On June 24, 2022, the Supreme Court issued a ruling in Dobbs v. Jackson Women’s Health Organization that overturned the constitutional right to abortion as well as the federal standards of abortion access, established by prior decisions in the cases Roe v. Wade and Planned Parenthood v. Casey. Prior to the Dobbs ruling, the federal standard was that abortions were permitted up to fetal viability. That federal standard has been eliminated, allowing states to set policies regarding the legality of abortions and establish limits. Access to and availability of abortions varies widely between states, with some states banning almost all abortions and some states protecting abortion access.
This report answers some key questions about abortion in the United States and presents data collected before and new data that was published shortly after the overturn of Roe v. Wade.
Abortion is the medical termination of a pregnancy. It is a common medical service that many women obtain at some point in their life. There are different types of abortion methods, which the National Academy of Sciences, Engineering, and Medicine (NASEM) places in four categories:
- Medication Abortion – Medication abortion, also known as medical abortion or abortion with pills, is a pregnancy termination protocol that involves taking oral medications. There are two widely accepted protocols for medication abortion. In the U.S., the most common protocol involves taking two different drugs, Mifepristone and Misoprostol. Typically, an individual using medication abortion takes Mifepristone first, followed by misoprostol 24-48 hours later. In the U.S., the Food and Drug Administration (FDA) has approved this protocol of medication abortion for use up to the first 70 days (10 weeks) of pregnancy, and its use has been rising for years. Another medication abortion protocol uses misoprostol alone. Patients can take 800 µg (4 pills) of misoprostol sublingually or vaginally every three hours for a total of 12 pills. The regimen is also recommended for up to 70 days (10 weeks) of pregnancy, but it is not currently approved by the FDA and is more commonly used in other countries.
- Guttmacher Institute estimates that in 2020, medication was used for more than half (53%) of all abortions. While medication abortion has been available in the U.S. for more than 20 years, studies have found that many adults and women of reproductive age have not heard of medication abortion. Many have confused emergency contraception (EC) pills with medication abortion pills, but EC does not terminate a pregnancy. EC works by delaying or inhibiting ovulation and will not affect an established pregnancy.
- Aspiration, a minimally invasive and commonly used gynecological procedure, is the most common form of procedural abortion. It can be used to conduct abortions up to 14-16 weeks of gestation. Aspiration is also commonly used in cases of early pregnancy loss (miscarriage).
- Dilation and evacuation abortions (D&E) are usually performed after the 14th week of pregnancy. The cervix is dilated, and the pregnancy tissue is evacuated using forceps or suction.
- Induction abortions are rare and conducted later in pregnancy. They involve the use of medications to induce labor and delivery of the fetus.
Decades of research have shown that abortion is a very safe medical service.
Despite its strong safety profile, abortion is the most highly regulated medical service in the country and is now banned in several states. In addition to bans on abortion altogether and telehealth, many states impose other limitations on abortion that are not medically indicated, including waiting periods, ultrasound requirements, gestational age limits, and parental notification and consent requirements. These restrictions typically delay receipt of services.
- NASEM completed an exhaustive review on the safety and effectiveness of abortion care and concluded that complications from abortion are rare and occur far less frequently than during childbirth.
- NASEM also concluded that safety is enhanced when the abortion is performed earlier in the pregnancy. State level restrictions such as waiting periods, ultrasound requirements, and gestational limits that impede access and delay abortion provision likely make abortions less safe.
- When medication abortion pills, which account for the majority of abortions, are administered at 9 weeks’ gestation or less, the pregnancy is terminated successfully 99.6% of the time, with a 0.4% risk of major complications, and an associated mortality rate of less than 0.001 percent (0.00064%).
- Medication abortion pills can be provided in a clinical setting or via telehealth (without an in-person visit). Research has found that the provision of medication abortion via telehealth is as safe and effective as the provision of the pills at an in person visit.
- Studies on procedural abortions, which include aspiration and D&E, have also found that they are very safe. Research on aspiration abortions, the most common procedural method, have found the rate of major complications of less than 1%.
There are three major data sources on abortion incidence and the characteristics of people who obtain abortions in the U.S: the Centers for Disease Control and Prevention (CDC), the Guttmacher Institute, and most recently, the Society of Family Planning’s (SFP) #WeCount project.
The federal CDC Abortion Surveillance System requests data from the central health agencies of the 50 states, DC, and New York City to document the number and characteristics of women obtaining abortions. Most states collect data from facilities where abortions are provided about the clinicians providing abortions, demographic characteristics of patients, gestational age, and type of abortion procedure. Reporting these data to the CDC is voluntary and not all states participate in the surveillance system. Notably, California, Maryland, and New Hampshire have not reported data on abortions to the CDC system for years. CDC publishes available data from the surveillance system annually.
Guttmacher Institute, an independent research and advocacy organization, is the other major source of data on abortions in the U.S. Periodically, Guttmacher conducts the Abortion Provider Census (APC) which provides data on abortion incidence, abortion facilities, and characteristics of abortion patients. Data from this Census are based primarily on questionnaires collected from all known facilities that provide abortion in the country, information obtained from state health departments, and Guttmacher estimates for a small portion of facilities.
The CDC and Guttmacher data differ in terms of methods, timeframe, and completeness, but both show similar trends in abortion rates over the past decade. One notable difference is that Guttmacher’s study includes continuous reporting from California, D.C., Maryland, and New Hampshire, which explains at least in part the higher number of abortions in their data.
Society of Family Planning’s (SFP) #WeCount is a national reporting effort that measures changes in abortion access following the Dobbs ruling. The project reports on the number of abortions per month by state and includes data on abortions provided through clinics, private practices, hospitals, and virtual-only providers. The report does not include data on self-managed abortions that are performed without clinical supervision. The first #WeCount report compares data from April 2022 to data from August 2022, and the second report analyzes data up to December 2022. The effort represents 83% of all providers known to #WeCount who agreed to participate in their research.
This KFF report uses data from the CDC, Guttmacher, and SFP as well as other research organizations.
How has the abortion rate changed over time?
For most of the past decade, there was a steady decline in abortion rates nationally, but there was a slight increase in the years just before the Dobbs ruling.
In their most recent national data, Guttmacher Institute reported 930,160 abortions in 2020 and a rate of 14.4 per 1,000 women. CDC reported 615,991 abortions in 2020 and a rate of 11.2 abortions per 1,000 women (excludes CA, DC, MD, NH). Guttmacher’s study showed an upward trend in abortion from 2017 to 2020 whereas CDC’s report showed an increase in abortions from 2017 to 2019 followed by a slight decrease from 2019 to 2020.
While most attribute the long-term decline in abortion rates to increased use of more effective methods of contraception, several states had reduced access to low- or no-cost contraceptive care as a result of reductions in the Title X network under the Trump Administration, which may have contributed to the slight rise in abortions prior to the Dobbs ruling. Other factors that may have contributed to the increase could include greater coverage under Medicaid that subsequently made abortions more affordable in some states and broader financial support from abortion funds to help individuals pay for the costs of abortion care.
Even prior to the Dobbs ruling, abortion rates varied widely between states.
National averages can mask local and more granular differences. Lower state-level abortion rates do not reflect less need. Some of the variation has been due to the wide differences in state policies, with some states historically placing restrictions on abortion that make access and availability to nearly out of reach and, on the other side, some states enshrining protections in state Constitutions and legislation.
- In 2020, the abortion rate (per 1,000 women ages 15-44) ranged from 0.1 in Missouri to 48.9 in the District of Columbia (DC). Trends also varied between states. While the national rate of abortion increased between 2017 and 2019, some states saw declines, with particularly sharp drops in states where heavy restrictions were put into place.
However, the number of abortions in the U.S. dropped immediately following the ruling in Dobbs v. Jackson Women’s Health Organization in June 2022.
SFP’s #WeCount estimates the number of abortions provided by a clinician decreased from 82,450 abortions in April 2022 to 80600 abortions that following December. States without abortion bans experienced an increase of abortions following the Dobbs ruling likely due to interstate travel for abortion access, rising from an estimated 74,950 abortions in April 2022 to an estimated 80,600 abortions in December 2022. States that have implemented abortion bans saw a drop in the number of abortions, from an estimated 7,500 abortions in April 2022 to fewer than 10 abortions per month after August 2022. These estimates, however, do not include abortions that may have been performed through self-managed means, outside of clinical setting or telehealth with a clinician.
In 2020, women across a range of age groups, socioeconomic status, and racial and ethnic backgrounds obtained abortions, but the majority were obtained by women who were in their twenties, low-income, and women of color.
- Women in their twenties accounted for more than half (57%) of abortions. Nearly one-third (30%) were among women in their thirties and a small share were among women in their 40s (4%) and teens (9%).
- More than half of abortions were among women of color. Black women comprised 39% of abortion recipients, 33% were provided to White women, 21% to Hispanic women, and 7% were among women of other races/ethnicities.
- Many women who sought abortions have children. Nearly six in 10 (61%) abortion patients in 2020 had at least one previous birth.
The vast majority (92%) of abortions occur during the first trimester of pregnancy according to data available from before the Dobbs decision.
Before the 2022 ruling in Dobbs, there was a federal constitutional right to abortion before the pregnancy is considered to be viable, that is, can survive outside of a pregnant person’s uterus. Viability is generally considered around 24 weeks of pregnancy. Most abortions, though, occur well before the point of fetal viability.
- Data from 2020 found that four in ten (40%) abortions occurred by six weeks of gestation, another four in ten (39%) occurred between seven and nine weeks, and 13% at 10-13 weeks. Just 8% of abortions occurred after the first trimester.
- Prior to the decision in the Dobbs case, almost half of states (22) had enacted laws that ban abortion at a certain gestational age. Most of these limits are in the second trimester, but some are in the first trimester, well before fetal viability. Many of these laws were blocked because they violated the federal standard established by Roe v Wade. Some states have enacted laws banning abortions after fetal cardiac activity can be detected, or around 6 weeks of pregnancy, which is often before a person knows they are pregnant. In addition to banning abortion, states can now establish pre-viability gestational restrictions because the federal standard has been overturned.
Just over half of abortions were provided at clinics that specialize in abortion care in 2020. Others were provided at clinics that offer abortion care in addition to other family planning services.
Guttmacher Institute estimated that 96% of abortions were provided at clinics and just 4% were provided in doctors’ offices or hospitals in 2020. Most clinic-based abortions were provided at clinics that specialize in providing abortion care, but many were provided at clinics that offer a wide range of other sexual and reproductive health services like contraception and STI care. Most abortions are provided by physicians. However, in 19 states and D.C., Advanced Practice Clinicians (APCs) such as Nurse Practitioners and midwives may provide medication abortions. Conversely, 31 states prohibit clinicians other than physicians from providing abortion care.
Even prior to the ruling in Dobbs, access to abortion services was very uneven across the country though. The proliferation of restrictions in many states, particularly in the South, had greatly shrunk the availability of services in some areas. In the wake of overturning Roe v. Wade, these geographic disparities are likely to widen as more states ban abortion services altogether.
Telehealth has grown as a delivery mechanism for abortion services.
While procedural abortions must be provided in a clinical setting, medication abortion can be provided in a clinical setting or via telehealth. Access to medication abortion via telehealth had been limited for many years by a Food and Drug Administration (FDA) restriction that had permitted only certified clinicians to dispense mifepristone in a health care setting. The drug could not be mailed or picked up at a retail pharmacy. However, in December 2021, the FDA permanently revised its policy and no longer requires clinicians to dispense the drug in person. Additionally, in January 2023, the FDA finalized a change that allows retail pharmacies to dispense medication abortion pills to patients with a prescription.
While some states are regulating the use of mifepristone as an abortion method, the Biden Administration has asserted that the FDA has regulatory power over all drugs, including mifepristone. This could result in future legal action as the authority of the state to regulate health care will be pitted against the authority of the federal government to regulate drugs through the FDA will be contested.
- In a telehealth abortion, the patient typically completes an online questionnaire to assess (1) confirmation of pregnancy, (2) gestational age and (3) blood type. If determined eligible by a remote clinician, the patient is mailed the medications. This model does not require an ultrasound for pregnancy dating if the patient has regular periods and is sure of the date of their last menstrual period (in line with ACOG’s guidelines for pregnancy dating). If the patient has irregular periods or is unsure how long they have been pregnant, they must obtain an ultrasound to confirm gestational age and rule out an ectopic pregnancy3and send in the images for review before receiving their medications. If the patient does not know their blood type or has Rh negative blood, the provider may prompt the patient to visit a nearby clinic for an injection to prevent adverse reactions between maternal and fetal blood (RhoGAM), The follow-up visit with a clinician can also happen via a telehealth visit.
- However, even in some of the states that have not banned abortion altogether, telehealth may not be available. Many states had established restrictions prior to the Dobbs ruling that limit the use of telehealth abortions by either requiring abortion patients to take the pills at a physical clinic, require ultrasounds for all abortions, set their own policies regarding the dispensing of the medications used for abortion care, or directly ban the use of telehealth for abortion care. As of November 2022, of the 33 states that have not banned abortion, eight had at least one of these restrictions, effectively prohibiting telehealth for medication abortion.
- Medication abortion has emerged as a major legal front in the battle over abortion access across the nation. Multiple cases have been filed in federal courts regarding aspects of the FDA’s regulation of medication abortion as well as the mailing of medications. One notable ongoing case is Alliance for Hippocratic Medicine v. FDA, where the plaintiffs are challenging the FDA’s authority and approval process for mifepristone. The plaintiffs also contend that an 1873 anti-obscenity law, the Comstock Act, prohibits the mailing of any medication used for abortion. In April 2023, a US Supreme Court ruling allowed current FDA rules to remain in effect as the case proceeds through the courts. This means that mifepristone remains available for medication abortion either in a clinic or via telehealth where state law permits.
Data from SFP’s April 2023 #WeCount report show that abortions provided by virtual-only clinics represent approximately 9% of all abortions post-Roe. The number of telehealth abortions increased 137% from 3,590 abortions in April 2022 to 8,540 abortions in December 2022. Virtually all of these abortions occurred in states that permit abortions.
Self-managed abortions are provided without a clinician visit.
Self-managed abortions typically involve obtaining medication abortion pills from an online pharmacy that will send the pills by mail or by purchasing the pills from a pharmacy in another country. This does not typically involve a direct consultation with a clinician either in person or via telehealth.
Research has found that prior to Dobbs, more than one in ten patients who obtained abortions at clinics had considered self-managing their abortions. This is likely to increase going forward since abortion care is not available in many states, and there have already been reports of people ordering pills from online markets outside the U.S. medical system. Tracking information on these online orders can help fill in gaps in abortion count estimates but can also be difficult. Some companies may not share data on purchases, and it would also be unclear whether patients take the abortion medication after receiving it in the mail.
The median costs of abortion services exceed $500.
Obtaining an abortion can be costly. On average, the costs are higher for abortions in the second trimester than in the first trimester. State restrictions can also raise the costs, as people may have to travel if abortions are prohibited or not available in their area. Many people pay for abortion services out of pocket, but some people can obtain assistance from local abortion funds.
- In 2021, the median costs for people paying out of pocket in the first trimester were $568 for a medication abortion and $625 for a procedural abortion. The Federal Reserve estimates that nationally about one-third of people do not have $400 on hand for unexpected expenses. For low-income people, who are more likely to need abortion care, these costs are often unaffordable.
- The costs of abortion are higher in the second trimester compared to the first, with median self-pay of $775. In the second trimester, more intensive procedures may be needed, more are likely to be conducted in a hospital setting (although still a minority), and local options are more limited in many communities that have fewer facilities. This results in additional nonmedical costs for transportation, childcare, lodging, and lost wages. nonmedical costs for transportation, childcare, lodging, and lost wages.
- Abortion funds are independent organizations that help some people pay for the costs of abortion services. Most abortion funds are regional and have connections to clinics in their area. Funds vary, but they typically provide assistance with the costs of medical care, travel, and accommodations if needed. However, they do not reach all people seeking services, and many people are not able to afford the costs of obtaining an abortion because they cannot pay for the abortion itself or cover the costs of travel, lodging or missed work.
Insurance coverage for abortion services is heavily restricted in certain private insurance plans and public programs like Medicaid and Medicare.
Private insurance covers most women of reproductive age, and states have the responsibility to regulate fully insured private plans in their state, whereas the federal government regulates self-funded plans under the Employee Retirement Income Security Act (ERISA). States can choose whether abortion coverage is included or excluded in private plans that are not self-insured.
- Prior to the Dobbs ruling, several states had enacted private plan restrictions and banned abortion coverage from ACA Marketplace plans. Currently, there are 11 states that have policies restricting abortion coverage in private plans and 26 that ban coverage in any Marketplace plans. Since the Dobbs ruling, some of these states have also banned the provision of abortion services altogether.
- A handful of states (7), however, have enacted laws that require private plans to cover abortion.
- The Medicaid program covers approximately one in five women of reproductive age and four in ten who are low-income. For decades, the Hyde Amendment has banned the use of federal funds for abortion in Medicaid and other public programs unless the pregnancy is a result of rape, incest, or it endangers the woman’s life.
- States have the option to use state-only funds to cover abortions under other circumstances for women on Medicaid, which 16 states do currently. However, more than half (56%) of women covered by Medicaid live in Hyde states.
- According to a Guttmacher Institute survey of patients in the year prior to the Dobbs ruling, a quarter (26%) of abortion patients in the study used Medicaid to pay for abortion services, 11% used private insurance, and 60% paid out of pocket. People in states with more restrictive abortion policies were less likely to use Medicaid or private insurance and more likely to pay out of pocket compared to people living in less restrictive states.
- Federal law also restricts abortion funding under the Indian Health Service, Medicare, and the Children’s Health Insurance Program. Over the years, language similar to that in the Hyde Amendment has been incorporated into a range of other federal programs that provide or pay for health services to women including: the military’s TRICARE program, federal prisons, the Peace Corps, and the Federal Employees Health Benefits Program.
National polls have consistently found that a majority of the public did not want to see Roe v. Wade overturned and that most people feel that abortion is a personal medical decision. The public also strongly opposes the criminalization of abortion both among people who get abortion and the clinicians who provide abortion services.
- Prior to the ruling in Dobbs, most adults (64%) said they do not want to see the Supreme Court overturn its decision in Roe v. Wade. This share rises to 71% among reproductive age women, who are most affected by abortion policies.
- Nearly three quarters of adults (74%) and 79% of reproductive age women say that obtaining an abortion should be a personal choice rather than regulated by law.
- Majorities of the public oppose policies that greatly limit access and availability of abortion services, including restrictions that effectively block abortion access altogether. Large majorities oppose imposing criminal penalties on doctors who perform abortions or women who obtain them as well as state laws that impose civil penalties on those who provide or assist women who get abortions like the SB8 law in Texas.
Source : KFF News