Abortion in the United States

Abstract

Abortion is an extremely safe and common medical procedure. In the United States, over one million women had an abortion in the year 2000. Advances in early abortion techniques have helped to increase the proportion of early procedures, the safest type. Abortion rates have been declining since the early nineties among adults and adolescents, but rates among poor, minority women remain high. State restrictions to abortion have a larger impact on poor women and young women. Restrictions and regulations have also resulted in the concentration of abortion services in specialized clinics. These clinics are subject to harassment. The expansion of abortion services to more types of providers could increase access, as well as integrate abortion into women's health care.

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Annu. Rev. Public Health 2005. 26:3.1–3.12
doi: 10.1146/annurev.publhealth.26.021304.144351
Copyright c
2005 by Annual Reviews. All rights reserved
ABORTIONINTHEUNITED STATES
Cynthia C. Harper, Jillian T. Henderson,
and Philip D. Darney
Center for Reproductive Health Research and Policy, Department of Obstetrics,
Gynecology, and Reproductive Sciences, University of California, San Francisco,
California 94143; email: harperc@obgyn.ucsf.edu, hendersonj@obgyn.ucsf.edu,
darneyp@obgyn.ucsf.edu
KeyWords legal restrictions, access to services, medical abortion, socioeconomic
disparities
■Abstract Abortion is an extremely safe and common medical procedure. In the
United States, over one million women had an abortion in the year 2000. Advances in
early abortion techniques have helped to increase the proportion of early procedures,
the safest type. Abortion rates have been declining since the early nineties among adults
and adolescents, but rates among poor, minority women remain high. State restrictions
to abortion have a larger impact on poor women and young women. Restrictions and
regulations have also resulted in the concentration of abortion services in specialized
clinics. These clinics are subject to harassment. The expansion of abortion services
to more types of providers could increase access, as well as integrate abortion into
women’s health care.
LEGAL CHANGES AND STATE RESTRICTIONS
Since the passage of Roe v. Wade in 1973, many legal challenges to abortion rights
have been mounted. The 1992 decision Planned Parenthood v. Casey upheld the
right to abortion but, at the same time, gave states the right to enact restrictions that
do not create an “undue burden” for women seeking abortion. This decision en-
couraged numerous legal and regulatory restrictions on abortion. These restrictions
tend to have a greater effect on women who are at the highest risk of unintended
pregnancy, namely poor women and young women. The restrictions also often
define the clinical settings where services can be delivered. State regulatory re-
strictions, including zoning rules, state licensing, and inspection requirements,
explain the concentration of abortions in specialized abortion clinics (24).
In addition to targeted regulations, abortion restrictions that impede access
to services include state-mandated waiting periods and counseling topics, such
as showing women sonographic or other images of fetal development, parental
involvement for minors, and insurance restrictions. Although many states require
some kind of counseling, five states (Louisiana, Mississippi, Utah, Wisconsin, and
Indiana) require counseling in person at least 18 h before the procedure, which
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3.2 HARPER HENDERSON DARNEY
means women must make at least two trips to the office or clinic (3). This type
of requirement is particularly burdensome for women who have to travel some
distance to reach a clinic, including women who live in the 87% of counties,
mostly rural, that do not have abortion services (24).
Most states require parental consent or notification for minors,1but provide
the option of seeking a court order exempting minors from the requirement. The
regulations are complex, ranging from consent, notification, judicial bypass, in-
volvement of other adult relatives, to exceptions for medical emergencies or abuse,
assault, incest or neglect (4). Such extensive variation in different laws means that
few minors are likely to be aware of all requirements.
Coverage of abortion costs is limited. The federal Medicaid program pays for
abortion only for life endangerment, incest, or rape, as required by the Hyde
Amendment [1977]. Only 18 states cover abortion under Medicaid for reasons
beyond rape, incest, and life endangerment, as of December 2002. South Dakota,
however, will cover Medicaid recipients only for life endangerment and not for
incest or rape (5). State prohibitions on coverage for abortion exist for both public
employee plans and private insurance plans. In Colorado and Kentucky, abortion
coverage is never given for public employees, not even when life is at risk. In four
states (Idaho, Kentucky, Missouri, and North Dakota), private insurance can cover
abortion only in cases of life endangerment (6).
“Partial-Birth” Abortion
During the 1990s several states passed a ban on a procedure referred to as “partial-
birth” abortion, though the accepted medical term is dilation and extraction (D&X),
a procedure used rarely in second-trimester terminations. The procedure accounted
for approximately 0.17% or 2000 abortions in the year 2000 (19). In Stenberg v.
Carhart,in2000, the Supreme Court declared unconstitutional Nebraska’s law
criminalizing “partial-birth” abortion because the law lacked an exception to pro-
tect health and was written so broadly as to confuse D&X with other second-
trimester procedures including dilation and evacuation (D&E). Whereas state
courts blocked 18 state bans, in other states the bans were unchallenged (5).
The legal movement to ban D&X culminated in the passage of the federal
Partial Birth Abortion Act. The Act went into effect in November 2003. However,
hospitals and physicians immediately began to challenge the constitutionality of
the ban because it potentially includes many different types of procedures that
may be medically necessary (7). The Justice Department responded by issuing
subpoenas for medical records of patients who have had abortions. However, the
clinics and hospitals have stated that the subpoena violates the patient-privacy
1Thirty-three states require parental consent or notification: Alabama, Arkansas, Arizona,
Delaware, Georgia, Iowa, Idaho, Indiana, Kansas, Kentucky, Louisiana, Massachusetts,
Maryland, Michigan, Minnesota, Missouri, Mississippi, North Carolina, North Dakota,
Nebraska, Ohio, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee,
Texas, Utah, Virginia, Wisconsin, West Virginia, and Wyoming.

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ABORTION IN THE UNITED STATES 3.3
provisions of the Health Insurance Portability and Accountability Act (HIPAA),
and the Justice Department has amended its request for patient records and lists
of physicians who provide abortion at the plaintiff institutions (34). The Federal
District Court in San Francisco recently rejected the constitutionality of the ban, but
decisions are pending in other cases and appeals are likely to bring the legislation
before the Supreme Court.
Clinics Under Siege
Harassment and violence have aroused fear in women seeking abortions and are
significant factors in the decline in the numbers of abortion providers over the past
few decades. In response to clinic harassment and violence, in 1994 the federal
government enacted the Freedom of Access to Clinic Entrances Act, prohibiting
property damage, use of force or threat of force, or obstruction of someone entering
a clinic. Several states have passed specific legislation to ensure the federal act is
upheld (8). However, harassment is still common, particularly at larger clinics.
Eighty percent of providers of 440 or more abortions per year reported harassment
in 2000, 28% reported picketing with physical contact with patients, 18% reported
vandalism, 14% reported picketing homes of staff, and 15% reported receiving
bomb threats. Aside from picketing, other types of harassment have declined since
implementation of the act to protect clinics (24).
In addition to harassment, there have also been attempts to arouse fear in women
seeking services by linking abortion to the risk of breast cancer. Although scientific
evidence does not support this link (14, 15), it took a full panel of experts to
remove misleading information from the Web site of the National Cancer Institute.
However, the misinformation did not stop at the Web site; several states enacted
legislation that required the inclusion of misleading breast cancer information as
part of “informed consent” for abortion. In some states it is also required to include
photographs of developing fetuses and descriptions of mental and physical risks
not proven to be associated with abortion.
SERVICES
Advances in medicine and other areas have helped to improve abortion services
in spite of the myriad factors that work to block access. Abortion in the early
first trimester (before eight weeks) is far more accessible than in the past, and the
choice of methods has expanded to include several regimens of medical abortion
and manual uterine aspiration. Advancements in abortion clinic protocols, such as
the requirement of fewer clinic visits and provision of all types of contraception,
including emergency contraception, have increased convenience for women and
efficiency for clinics and decreased costs (32, 37). Clinical research on abortion
continues to improve the safety of the various procedures and opens up new pos-
sibilities for the future as well (21, 36). Scientific progress in abortion research
and improvements in services are important for women’s health because induced

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3.4 HARPER HENDERSON DARNEY
abortion is among the most common medical procedures in the United States. In
the year 2000 there were 1.31 million abortions. Nearly half of American women
will have one or more in their lifetimes (19).
Although abortion is a common procedure, the abortion rate has been declining
over time since the early nineties. In 1973, when abortion was first made legal
throughout the United States, there were 16.3 abortions per 1000 women aged 15–
44; the rate increased to 29.3 in 1982 and fell to 21.3 in 2000 (19). The adolescent
abortion rate has been declining since 1987, and from the mid-nineties to 2000, it
declined at a faster rate than that of adult women (28). Almost 90% of abortions
occur in the first trimester (by 12 weeks gestation), and more than 98% are done
by 20 weeks gestation (19).
The majority of abortions in the United States are provided in freestanding
clinics. Clinics provided 93% of abortions in 2000; specialized abortion clinics
provided 71%. Hospitals provided 5%, down from 22% in 1980. Physicians’ offices
accounted for only 2% of abortions (19). Although this service delivery model has
been satisfactory for many years, it has also served to isolate abortion from the
broader spectrum of women’s health care and has made providers and clients
more susceptible to antiabortion harassment and violence. If abortion services
were integrated into mainstream medical care, harassment and violence would be
less common.
Demographic Characteristics
Data from a nationally representative survey of women undergoing abortions in
2000–2001 showed the overall adolescent abortion rate (aged 15–19 years) to be
25 per 1000 women aged 15–19; the younger adolescents, ages 15–17 years, had
a rate of 15 per 1000; and ages 18–19 years had a rate of 39 per 1000. Women
aged 20–24 years had the highest rate of 47 per 1000. Higher rates among young
women ages 18–24 years are due to lower usage of effective contraception in that
age range than in older women, as well as to higher fecundity (28).
Women who are unmarried (single or cohabitating) are more likely to have
abortions than are married women. Low-income women also have more abor-
tions because they have far more unintended pregnancies than do high-income
women. Abortion rates in the year 2000 among low-income women were 44
per 1000 compared with 10 per 1000 among high income. Abortion rates fell
for high- and middle-income women from the mid-nineties to the year 2000, but
they increased among low-income and Medicaid recipients, including low-income
teenagers. Black women are more likely to have unintended pregnancies than are
women in other racial/ethnic groups, and thus they are more likely to have abor-
tions. The abortion rate is 49 per 1000 for blacks, 33 per 1000 for Hispanics, 31
per 1000 for Asians, and 13 per 1000 for whites (28).
Safety
After legalization, deaths and morbidity caused by abortion experienced a steep
and rapid decline (12, 18, 42). Data from the Abortion Mortality Surveillance

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ABORTION IN THE UNITED STATES 3.5
System of the Centers for Disease Control and Prevention show that the risk of
death associated with abortion is low, at 0.6 per 100,000 abortions. The risk of
death from childbirth is 11 times greater than the risk of death from abortion. The
causes of death from abortion are equally distributed among hemorrhage, infection,
embolism, and anesthesia complications. The risk of major complications is less
than 1%, and there is no evidence of subsequent childbearing problems among
women who have had abortions (18).
Early procedures are extremely safe. Most deaths result from abortion during
more advanced gestational periods. Bartlett et al. (9) estimated the relative risk
of abortion-related mortality at higher gestations compared with abortions at 8
weeks or less. The relative risk was 14.7 at 13–15 weeks gestation, 29.5 at 16–
20 weeks, and 76.6 at 20+weeks (95% CI 32.5, 180.8). The authors concluded
that up to 87% of deaths in women having abortions may have been avoided if
the pregnancy had been terminated before 8 weeks gestation. Increased access to
abortion services, and particularly early abortion services, may help to decrease
abortion-related deaths.
Early Abortion
Before 1990 provision of early abortion was rare. However, a growing proportion
of providers now offer very early abortion: Whereas only 7% of providers offered
early abortion in 1993, 37% did in 2000. Abortion clinics are more likely to offer
very early abortion than are other providers. The proportion of abortions performed
in early pregnancy (up to 6 weeks gestational age) increased from 14% in 1992 to
22% in 1999 (19).
Research has shown high rates of success at early gestational ages with both
medical and surgical abortion owing to advances such as vaginal ultrasonography
and highly sensitive urine pregnancy tests (17). Manual uterine aspiration, a non-
electric aspiration technique used in low-resource settings for postabortion care,
has recently been shown to be an acceptable and effective method in the United
States as well (20). Manual uterine aspiration can be used for early abortion and
as a backup for failed medical abortions.
Medical Abortion
In September 2000, the U.S. Food and Drug Administration (FDA) approved
mifepristone for abortion in the United States. While methotrexate had been avail-
able earlier for medical abortion, its use was off-label and infrequent. Distribution
of mifepristone began in November 2000, and in the first half of 2001, there were
approximately 37,000 medical abortions, or 6% of all abortions. One third of
abortion providers offered medical abortion in that time period: 72% of these used
mifepristone, and the rest used methotrexate. Medical abortion was more likely
to be available from large clinics that already used surgical methods than from
doctors’ offices or hospitals. The average cost of a medical abortion in nonhospital
facilities in 2000 was $490 (24). By comparsion, the inflation-adjusted cost of
surgical abortion remained steady until the late nineties, and then began to rise;

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3.6 HARPER HENDERSON DARNEY
the average client paid $319 for surgical abortion at 10 weeks in 1997 and $373
in 2001 (24).
Research has shown that medical abortion can be provided in any physician’s
office or medical facility and that it could be done successfully by all types of
providers (10). Because the method requires no surgical training, primary care
physicians, family practice physicians, internists, and adolescent health specialists
could offer medical abortion (26). The involvement of nurse practitioners and
physicians’ assistants, along with more streamlined protocols such as home use of
misoprostol, can reduce the cost of medical abortions. The expansion of abortion
services outside of specialized clinics also means that abortions could take place
in privacy, outside of the scrutiny of picketers and protesters (11, 22).
However, integrating medical methods of abortion into mainstream medical
practice will take some experimentation and flexibility. The FDA-approved label-
ing is restrictive (use within 7 weeks gestational age, mifepristone dose 600 mg;
misoprostol oral dose in person in physician’s office; follow-up visit for exam). In
addition, other requirements such as sonographic evaluation, backup for surgical
abortion, and direct ordering of the drug rather than availability through pharmacies
have hindered the expansion to providers who do not perform surgical abortions
(27).
Both research and clinical practice have shown more convenient and efficient
approaches to be safe and effective, including a 200-mg, rather than a 600-mg, dose
of mifepristone, vaginal rather than oral misoprostal, and fewer clinic visits (35,
37, 38). Most providers in the United States have adopted the newer, convenient
protocols, giving a dose of 200 mg mifepristone (83%) and allowing the client
to take misoprostol at home (84%) (24). The experience in Europe with medical
abortion has shown that although it has taken a long time to integrate services into
the health care system, once this integration happens over half of women seek-
ing early abortion choose medical abortion. The availability of medical abortion
services in Europe has not increased overall abortion rates, although women have
begun to seek abortions earlier in the pregnancy.
ACCESS TO ABORTION
Geography
Many women in need of an abortion face obstacles to services. For example, women
encounter bureaucratic barriers such as state laws requiring waiting periods and
parental consent prior to obtaining an abortion. Another barrier to access is the
absence of physicians who do abortions. The number of abortion providers has
declined substantially since rising to a peak level in 1982 (24). The percentage
of counties without an abortion provider has remained high since 1973. Yet more
counties than ever lack an abortion provider: 87% of counties had no abortion
provider as of the year 2000, and these counties contain over one third of the
population of women aged 15–44 (19). Consequently, nearly one quarter (24%) of

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ABORTION IN THE UNITED STATES 3.7
women seeking an abortion travel 50 miles or more to find a capable physician (24).
Long travel distances, along with mandatory wait periods, can delay services (28).
Counties without an abortion provider usually are in a rural region. Just 3% of
nonmetropolitan counties have an abortion provider. Abortion providers are more
likely to be found in urban areas; nonetheless, over one third of metropolitan areas
have no abortion provider. Women in the northeast and the western regions of the
United States are served by a greater number of abortion providers than are women
in other regions; these regions also have less-restrictive laws, and abortion rates are
higher. Some variation in state abortion rates can be attributed to women’s travel
from states that have fewer providers or more-restrictive policies and gestational
limits to states where they can receive care (25). An example is the decline in the
Wisconsin abortion rate after the passage of a two-day mandatory delay law and a
concomitant rise in Illinois.
Providers and Training
Currently the majority of abortion providers are physicians specializing in ob-
stetrics and gynecology (OB-GYN). A smaller proportion of providers who offer
abortions are family practice physicians and general internists. Interest in offering
medication abortion was relatively high among obstetrician gynecologists, family
practice physicians, and even nonphysician providers (APNs, CNMs, PAs) prior to
the approval of mifepristone (23). Consequently, in states permitting nonphysician
clinicians to offer first-trimester abortions (e.g., Colorado, Maine, and California),
small numbers of nurse practitioners (NP), physician assistants (PA), and certi-
fied nurse midwives (CNM) have sought training and are beginning to provide
first-trimester abortions.
Abortion training opportunities, which had remained at low levels for more
than two decades, have begun to increase, though primarily as an optional rather
than a mandatory component of medical education. More OB-GYN residency
programs are including abortion training as a routine part of medical education
(2). For example, all public hospitals offering OB-GYN residencies in New York
City must now provide abortion training; California passed similar legislation in
2002 applying to state-supported residencies. In 1991–1992, 70% of residency
programs in obstetrics and gynecology offered first-trimester abortion training;
however, only 12% of OB-GYN residency programs included the training as a
standard component of medical education (33). Residency programs in family
medicine are also beginning to incorporate abortion training, but levels of training
among family practice residents remain low: Only 12% of residencies provided the
option in 1994 (41). A survey found that 29% offered optional or routine training in
first-trimester abortion, but only 15% of chief residents had any clinical experience
providing abortion (39). Changes to graduate medical education requirements and
the development of new fellowship programs in family planning may increase the
availability of abortion training. The likelihood that a physician will offer abortion
services is highly associated with the training they receive during residency (1, 40).

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3.8 HARPER HENDERSON DARNEY
FUTURE PROSPECTS
Early Abortion
New abortion techniques and medical protocols that have recently been devel-
oped are expanding the options women have for obtaining abortions in the early
weeks of an unwanted pregnancy. The benefits for women are substantial, as are
the potential benefits for abortion access. Expanded abortion options in the first
eight weeks of pregnancy are available using either medication or manual uterine
aspiration. The availability of medication abortion is increasing, but only approx-
imately one third of abortion facilities offer it (24). A survey of National Abortion
Federation (NAF) members in 2000 found that 59% of sites were offering early
surgical or medication abortion (11), and in early 2002, two thirds of NAF mem-
bers were offering medication abortion (30). The expansion of medication abortion
services in France, Great Britain, and Sweden provide some insight into the po-
tential for the United States because these countries approved mifepristone years
ago and have observed the diffusion ofthe new option (30), though in a much-less-
contested political environment. In each of these countries, medical abortion be-
came more accessible over time. Given the size of the United States and the absence
of providers in most counties, medication abortion has the potential to increase
access.
Unique barriers to offering medical abortion and strategies to overcome them
have been identified for the United States (13). The opportunities to make abortion
available in new settings and to expand the number of providers increase with these
new options, but they will not be realized without organizational and financial
assistance to training programs wanting to establish new services.
Contraceptive Use
A recent nationally representative study of contraceptive use among women ob-
taining abortions found that more than half of women were using some kind of
contraceptive (either consistently or inconsistently) in the month they became
pregnant (29). Low-income women were more likely to report difficulty accessing
contraceptive services as one reason for their nonuse or inconsistency. Reduc-
tions in Medicaid health insurance coverage and stagnating Title X funding for
reproductive health services and supplies are undoubtedly decreasing access to
contraceptives in many states. Women and couples need a range of contraceptive
options and comprehensive information to help them select and use a method that
suits their needs.
Sixteen percent of all women obtaining abortions became pregnant because
they were not expecting to have sex (29). Research suggests that increased em-
phasis on abstinence as a method of contraception may result in increased demand
for abortion; although theoretical effectiveness is high, use effectiveness is low.
Emergency contraception use may be responsible for some of the decline in the
abortion rate during the nineties (29).

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ABORTION IN THE UNITED STATES 3.9
Sociodemographics, Social Disparities, and Abortion
Public health researchers and policy makers are increasingly attentive to social
disparities in health and health care access in the United States (43). But little
attention is paid to trends in abortion and how they are affecting women differently
by race and class. In recent years, the rate of abortion has risen among low-income
women (those living below 200% of the federal poverty line) so that these women
account for over half of all abortions obtained in the United States, although they
comprise only 15% of the population. Abortion rates among black and Hispanic
women have risen in recent years, whereas rates fell for white women. Access
to information, education, quality health care, and contraceptive methods and
services may contribute to the disparity in rates. Policies and programs that help
women avoid unintended pregnancy are important public health measures, but
maintaining access to abortion services is also critical to the lives of women with
limited resources.
Changes in welfare policy in the United States may affect abortion access and
incidence. The 1996 Personal Responsibility and Work Opportunity Reconcilia-
tion Act (P.L. 104–193) introduced new U.S. welfare policy that included work
requirements and permitted states to place caps on the amount of money a woman
could receive irrespective of her family size. The reform to welfare policy was
driven, in part, by public perceptions that poor women were having additional
children to get more money from the government. Twenty-three states imple-
mented the family cap policies, which were intended to discourage women reliant
on Temporary Assistance for Needy Families (TANF) from having more children.
The act may reduce women’s capacity to support children and might increase rates
of abortion. Research on the impact of welfare reform and family cap policies on
abortion rates is limited but has not found such an association thus far (16, 31).
The increase in abortion rates for poor women that has occurred in recent years,
as overall rates have fallen, could be partially a result of the economic pressures
poor families increasingly face; but no evidence supports the assumption that poor
families have changed their childbearing patterns because of changes in welfare
policy. Broadening the abortion rights platform to include the right to bear children
and to support wanted children with profamily policies could result in reductions
in the abortion rate for low-income women if some of these women are having
abortions for economic reasons. Conversely, if they want fewer children for other
reasons, such as work opportunity, rates may not change.
Women over the age of 25 comprise a greater proportion of the population
of women having abortions than they did in 1973. Increases in the mean age for
women at first marriage, as well as changes in the U.S. age structure, may have
contributed to this shift. In addition, women under the age of 18 have faced increas-
ing challenges to their autonomy and access to confidential abortion services with
more states mandating parental involvement. The impact of parental involvement
laws on abortion rates is difficult to estimate. Teen pregnancy rates have fallen
overall in recent years, so declines in abortion rates for this age group do not
necessarily reflect reduced access to services. Comparisons of abortion rates in

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3.10 HARPER HENDERSON DARNEY
states with parental consent laws and states without parental consent laws are also
difficult to interpret since some women cross state lines to obtain abortions.
FUTURE
Interpreting the 30 years of trend data on legal abortion incidence is challenging
but important because the sources of change in abortion rates have very differ-
ent public health implications. Increased use of more effective contraceptives, for
example, would support a positive interpretation of a downward trend. A decline
due to decreased access to abortion, however, could have detrimental effects on
the health of women and children. Similarly, if legal restrictions were responsible,
women might be unable to gain access to safe abortion and rely on unsafe, clan-
destine sources. As more effective long-acting contraceptives are utilized, there is
potential for the abortion rate to decline. Access to health services and contracep-
tion, however, is not evenly distributed in the United States, and it is likely that
reductions in the need for abortion will occur among the most privileged segments
of the population. Such a demographic shift may further undermine support for
access to safe and legal abortion.
The reasons women unintentionally become pregnant are many, and pregnancy
is not always avoidable. Therefore, abortion will continue to be an important
component of women’s health care even with the advent of better methods of
contraception. New developments in abortion technology and practice are encour-
aging because they have the potential to increase access to earlier (and hence safer)
abortion. Integrating abortion care into settings where it has not been available and
increasing the number of providers may be more possible with medical abortion
than it has been in the past with surgical abortion.
The public health implications of legal and safe access to abortion are clear.
Women’s lives are saved when they are able to terminate unwanted pregnancies
as early as possible and in safe medical conditions. Legalizing abortion in the
United States has allowed women to get abortions earlier and has dramatically
decreased the rate of complications and deaths related to induced abortion. Fur-
thermore, the legality of abortion has allowed researchers to develop and improve
the technologies and procedures that make abortion safer than it has ever been
(12). Unfortunately, abortion remains highly contested in U.S. society and politics
and is also stigmatized within medicine.
The Annual Review of Public Health is online at
http://publhealth.annualreviews.org
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ABORTION IN THE UNITED STATES 3.11
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