"An estimated 30% of U.S. women will have an abortion by age 45, and abortion incidence is one indicator of unintended pregnancy. In 2008, 51% of pregnancies were unintended, and 40% of these ended in abortion. While one of the goals established in 2000 in Healthy People 2010 was to reduce the incidence of unintended pregnancy, progress has been elusive. Between 2001 and 2008, the unintended pregnancy rate increased from 49 to 54 pregnancies per 1,000 women aged 15–44, and the proportion of pregnancies that were unintended increased from 48% to 51%; the proportion of unintended pregnancies ending in abortion declined from 47% to 40%. These patterns could represent increased difficulty in accessing abortion services.
In 2008, the most recent year for which we have complete abortion data, 1.21 million abortions were performed.4 This figure was notable because it was similar to that found for several preceding years, which suggested that the long-term decline in abortion had stalled. The abortion rate declined steadily from 1990 to 2005—from 27.4 to 19.4 abortions per 1,000 women aged 15–44—but leveled off between 2005 and 2008, when it was also 19.4.* The Centers for Disease Control and Prevention (CDC) compiles and publishes annual abortion statistics, and while its counts are incomplete (e.g., abortions in California are not included), the trends are often consistent with more complete abortion counts.4,5 The most recent CDC abortion surveillance reports showed a 5% drop in the number and rate of abortions between 2008 and 2009,5 and a 3% decline between 2009 and 2010.6
Changes in abortion rates, or lack thereof, may be influenced by a number of variables, including changes in sexual activity, the economy and the demographic profile of the population. Two well-monitored variables that may directly influence both the need for and the use of abortion services are contraceptive use and the availability of abortion services.
The increased use of contraceptives, improvements in consistency of use and greater reliance on highly effective methods can reduce levels of unintended pregnancy.7–9 According to an analysis of data from the 2006–2010 National Survey of Family Growth, long-acting reversible contraceptive (LARC) methods have begun to displace shorter term methods among women using contraceptives, especially those younger than 25, who are traditionally at high risk of unintended pregnancy.7 Consequently, fewer unintended pregnancies and abortions may be occurring.
A change in the number of abortion providers could affect access to abortion, and the number of facilities that offer abortions is one measure of service availability. The number of providers peaked in 1981 at approximately 2,900 facilities, and declined steadily to about 1,800 facilities in 2000.10 Since then, the decline in provider numbers appears to have stalled, as slightly fewer than 1,800 facilities were identified in 2008.4 However, a focus on the total number of facilities can obscure the dynamics of abortion access, as caseloads vary substantially by provider type. In 2008, hospitals accounted for 34% of abortion facilities, but they performed only 4% of abortions. By contrast, clinics accounted for 47% of facilities and 94% of procedures. Physicians’ offices represented 19% of facilities but provided only 1% of abortions.4 Hence provider type, and the number of clinics in particular, may be a more important indicator of access than the total number of providers.
Abortion restrictions can also reduce access to services and, in turn, abortion incidence. Many abortion laws, such as mandated counseling and waiting periods, are intended to discourage women from obtaining abortions, thereby reducing the “demand” for services.11 To date, little evidence indicates that these demand-side laws have substantially reduced state abortion rates; the potential exceptions are 24-hour waiting periods that require two in-person visits12 and the elimination of state Medicaid funding of abortion services.13 Legislators have also increased efforts to restrict the “supply” of abortion, typically through targeted regulation of abortion providers (TRAP) laws. TRAP laws place unnecessary and burdensome regulations on providers, typically by targeting clinics. For example, a handful of states have implemented, or attempted to implement, laws that require physicians at abortion clinics to have admitting privileges at local hospitals or that require clinics to meet the same requirements as surgical centers. Since 2008, a number of states have enacted a range of laws pertaining to abortion services,14–17 and these restrictions potentially made it more difficult for women to obtain abortions and for abortion facilities to provide services.18
In the last decade, early medication abortion has played an important role in abortion care in the United States and developed the potential to influence service provision and availability. Mifepristone was introduced in late 2000, and by the first half of 2001, early medication abortions accounted for 6% of procedures.19 The role of early medication abortions has continued to increase: Fourteen percent of nonhospital abortions were medication procedures in 2005,20 as were 17% in 2008.4 The majority of these early procedures were provided by clinics that specialized in abortion services, but some physicians’ offices and nonspecialized clinics that are unable or unwilling to provide surgical procedures (e.g., because the latter require more equipment and training) now offer early medication abortions. Provision of this procedure at physicians’ offices increased substantially immediately after mifepristone was introduced, but quickly stabilized;21 the number of physicians’ offices offering this service decreased slightly between 2005 and 2008, though the number of nonspecialized clinics doing so increased.4 In Iowa, early medication abortion provided via telemedicine appears to have made abortion more accessible to women living in rural areas:22 After this procedure became available through telemedicine, women were more likely to obtain a medication abortion and to obtain an abortion at an earlier gestation, even though the overall abortion rate in the state decreased.
This study summarizes information from the Guttmacher Institute’s most recent Abortion Provider Census, and provides updated information about abortion incidence and facilities in the United States, focusing on changes between 2008 and 2011. It also considers abortion restrictions enacted during the study period, and discusses whether they may have affected state patterns in abortion incidence and access to services."