I. Executive Summary: The Geographic Reallocation of Pregnancy Termination
Analysis of longitudinal data from 2018 through 2023 demonstrates that the implementation of a comprehensive state statute restricting induced termination of pregnancy, following the June 2022 Supreme Court decision, generated a marked shift in where procedures were obtained by Missouri residents.
The primary finding is the clear distinction between procedures performed within the state of Missouri (in-state occurrence data) and procedures obtained by Missouri residents (residence data) from all sources. The number of in-state procedures reported in Missouri declined significantly, from 1,471 in 2019 to just 37 in the full year of 2023, reflecting the enforcement of state laws. 1 Concurrently, the estimated total number of procedures obtained by Missouri residents, predominantly through interstate travel, increased from a reported 3,653 in 2021 3 to an estimated 11,600 in 2023. 1
This redirection of demand resulted in a marginal increase in the state’s resident live births. While certain external analyses estimated that states with comparable restrictions experienced an average 2.3% increase in birth rates, Missouri experienced a rise of only 0.4% attributable to the restriction of procedures. 4 This minimal change suggests that alternative access channels, primarily proximity to neighboring states and medication dispensing via telehealth, largely maintained the overall rate of pregnancy termination for Missouri residents. The computed Estimated Resident Procedure Ratio, an indicator of total resident demand, climbed to approximately 172.8 procedures per 1,000 live births in 2023.
II. Methodology and Data Reconciliation: Accounting for External Access
Accurate analysis of pregnancy resolution trends necessitates distinguishing between data that reflect procedures performed by location and those obtained by residents, regardless of location.
A. Defining Pregnancy Outcome Metrics
The Missouri Department of Health and Senior Services (DHSS) tracks resident live births, utilizing data exchange with other states to ensure comprehensive resident birth counts.
Tracking induced termination of pregnancy, however, involves distinct metrics:
- Missouri In-State Occurrence: This metric counts procedures performed within Missouri boundaries. Following the trigger law implementation in June 2022, this number became minimal. 6
- Estimated Total Resident Procedures: This metric captures all procedures obtained by Missouri residents, including those performed in Missouri, in other states via interstate travel, or through non-clinical methods such as mail-order medication dispensing.
State-to-state data exchange for tracking procedures is incomplete. 7 While Missouri reported 3,029 resident procedures in 2023 based on shared data 1, independent external estimates indicated that 11,600 Missouri women obtained a procedure out of state that year. 1 This significant difference highlights the limitations of official state reporting, as it often omits procedures obtained in non-reporting jurisdictions or via uncounted medication access methods. 1 The estimated data often incorporates non-clinical access, such as the estimated 780 residents who obtained medications from telehealth providers operating under shield laws in the latter half of 2023. Therefore, to establish a statistically relevant comparison against resident live births, comprehensive external estimates are necessary.
III. Longitudinal Trends: Live Births and the Pre-Restriction Baseline (2018–2021)
Missouri’s demographic trends prior to 2022 were characterized by long-term declines in fertility and pre-existing restrictions on in-state procedures.
A. Resident Live Births and Demographic Trends
The resident live birth rate per 1,000 population in Missouri declined prior to 2022, falling from 12.0 in 2018 to 11.2 in 2022. This is consistent with general national trends and resulted in a natural decrease in population (deaths exceeding births) for the first time since centralized vital statistics began in Missouri in 1911.
B. Pre-Restriction Resident Procedure Utilization (2018–2021)
Prior to the 2022 law change, Missouri already exhibited low in-state procedure counts due to pre-existing restrictive state policies.
Missouri Resident Live Births and Procedure Incidence (2019–2023)
| Year | MO Resident Live Births (A) | MO In-State Procedure Occurrence (B) | Estimated Total Resident Procedures (C) |
|---|---|---|---|
| 2019 | (Data Varies) | 1,471 | 4,333 |
| 2020 | (Data Varies) | 167 | 3,391 |
| 2021 | (Data Varies) | 150 | 3,653 |
| 2022 | 68,954 | 88 | 10,255 |
| 2023 | 67,123 | 37 | 11,600 |
Sources: 1
The official reported in-state occurrence dropped by 89% between 2019 (1,471) and 2020 (167). 12 This reduction confirms that pre-existing state policies were effective in significantly limiting local access prior to the 2022 ruling. This limited in-state provision meant that the majority of Missouri residents seeking procedures were already obtaining them in other states, establishing a pattern of external access before the trigger law was fully enforced.
IV. The Post-Restriction Discontinuity (2022–2023): Quantification
Data from 2022 and 2023 highlights the discrepancy between the in-state occurrence count and the total number of procedures obtained by residents.
A. The Reduction of In-State Provision
Missouri became one of the first states to enforce its trigger law in June 2022, prohibiting nearly all procedures. 13 The total number of procedures performed in Missouri fell to 88 in 2022 (a partial year) and further decreased to just 37 procedures in the full year of 2023. 1 The in-state procedure ratio fell to 0.1 per 1,000 women of reproductive age in 2022. This figure confirms the success of the state statute in eliminating regulated clinical services within state lines.
B. Estimated Total Resident Procedures (Travel and Telehealth)
In contrast to the minimal in-state occurrence, the volume of procedures obtained by Missouri residents through external sources increased substantially:
- 2022: The official resident estimate, incorporating partial data from other states, reached 10,255 procedures. This figure was significantly higher than the pre-restriction count (3,653 in 2021). 3
- 2023: External analysis estimated that 11,600 Missouri women traveled out of state to obtain a procedure. 1 This demand was largely met by facilities in Illinois (estimated 8,740 women) and Kansas (estimated 2,860 women). 8
The estimated 2023 resident count (11,600) suggests that the legislative prohibition redirected procedure demand rather than eliminating it. The significant volume of procedures obtained out of state confirms the availability of external resources for Missouri residents.
V. Non-Clinical Dispensing: Procedures via Mail and Telehealth
A growing number of procedures are now obtained through medication dispensed via mail, a method generally excluded from state occurrence reports. 9
A. Official Data Exclusion
Missouri’s official reports do not include the number of medication procedures obtained by residents from providers operating under shield laws in other states, nor do they track procedures that were self-managed. 9 The state utilizes statutes aimed at restricting providers from using telemedicine for procedures.
B. Quantitative Estimates from External Sources
External monitoring by the #WeCount project provides some quantitative estimates for non-clinical access:
- In the second half of 2023 (July to December), an estimated 780 Missouri residents obtained medication procedures from external providers operating under shield laws.
When incorporated with in-person travel, this technological pathway contributed to the estimated total resident procedure count. The ability of residents to obtain medications through mail from providers in other states suggests that technological alternatives provide a means of access that circumvents the requirement for in-state facility visits.
VI. Correlation Between Procedures and Live Births
Analyzing the relationship between total procedures and live births is crucial for measuring the policy impact of the restriction period and for projecting the potential impact of Amendment 3 (Missouri House HJR 73).
A. The Marginal Change in Live Births
The provisional count of Missouri resident live births fell to 67,123 in 2023, the lowest number recorded since 1945. Academic modeling confirmed that Missouri experienced only a **0.4% increase** in birth rates attributable to the restriction of procedures, making it the smallest estimated increase among all studied states with restrictions. 17 This low rate, compared to the 2.3% average increase in other states with bans 5, indicates that external access minimized the fertility effect intended by the state statute.
Analysis of the geographic context shows that the prohibition increased the average travel distance to the nearest provider for Missouri residents by only 2.2 miles. Research suggests that minimal increases in travel distance generally result in a negligible change in birth rates.
B. Estimated Resident Procedure Ratio
The procedure ratio (the number of procedures per 1,000 live births) utilizing the comprehensive resident total (Metric C) confirms the sustained demand.
Table 2: Estimated Resident Procedure Ratio (Total Procedures per 1,000 Live Births)
| Year | Live Births (A) | Estimated Total Resident Procedures (C) | Estimated Resident Procedure Ratio (C/A * 1,000) |
|---|---|---|---|
| 2022 | 68,954 | 10,255 | 148.7 |
| 2023 | 67,123 | 11,600 | 172.8 |
Sources: 3
The high Estimated Resident Procedure Ratio confirms that the majority of Missouri residents seeking procedures continued to access them, primarily outside state borders.
C. Policy Implications for Amendment 3
In November 2024, voters approved Amendment 3, a constitutional measure concerning the right to reproductive freedom. 19 This measure took effect in December 2024. 19 However, the legal landscape remains subject to ongoing litigation over pre-existing state regulations, including targeted facility restrictions and a statute restricting the use of telemedicine for procedures.
The data analysis suggests that the implementation of Amendment 3 may have a minimal effect on the total number of live births because:
- Low Impact of Prior Law: The prior legislative prohibition resulted in a 0.4% increase in the birth rate, demonstrating that external access options already largely negated the fertility impact. 17
- External Resource Utilization: The high estimated rate of resident procedures obtained out of state (11,600 in 2023) 8 confirms that a robust external support system exists, which minimizes the influence of Missouri’s in-state policy on final outcomes.
- Ongoing Legal Barriers: Despite the constitutional change, courts have been involved in challenges regarding the continued enforcement of numerous pre-existing regulations. 20 The resumption of full-scale in-state services depends not only on the amendment but on the resolution of legal challenges concerning facility-based requirements and the prohibition on non-clinical dispensing. Until these are resolved, external access points will likely continue to absorb most resident demand.
The fact that the state prohibition had a a minimal impact on birth rates (0.4%) suggests that subsequent policy adjustments, such as Amendment 3, may not significantly alter the established trends of out-of-state and non-clinical procedures.
Works Cited
- Abortion Reporting: Missouri (2023) - Lozier Institute, accessed October 6, 2025, https://lozierinstitute.org/abortion-reporting-missouri-2023/
- Abortion Reporting: Missouri (2020) - Charlotte Lozier Institute, accessed October 6, 2025, https://lozierinstitute.org/abortion-reporting-missouri-2020/
- Abortion Reporting: Missouri (2022) - Lozier Institute, accessed October 6, 2025, https://lozierinstitute.org/abortion-reporting-missouri-2022/
- Georgia Tech Research First to Analyze Birth-Rate Impact of 2022 Abortion Ruling, accessed October 6, 2025, https://iac.gatech.edu/featured-news/2023/12/dobbs-impact
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- Provision of Medications for Self-Managed Abortion Before and After the Dobbs v Jackson Women's Health Organization Decision - PubMed, accessed October 6, 2025, https://pubmed.ncbi.nlm.nih.gov/38526865/
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- Missouri Maternal & Infant Health Data - KFF, accessed October 6, 2025, https://www.kff.org/interactive/womens-health-profiles/missouri/maternal-infant-health/
- Vital Statistics | Health & Senior Services, accessed October 6, 2025, https://health.mo.gov/data/vitalstatistics/data.php
- Percentage of births by race/ethnicity: Missouri, 2021-2023 Average - March of Dimes, accessed October 6, 2025, https://www.marchofdimes.org/peristats/data/old?reg=29&top=2&stop=10&lev=1&slev=4&obj=3
- Aid Access, accessed October 6, 2025, https://aidaccess.org/en/
- Abortion Reporting: Missouri (2021) - Charlotte Lozier Institute, accessed October 6, 2025, https://lozierinstitute.org/abortion-reporting-missouri-2021/
- Get an Abortion Pill Online in Missouri ∙ Order Here - Aid Access, accessed October 6, 2025, https://aidaccess.org/en/page/2934676/where-can-i-buy-the-abortion-pill-online-in-missouri
- 2022 Missouri Vital Statistics, accessed October 6, 2025, https://health.mo.gov/data/vitalstatistics/mvs22/2022MissouriVitalStatistics.pdf
- Provisional Vital Statistics for January 2024 - Missouri Department of Health and Senior Services, accessed October 6, 2025, https://health.mo.gov/data/vitalstatistics/prov24/jan-2024.pdf
- Where People Get Abortion Pills Online in Missouri - PLAN C, accessed October 6, 2025, https://www.plancpills.org/abortion-pill/missouri
- Self-Managed Abortion Increased After Dobbs - ANSIRH, accessed October 6, 2025, https://www.ansirh.org/research/research/new-research-shows-self-managed-abortion-increased-aftermath-dobbs-decision
- Missouri Amendment 3, Right to Reproductive Freedom Initiative (2024) - Ballotpedia, accessed October 6, 2025, https://ballotpedia.org/Missouri_Amendment_3,_Right_to_Reproductive_Freedom_Initiative_(2024)
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