to identify those conceived through fertility, but this can be an incomplete method of identifying these pregnancies. The magnitude of maternal morbidity could have been underestimated in this way. The type of fertility treatment used could not be identified. The effect size of the abortion legislation across the multiple states could not be standardized. The study was also limited to single gestations, which made it impossible to avoid overcounting maternal morbidity from 1 individual mother.

The researchers concluded that “even in the setting of well-resourced patients and desired, planned pregnancies, restrictive access to abortion care was associated with higher preterm birth and maternal morbidity per a standardized composite.” Restricting access to abortion, therefore, may have implications for all pregnant individuals, regardless of the means by which they became pregnant.

References

1. Melville SJF, Shi J, Garg B, Caughey AB, Kornfield M. Targeted regulation of abortion providers laws and pregnancies conceived through fertility treatment. JAMA Health Forum. 2026;7(1):e255920. doi:10.1001/jamahealthforum.2025.5920
2. Forouzan K. Targeted regulation of abortion providers. Guttmacher. Updated December 1, 2025. Accessed January 8, 2026. https://www.guttmacher.org/state-policy/explore/targeted-regulation-abortion-providers