Abortion Surveillance — United States, 2016
Surveillance Summaries / November 29, 2019 / 68(11);1–41
Please note: This report has been corrected. An erratum has been published.
Tara C. Jatlaoui, MD1; Lindsay Eckhaus, MPH1,2; Michele G. Mandel1; Antoinette Nguyen, MD1; Titilope Oduyebo, MD1; Emily Petersen, MD1; Maura K. Whiteman, PhD1 (View author affiliations)
View suggested citationAbstract
Problem/Condition: Since 1969, CDC has conducted abortion surveillance to document the number and characteristics of women obtaining legal induced abortions in the United States.
Period Covered: 2016.
Description of System: Each year, CDC requests abortion data from the central health agencies of 52 reporting areas (the 50 states, the District of Columbia, and New York City). The reporting areas provide this information voluntarily. For 2016, data were received from 48 reporting areas. Abortion data provided by these 48 reporting areas for each year during 2007–2016 were used in trend analyses. Census and natality data were used to calculate abortion rates (number of abortions per 1,000 women aged 15–44 years) and ratios (number of abortions per 1,000 live births), respectively.
Results: A total of 623,471 abortions for 2016 were reported to CDC from 48 reporting areas. Among these 48 reporting areas, the abortion rate for 2016 was 11.6 abortions per 1,000 women aged 15–44 years, and the abortion ratio was 186 abortions per 1,000 live births. From 2015 to 2016, the total number of reported abortions decreased 2% (from 636,902), the abortion rate decreased 2% (from 11.8 abortions per 1,000 women aged 15–44 years), and the abortion ratio decreased 1% (from 188 abortions per 1,000 live births). From 2007 to 2016, the total number of reported abortions decreased 24% (from 825,240), the abortion rate decreased 26% (from 15.6 abortions per 1,000 women aged 15–44 years), and the abortion ratio decreased 18% (from 226 abortions per 1,000 live births). In 2016, all three measures reached their lowest level for the entire period of analysis (2007–2016).
In 2016 and throughout the period of analysis, women in their 20s accounted for the majority of abortions and had the highest abortion rates. In 2016, women aged 20–24 and 25–29 years accounted for 30.0% and 28.5% of all reported abortions, respectively, and had abortion rates of 19.1 and 17.8 abortions per 1,000 women aged 20–24 and 25–29 years, respectively. By contrast, women aged 30–34, 35–39, and ≥40 years accounted for 18.0%, 10.3%, and 3.5% of all reported abortions, respectively, and had abortion rates of 11.6, 6.9, and 2.5 abortions per 1,000 women aged 30–34, 35–39, and ≥40 years, respectively. From 2007 to 2016, the abortion rate decreased among women in all age groups.
In 2016, adolescents aged <15 and 15–19 years accounted for 0.3% and 9.4% of all reported abortions, respectively, and had abortion rates of 0.4 and 6.2 abortions per 1,000 adolescents aged <15 and 15–19 years, respectively. From 2007 to 2016, the percentage of abortions accounted for by adolescents aged 15–19 years decreased 43%, and the abortion rate decreased 56%. This decrease in abortion rate was greater than the decreases for women in any older age group.
In contrast to the percentage distribution of abortions and abortion rates by age, abortion ratios in 2016 and throughout the entire period of analysis were highest among adolescents and lowest among women aged 25–39 years. Abortion ratios decreased from 2007 to 2016 for women in all age groups.
In 2016, almost two-thirds (65.5%) of abortions were performed at ≤8 weeks’ gestation, and nearly all (91.0%) were performed at ≤13 weeks’ gestation. Fewer abortions were performed between 14 and 20 weeks’ gestation (7.7%) or at ≥21 weeks’ gestation (1.2%). During 2007–2016, the percentage of abortions performed at >13 weeks’ gestation remained consistently low (8.2%–9.0%). Among abortions performed at ≤13 weeks’ gestation, the percentage distributions of abortions by gestational age were highest among those performed at ≤6 weeks’ gestation (35.0%–38.4%).
In 2016, 27.9% of all abortions were performed by early medical abortion (a nonsurgical abortion at ≤8 weeks’ gestation), 59.9% were performed by surgical abortion at ≤13 weeks’ gestation, 8.8% were performed by surgical abortion at >13 weeks’ gestation, and 3.4% were performed by medical abortion at >8 weeks’ gestation; all other methods were uncommon (0.1%). Among those that were eligible for early medical abortion on the basis of gestational age (i.e., performed at ≤8 weeks’ gestation), 41.9% were completed by this method.
In 2016, women with one or more previous live births accounted for 59.0% of abortions, and women with no previous live births accounted for 41.0%. Women with one or more previous induced abortions accounted for 40.7% of abortions, and women with no previous abortions accounted for 59.4%.
Deaths of women associated with complications from abortion are assessed as part of CDC’s Pregnancy Mortality Surveillance System. In 2015, the most recent year for which data were reviewed for abortion-related deaths, two women were identified to have died as a result of complications from legal induced abortion and for one additional death, it was unknown whether the abortion was induced or spontaneous.
Interpretation: Among the 48 areas that reported data every year during 2007–2016, decreases in the total number, rate, and ratio of reported abortions resulted in historic lows for the period of analysis for all three measures of abortion.
Public Health Action: The data in this report can help program planners and policymakers identify groups of women with the highest rates of abortion. Unintended pregnancy is the major contributor to induced abortion. Increasing access to and use of effective contraception can reduce unintended pregnancies and further reduce the number of abortions performed in the United States.
Introduction
This report summarizes abortion data for 2016 that were provided voluntarily to CDC by the central health agencies of 48 reporting areas (New York City and 47 states, excluding California, the District of Columbia [DC], Maryland, and New Hampshire). Data obtained every year during 2007–2016 from these same 48 reporting areas were used for trend analyses.
Since 1969, CDC has conducted abortion surveillance to document the number and characteristics of women obtaining legal induced abortions in the United States (1). After nationwide legalization of abortion in 1973, the total number, rate (number of abortions per 1,000 women aged 15–44 years), and ratio (number of abortions per 1,000 live births) of reported abortions increased rapidly, reaching the highest levels in the 1980s before decreasing at a slow yet steady pace (2–4). During 2006–2008, a break occurred in the previously sustained pattern of decrease (5–8), although this break has been followed in subsequent years by even greater decreases (9–18). Nonetheless, throughout the years, the incidence of abortion has varied considerably across subpopulations and remains higher in certain demographic groups than others (19–25). Continued surveillance is needed to monitor changes in the incidence of abortion in the United States.
Methods
Description of the Surveillance System
Each year, CDC requests aggregated data from the central health agencies of 52 reporting areas (the 50 states, DC, and New York City) to document the number and characteristics of women obtaining legal induced abortions in the United States. This report contains data reported to CDC as of April 1, 2019. For the purpose of surveillance, a legal induced abortion* is defined as an intervention performed within the limits of state law by a licensed clinician (e.g., a physician, nurse-midwife, nurse practitioner, or physician assistant) that is intended to terminate a suspected or known intrauterine pregnancy and that does not result in a live birth.
In most states, collection of abortion data is facilitated by the legal requirement for hospitals, facilities, and physicians to report all abortions to a central health agency (26). These central health agencies then voluntarily report the abortion data they have collected through their independent surveillance systems (27). CDC receives only aggregate numbers, and reporting is not complete in all areas, including in certain areas with reporting requirements (27). Moreover, the level of detail received on the characteristics of women obtaining abortions varies considerably from year to year and by reporting area (17). However, because the collection and reporting of abortion data are not federally mandated, many reporting areas have developed their own data collection forms and therefore do not collect or provide all the information or level of detail included in this report. To encourage more uniform collection of these data, CDC has collaborated with the National Association for Public Health Statistics and Information Systems to develop reporting standards and provide technical guidance for vital statistics personnel who collect and summarize abortion data within the United States.
Variables and Categorization of Data
Each year, CDC sends suggested templates to the central health agencies for compilation of abortion data in aggregate. Aggregate abortion numbers, without individual-level records, are requested for the following variables:
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Maternal age in years (<15, 15–19 by individual year, 20–24, 25–29, 30–34, 35–39, or ≥40)
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Gestational age in completed weeks at the time of abortion (≤6, 7–20 by individual week, or ≥21)
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Race (black, white, or other [including Asian, Pacific Islander, other races, and multiple races]), ethnicity (Hispanic or non-Hispanic), and race by ethnicity
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Method type (surgical abortion,† intrauterine instillation, medical [nonsurgical] abortion, or hysterectomy/hysterotomy)
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Marital status (married [including currently married or separated] or unmarried [including never married, widowed, or divorced])
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Number of previous live births (0, 1, 2, 3, or ≥4)
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Number of previous induced abortions (0, 1, 2, or ≥3)
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Maternal residence (the state, reporting area, territory, or foreign country in which the woman obtaining the abortion lived, or, if additional details are unavailable, in-reporting area versus out-of-reporting area)
In addition, templates provided by CDC request that aggregate numbers for certain variables be cross-tabulated by a second variable. These cross-tabulations include gestational age (separately by maternal age, by method type, by race, by ethnicity, and by race/ethnicity) and maternal age and marital status (separately by race, by ethnicity, and by race/ethnicity).
Beginning with 2014 data, instead of reporting clinician’s estimates of gestational age or estimates of gestational age on the basis of last menstrual period, certain areas reported “probable postfertilization age,” “clinician’s estimate of gestation based on date of conception,” and “probable gestational age” to CDC. To make data reported as postfertilization age consistent with gestational age data collection practices recommended by the CDC’s National Center for Health Statistics (28), 2 weeks were added to probable postfertilization age. This method was used to account for time after last menstrual period until ovulation in a standard 28-day cycle because fertilization occurs around the time of ovulation (29). No modifications were made to data reported as clinician’s estimate of gestation based on date of conception or data reported as probable gestational age.
In this report, medical and surgical abortions are further categorized by gestational age. Early medical abortion is defined as the administration of medication or medications (typically mifepristone followed by misoprostol) to induce an abortion at ≤8 completed weeks’ gestation§; medical abortion at >8 completed weeks’ gestation is defined as the administration of medication or medications (typically serial vaginal prostaglandins, sometimes after mifepristone) to induce an abortion at >8 weeks’ gestation. For surgical abortions, abortions are categorized as having been performed at ≤13 weeks’ gestation or at >13 weeks’ gestation because of differences in technique used generally before and after 13 weeks (31). Finally, because intrauterine instillations cannot be performed early in gestation, abortions reported to have been performed by intrauterine instillation at ≤12 weeks’ gestation are excluded from calculation of the percentage of abortions by known method type.¶
Measures of Abortion
Four measures of abortion are presented in this report: 1) the number of abortions in a given population, 2) the percentage of abortions obtained by women in a given population, 3) the abortion rate (number of abortions per 1,000 women aged 15–44 years or other specific group within a given population), and 4) the abortion ratio (number of abortions per 1,000 live births within a given population). Although total numbers and percentages are useful for determining how many women have obtained an abortion, abortion rates adjust for differences in population size and reflect how likely abortion is among women in particular groups. Abortion ratios measure the relative number of pregnancies in a population that end in abortion compared with live birth.
U.S. Census Bureau estimates of the resident female population of the United States were used as the denominator for calculating abortion rates (34–43). Overall abortion rates were calculated from the population of women aged 15–44 years living in the reporting areas that provided data. For adolescents aged <15 years, abortion rates were determined on the basis of the number of adolescents aged 13–14 years; similarly, for women aged ≥40 years, abortion rates were determined on the basis of the number of women aged 40–44 years. For the calculation of abortion ratios, live birth data were obtained from CDC natality files and included births to women of all ages living in the reporting areas that provided abortion data (44).
Data Presentation and Analysis
This report provides state-specific and overall abortion numbers, rates, and ratios for the 48 areas that reported to CDC for 2016 (excludes California, DC, Maryland, and New Hampshire). In addition, this report describes the characteristics of women who obtained abortions in 2016. Because the completeness of reporting on the characteristics of women varies by year and by variable, this report only describes the characteristics of women obtaining abortions in areas that met reporting standards (i.e., reported at least 20 abortions overall, provided data categorized in accordance with surveillance variables, and had <15% unknown values for a given characteristic). Abortion rates and ratios have been omitted for reporting areas with <20 abortions because calculations are considered statistically unstable (45). Cells with a value in the range of 1–4 or cells that would allow for calculation of these values have been suppressed to maintain confidentiality.
Although most of the data are presented by the reporting area in which the abortions were performed, 47 reporting areas in 2016 also provided the number of abortions by maternal residence.** Two areas (Illinois and Wisconsin) reported abortions for in-state and out-of-state residents but did not report certain characteristics for out-of-state residents. Three reporting areas (Iowa, Massachusetts, and New Mexico) provided only the total number of abortions for out-of-state residents without specifying individual states or areas of residence from which these women came. As a result, abortion statistics in this report by area of residence should be interpreted with caution and might underestimate the incidence of abortion, especially for reporting areas from which a substantial proportion of women travel to or from other states to obtain abortion services.
To evaluate overall trends in the number, rate, and ratio of reported abortions, annual data are presented for the 48 areas that reported every year during 2007–2016. Linear regression analysis was used to assess the overall rate of change among these areas during the entire 10-year period of analysis (2007–2016) and during the first and second halves of the period of analysis (2007–2011 and 2012–2016). The percentage change in abortion measures from the most recent past year (2015 to 2016) and from the beginning to the end of the 10-year period of analysis (2007 to 2016) also were calculated for these same 48 areas. Consistent with previous reports, key findings are highlighted to provide observed changes over time and differences between groups. However, comparisons do not infer statistical significance, and lack of comment regarding the difference between values does not imply that no statistically significant difference exists.
For the analysis of certain additional variables (i.e., abortions by maternal age and gestational age), annual data are presented for areas that met reporting standards every year during 2007–2016; the percentage change was calculated from the beginning to the end of the 10-year period of analysis (2007 to 2016), from the beginning to the end of the first and second halves of this period (2007 to 2011 and 2012 to 2016), and from the most recent past year (2015 to 2016). For other variables (i.e., race/ethnicity, method type, marital status, number of previous abortions, and number of previous live births), annual data are not presented every year during 2007–2016; areas were included if they met reporting standards for the years needed for percentage change calculations. To evaluate trends in the use of different methods for performing an abortion, reporting areas were included only if they met reporting standards and if they specifically included medical abortion as a method on their reporting form. Medical abortions performed at 9 completed weeks are also reported for 2011 to 2016. These data are reported to monitor any changes in clinical practice that might have occurred with the accumulation of evidence on the safety and effectiveness of medical abortion past 63 days of gestation (≤8 completed weeks) (46) and changes in professional practice guidelines published in 2013 and 2014 (47,48). Both of these events preceded the 2016 U.S. Food and Drug Administration (FDA) extension of the gestational age limit for the use of mifepristone for early medical abortion from 63 days to 70 days (≤9 completed weeks) (49).
Some of the 48 areas that reported for 2016 are not included in certain trend analyses when data did not meet reporting standards. As a result, summary measures for comparisons over time might differ from the point estimates presented for all areas that reported for 2016.
Abortion Mortality
CDC has reported data on abortion-related deaths periodically since information on abortion mortality first was included in the 1972 abortion surveillance report (17,50). An abortion-related death is defined as a death resulting from a direct complication of an abortion (legal or illegal), an indirect complication caused by a chain of events initiated by an abortion, or an aggravation of a preexisting condition by the physiologic or psychologic effects of abortion (51). An abortion is categorized as legal when it is performed by a licensed clinician within the limits of state law.
Since 1987, CDC has monitored abortion-related deaths through its Pregnancy Mortality Surveillance System (PMSS) (52,53). Sources of data for abortion-related deaths have included state vital records; media reports, including computerized searches of full-text newspaper and other print media databases; and individual case reports by public health agencies, including maternal mortality review committees, health care providers and provider organizations, private citizens, and citizen groups. For each death that possibly is related to abortion, CDC requests clinical records and autopsy reports. Two medical epidemiologists independently review these reports to determine the cause of death and whether the death was abortion related. Discrepancies are discussed and resolved by consensus. Each death is categorized by abortion type as legal induced, illegal induced, spontaneous, or unknown type.
This report provides PMSS data on induced abortion-related deaths that occurred in 2015, the most recent year for which PMSS data were reviewed for abortion-related deaths. Data on induced abortion-related deaths that occurred during 1972–2014 already have been published (7,17). During 1998–2015, abortion surveillance data reported to CDC cannot be used alone to calculate national legal induced abortion case-fatality rates (number of legal induced abortion-related deaths per 100,000 reported legal induced abortions in the United States) because certain states†† did not report abortion data every year during this period. Thus, denominator data for calculation of national legal induced abortion case-fatality rates were obtained from a published report by the Guttmacher Institute that includes estimated total numbers of abortions in the United States from a national survey of abortion-providing facilities (18). Because rates determined on the basis of a numerator of <20 deaths are highly variable (45), national legal induced abortion case-fatality rates were calculated for consecutive 5-year periods during 1973–2007 and for a consecutive 8-year period during 2008–2015.
Results
U.S. Totals
Among the 48 reporting areas that provided data for 2016, a total of 623,471 abortions were reported. All 48 of these areas provided data every year during 2007–2016.§§ In 2016, these areas had an abortion rate of 11.6 abortions per 1,000 women aged 15–44 years and an abortion ratio of 186 abortions per 1,000 live births (Table 1). From 2015 to 2016, the total number of reported abortions decreased 2% (from 636,902 to 623,471), the abortion rate decreased 2% (from 11.8 to 11.6 abortions per 1,000 women aged 15–44 years), and the abortion ratio decreased 1% (from 188 to 186 abortions per 1,000 live births). From 2007 to 2016, the total number of reported abortions decreased 24% (from 825,240), the abortion rate decreased 26% (from 15.6 abortions per 1,000 women aged 15–44 years), and the abortion ratio decreased 18% (from 226 abortions per 1,000 live births) (Figure 1). Among these same 48 areas, the annual rate of decrease fitted from the regression analysis was greater during 2007–2011 than during 2012–2016 for abortion number and rate, whereas the annual rate of decrease was greater during 2012–2016 than during 2007–2011 for abortion ratio. During 2007–2011, the number of reported abortions decreased by 25,563 abortions per year, the abortion rate decreased by 0.50 abortions per 1,000 women per year, and the abortion ratio decreased by 2.2 abortions per 1,000 live births per year. During 2012–2016, the number of reported abortions decreased by 17,120 abortions per year, the abortion rate decreased by 0.36 abortions per 1,000 women per year, and the abortion ratio decreased by 5.4 abortions per 1,000 live births per year.
Occurrence and Residence
Abortion numbers, rates, and ratios for 2016 have been calculated by reporting area of occurrence and the residence of the women who obtained the abortions (Table 2). By reporting area of occurrence, a considerable range existed in the abortion rate (from 3.0 abortions per 1,000 women aged 15–44 years in South Dakota to 21.8 abortions per 1,000 women in New York [city and state combined]) and the abortion ratio (from 38 abortions per 1,000 live births in South Dakota to 373 abortions per 1,000 live births in New York [city and state combined]).¶¶ Similarly, a considerable range existed in the abortion rate by residence*** (from 4.2 abortions per 1,000 women aged 15–44 years in South Dakota to 20.7 abortions per 1,000 women aged 15–44 years in New York [city and state combined]) and the abortion ratio (from 54 abortions per 1,000 live births in South Dakota to 354 abortions per 1,000 live births in New York [city and state combined]). Because of variation that occurred among reporting areas in the percentage of abortions obtained by out-of-state residents (from 0.6% in Alaska and Arizona to 49.8% in Kansas), abortion rates and ratios calculated by maternal residence might provide a more accurate reflection of the state-specific distribution of women obtaining abortions. However, because states vary in the level of detail they collect on maternal residence, 12.4% of abortions were reported to CDC with unknown information on maternal residence.
Maternal Age
Among the 46 areas that reported by maternal age for 2016, women in their 20s accounted for the majority (58.5%) of abortions and had the highest abortion rates (19.1 and 17.8 abortions per 1,000 women aged 20–24 and 25–29 years, respectively) (Figure 2) (Table 3). Women in the youngest (<15 years) and oldest (≥40 years) age groups accounted for the smallest percentages of abortions (0.3% and 3.5%, respectively) and had the lowest abortion rates (0.4 and 2.5 abortions per 1,000 women aged <15 and ≥40 years, respectively). Among the 44 reporting areas that provided data by maternal age every year during 2007–2016, this pattern across age groups was stable, with the majority of abortions and the highest abortion rates occurring among women aged 20–29 years and the lowest percentages of abortions and abortion rates occurring among women in the youngest and oldest age groups (Table 4). From 2007 to 2016, abortion rates decreased among all age groups, although the decreases for adolescents (67% and 56% for adolescents aged <15 and 15–19 years, respectively) were greater than the decreases for women in all older age groups. Decreases for women aged ≥20 years ranged from 4% among women aged ≥40 years to 35% among women aged 20–24 years. Decreases in the abortion rate for all age groups, except women aged 25–29 years and 30–34 years, were greater from 2012 to 2016 than from 2007 to 2011, and the rates for all age groups either did not change or decreased from 2015 to 2016.
In contrast to the percentage of abortions and abortion rates, abortion ratios in 2016 were lowest among women aged 25–39 years (Figure 2) (Table 3). Among the 44 reporting areas that provided data by maternal age for every year during 2007–2016, abortion ratios decreased among women in all age groups. The abortion ratio decreased for all age groups from 2012 to 2016; however, from 2015 to 2016, abortion ratios only decreased for women aged ≥30 years (Table 4).
Adolescents
Among the 43 areas that reported maternal age by individual year among adolescents for 2016, adolescents aged 18–19 years accounted for the majority (67.8%) of adolescent abortions and had the highest adolescent abortion rates (9.1 and 12.4 abortions per 1,000 adolescents aged 18 and 19 years, respectively) (Table 5). Adolescents aged <15 years accounted for the smallest percentage of adolescent abortions (2.6%) and had the lowest adolescent abortion rate (0.4 abortions per 1,000 adolescents aged 13–14 years). Among the 39 reporting areas that provided maternal age by individual year data for adolescents annually during 2007–2016, the percentage of abortions accounted for by adolescents aged 18 and 19 years increased, whereas the percentage of abortions accounted for by adolescents aged <18 years decreased (Table 6). For adolescents of all ages, decreases in abortion rates ≥50% occurred from 2007 to 2016, and were generally greater from 2012 to 2016 than from 2007 to 2011. Decreases occurred among all adolescents from 2015 to 2016.
In 2016, the abortion ratio for adolescents was highest among adolescents aged <15 years (694 abortions per 1,000 live births) and was lowest among adolescents aged ≥17 years (292, 295, and 249 abortions per 1,000 live births among adolescents aged 17, 18, and 19 years, respectively) (Table 5). During 2007–2016, abortion ratios decreased among adolescents of all ages (Table 6).
Gestational Age
Among the 41 areas††† that reported gestational age at the time of abortion for 2016, approximately two thirds (65.5%) of abortions were performed at ≤8 weeks’ gestation, and nearly all (91.0%) were performed at ≤13 weeks’ gestation (Table 7). Fewer abortions were performed at 14–20 weeks’ gestation (7.7%) or at ≥21 weeks’ gestation (1.2%). Among the 33 reporting areas that provided data on gestational age every year during 2007–2016, the percentage of abortions performed at ≤13 weeks’ gestation decreased minimally from 91.5% to 90.9% (Table 8). However, within this gestational age range, a shift occurred toward earlier gestational ages, with the percentage of abortions performed at ≤8 weeks’ gestation increasing 3% and the percentage of abortions performed at 9–13 weeks’ gestation decreasing 8%. For the entire period of analysis, abortions performed at >13 weeks’ gestation accounted for ≤9.0% of abortions.
Among abortions performed at ≤13 weeks’ gestation and reported by individual week of gestation for 2016, 37.8% were performed at ≤6 weeks’ gestation (Table 9). The percentage contribution to abortions performed at ≤13 weeks’ gestation was progressively smaller for each additional week of gestation: 19.4% were performed at 7 weeks’ gestation, and 3.0% were performed at 13 weeks’ gestation. Among the 33 areas that reported by exact week of gestation for abortions performed at ≤13 weeks’ gestation every year during 2007–2016, the highest percentage contributions were reported for abortions performed at ≤6 weeks’ gestation (35.0%–38.4%), and smaller percentages for each additional week of gestation were reported, with approximately 3.0% of abortions performed at 13 weeks’ gestation across the 10-year period (Table 10).
Method Type
Among the 43 areas that reported by method type for 2016 and included medical abortion on their reporting form, 59.9% of abortions were surgical abortions at ≤13 weeks’ gestation, 27.9% were early medical abortions (a nonsurgical abortion at ≤8 weeks’ gestation), 8.8% were surgical abortions at >13 weeks’ gestation, and 3.4% were medical abortions at >8 weeks’ gestation; other methods (intrauterine instillation and hysterectomy/hysterotomy) were uncommon (<0.1%) (Table 11). Among the 33 reporting areas§§§ that included medical abortion on their reporting form and provided these data for the relevant years of comparison (2007 versus 2016, 2007 versus 2011, 2012 versus 2016, and 2015 versus 2016), use of early medical abortion increased 14% from 2015 to 2016 (from 24.5% of abortions to 27.9%); from 2007 to 2016, use of early medical abortion increased 113% (from 13.1% of abortions to 27.9%). Increases in early medical abortion occurred both from 2007 to 2011 (from 13.1% of abortions to 19.7% [50% increase]) and from 2012 to 2016 (from 21.3% of abortions to 27.9% [31% increase]).
Among the 30 reporting areas¶¶¶ that provided data by procedure and individual week of gestational age each year from 2011 to 2016, during which time several clinical guidelines and an FDA labeling change extended mifepristone use to 70 days’ gestation, the percentage of abortions at 9 completed weeks’ gestation that were reported as medical abortions increased. Although the percentage of abortions at 9 weeks’ gestation reported as medical abortions did not change substantially between 2011, 2012, 2013, and 2014 (5.0%, 5.7%, 6.7%, and 7.7%, respectively), this percentage increased to 13.0% in 2015 and 24.0% in 2016. Among the 43 areas**** that reported by method type for 2016 and included medical abortion on their reporting form, 30.2% were medical abortions performed at ≤9 weeks’ gestation. Among these same reporting areas that reported medical abortions by individual week of gestational age, 92.5% of the medical abortions performed at ≤9 weeks’ gestation were performed at ≤8 weeks, and the remaining 7.5% were performed at 9 weeks.
As a corollary to the increase that occurred in use of early medical abortion at ≤8 weeks’ gestation, use of surgical abortion at ≤13 weeks’ gestation decreased 23% from 2007 to 2016 (from 78.1% of abortions to 59.8%).§§§ Surgical abortion at >13 weeks’ gestation consistently accounted for approximately 8.0%–8.8% of all abortions, and all other methods combined consistently accounted for a limited percentage of abortions (1.1%–3.4%) during 2007–2016.
Race/Ethnicity
Among the 32 areas that reported cross-classified race/ethnicity data for 2016, non-Hispanic white women and non-Hispanic black women accounted for the largest percentages of all abortions (35.0% and 38.0%, respectively), and Hispanic women and non-Hispanic women in the other race category accounted for smaller percentages (18.8% and 8.2%, respectively) (Table 12). Non-Hispanic white women had the lowest abortion rate (6.6 abortions per 1,000 women aged 15–44 years) and ratio (109 abortions per 1,000 live births), and non-Hispanic black women had the highest abortion rate (25.1 abortions per 1,000 women aged 15–44 years) and ratio (401 abortions per 1,000 live births). Data for 2016 also are reported separately by race and by ethnicity (Tables 13 and 14).
Among the 19 areas†††† that reported these data for the relevant years of comparison (2007 versus 2016, 2007 versus 2011, 2012 versus 2016, and 2015 versus 2016), abortion rates decreased substantially for the three largest race/ethnicity groups: for non-Hispanic white women, the abortion rate decreased 33% (from 9.4 abortions per 1,000 women in 2007 to 6.3 in 2016); for non-Hispanic black women, the rate decreased 29% (from 36.7 abortions per 1,000 women in 2007 to 26.2 in 2016); and for Hispanic women, the rate decreased 44% (from 21.2 abortions per 1,000 women in 2007 to 11.8 in 2016). For women in the three largest race/ethnicity groups, abortion rates decreased both from 2007 to 2011 and from 2012 to 2016, although the decreases were greater during the later period. From 2007 to 2011, the abortion rates decreased 15% for non-Hispanic white women (from 9.4 to 8.0 abortions per 1,000), 11% for non-Hispanic black women (from 36.7 to 32.5 abortions per 1,000), and 18% for Hispanic women (from 21.2 to 17.3 abortions per 1,000); by contrast, from 2012 to 2016, the abortion rates decreased 18% for non-Hispanic white women (from 7.7 to 6.3 abortions per 1,000), 13% for non-Hispanic black women (from 30.2 to 26.2 abortions per 1,000), and 24% for Hispanic women (from 15.6 to 11.8 abortions per 1,000).
Abortion ratios also decreased from 2007 to 2016 for the three largest race/ethnicity groups: for non-Hispanic white women, the abortion ratio decreased 29% (from 146 abortions per 1,000 live births in 2007 to 103 in 2016); for non-Hispanic black women, the ratio decreased 20% (from 517 abortions per 1,000 live births in 2007 to 416 in 2016); and for Hispanic women, the ratio decreased 26% (from 210 abortions per 1,000 live births in 2007 to 155 in 2016). From 2007 to 2011, abortion ratios decreased among non-Hispanic white women (10% from 146 abortion per 1,000 live births in 2007 to 131 in 2011) and non-Hispanic black women (3% from 517 abortions per 1,000 live births in 2007 to 504 in 2011), whereas abortion ratios increased among Hispanic women (2% from 210 abortion per 1,000 live births in 2007 to 214 in 2011). By contrast, from 2012 to 2016, abortion ratios decreased among all women in the three largest race/ethnicity groups. The abortion ratio decreased 18% for non-Hispanic white women (from 125 to 103 abortions per 1,000 live births), 11% for non-Hispanic black women (from 470 to 416 abortions per 1,000 live births), and 22% for Hispanic women (from 198 to 155 abortions per 1,000 live births).
Marital Status
Among the 42 areas that reported by marital status for 2016, 14.1% of all women who obtained an abortion were married, and 85.9% were unmarried (Table 15). The abortion ratio was 41 abortions per 1,000 live births for married women and 380 abortions per 1,000 live births for unmarried women. Among the 29 reporting areas§§§§ that provided these data for the relevant years of comparison (2007 versus 2016, 2007 versus 2011, 2012 versus 2016, and 2015 versus 2016), the percentage of abortions among unmarried women increased 3% from 2007 to 2016 (from 83.5% to 86.0%), with a larger increase from 2007 to 2011 (3%) than from 2012 to 2016 (<1%). Among unmarried women, the abortion ratio decreased 16% from 2007 to 2016 (from 390 to 326 abortions per 1,000 live births), with a larger decrease also occurring from 2012 to 2016 (10%) than from 2007 to 2011 (3%). Among married women, the abortion ratio decreased 31% from 2007 to 2016 (from 49 to 34 abortions per 1,000 live births), with similar decreases occurring from 2012 to 2016 (13%) and from 2007 to 2011 (14%).
Previous Live Births and Abortions
Data from the 42 areas that reported the number of previous live births for women who obtained abortions in 2016 indicate that 41.0%, 45.1%, and 13.9% of these women had zero, one or two, or three or more previous live births, respectively (Table 16). Among the 35 reporting areas¶¶¶¶ that provided these data for the relevant years of comparison (2007 versus 2016, 2007 versus 2011, 2012 versus 2016, and 2015 versus 2016), the percentage of women obtaining abortions with no previous live births or with one to two previous live births each decreased 2% from 2007 to 2016; by contrast, the percentage increased 16% for women with three or more previous live births over the same time period.
Data from the 41 areas that reported the number of previous abortions for women who obtained abortions in 2016 indicate that the majority (59.4%) had no previous abortions, 34.4% had one or two previous abortions, and 6.3% had three or more previous abortions (Table 17). Among the 34 reporting areas***** that provided data for the relevant years of comparison (2007 versus 2016, 2007 versus 2011, 2012 versus 2016, and 2015 versus 2016), the percentage of women who had no previous abortions increased 3% (from 57.4% to 59.1%), whereas a 4% decrease occurred among women who had one or two previous abortions, and a 4% decrease occurred among women who had three or more previous abortions from 2007 to 2016. However, the percentage of women who had no previous abortions decreased 1% from 2007 to 2011 (from 57.4% to 56.8%) and then increased 3% from 2012 to 2016 (from 57.6% to 59.1%). By contrast, the percentage of women who had three or more previous abortions increased 4% from 2007 to 2011 (from 6.8% to 7.1%) then decreased 6% from 2012 to 2016 (from 6.9% to 6.5%). The percentage of women who had one or two previous abortions increased 1% from 2007 to 2011 (35.8% to 36.1%) and then decreased 3% from 2012 to 2016 (from 35.5% to 34.5%).
Maternal Age and Marital Status by Race/Ethnicity
In select reporting areas, abortions that were categorized by maternal race and race/ethnicity were further categorized by maternal age and by marital status (Tables 18 and 19). A consistent pattern existed for abortions by maternal age across all race/ethnicity groups, with the smallest percentage of abortions occurring among adolescents aged <15 years (0.2%–0.3%) and the largest percentage occurring among women aged 20–24 years (25.6%–31.1%) and 25–29 years (26.6%–30.2%) (Table 19). A consistent pattern also existed for abortions by marital status across all race/ethnicity groups, with a higher percentage of abortions occurring among women who were unmarried (68.1%–92.1%) than among those who were married (7.9%–31.9%) (Table 19). For abortions among married women, the percentage was higher for non-Hispanic women in the other race group (31.9%) than for non-Hispanic white women (16.8%), Hispanic women (15.3%), and non-Hispanic black women (7.9%). For abortions among unmarried women, the percentage was higher for non-Hispanic black women (92.1%) than for non-Hispanic white women (83.2%), Hispanic women (84.7%), and women in the non-Hispanic other race group (68.1%) (Table 19).
Weeks of Gestation by Maternal Age, Race/Ethnicity, and Method Type
In select reporting areas, abortions that were categorized by weeks of gestation were further categorized by maternal age, and race/ethnicity (Tables 20 and 21). In every subgroup for these three characteristics, the largest percentage of abortions occurred at ≤8 weeks’ gestation. However, by maternal age, 42.8% of adolescents aged <15 years and 56.8% of adolescents aged 15–19 years obtained an abortion by ≤8 weeks’ gestation, compared with 63.7%–71.0% of women in older age groups (Figure 3) (Table 20). Conversely, 23.7% of adolescents aged <15 years and 12.4% of adolescents aged 15–19 years obtained an abortion after 13 weeks’ gestation, compared with 8.1%–9.1% for women in older age groups. By race/ethnicity, 59.8% of non-Hispanic black women obtained an abortion at ≤8 weeks’ gestation, compared with 67.5%–69.4% of women from other race/ethnicity groups. Differences in abortions after 13 weeks’ gestation across race/ethnicity groups were minimal (10.3% for non-Hispanic black women, compared with 8.2%–9.1% for women in the remaining race/ethnicity groups).
Among abortions categorized by weeks of gestation and method type, surgical abortion accounted for the largest percentage of abortions within every gestational age category (Table 22). At ≤8 weeks’ gestation, surgical abortion accounted for a smaller percentage of abortions (58.1%) than at any other stage of gestation; at 9–20 weeks’ gestation, surgical abortion accounted for 89.6%–98.8% of all abortions, and at ≥21 weeks’ gestation, it accounted for 92.7% of abortions. By contrast, at ≤8 weeks’ gestation, medical abortion accounted for 41.9% of abortions then decreased to 10.4% at 9–13 weeks and 1.0%–2.6% at 14–20 weeks before increasing to 6.5% at ≥21 weeks. For each gestational age category, abortions performed by intrauterine instillation or hysterectomy/hysterotomy were rare (<0.1%–0.5% of abortions).
Abortion Mortality
Using national PMSS data (52), CDC identified three abortion-related deaths for 2015, the most recent year for which data were reviewed for abortion-related deaths (Table 23). Investigation of these cases indicated that two deaths were related to legal abortion, no deaths were related to illegal abortion, and for one death, whether the abortion was induced or spontaneous was unknown.
The annual number of deaths related to legal induced abortion has fluctuated from year to year over the past 40 years (Table 23). Because of this variability and the relatively limited number of legal induced abortion-related deaths every year, national legal abortion case-fatality rates were calculated for consecutive 5-year periods during 1973–2007 and for a consecutive 8-year period. The national legal induced abortion case-fatality rate for 2008–2015 was 0.58 legal induced abortion-related deaths per 100,000 reported legal abortions. This case-fatality rate was similar to the rate for most of the preceding 5-year periods but lower than the case-fatality rate of 2.09 legal induced abortion-related deaths per 100,000 reported legal abortions for the 5-year period (1973–1977) immediately following nationwide legalization of abortion in 1973.
Discussion
For 2016, a total of 623,471 abortions were reported to CDC by 48 areas. Among these areas, the abortion rate was 11.6 abortions per 1,000 women aged 15–44 years and the abortion ratio was 186 abortions per 1,000 live births. All 48 of these reporting areas submitted data every year during the period of analysis from 2007 to 2016, thus providing the information necessary for evaluating trends. Among these areas, the number and rate of reported abortions decreased 2%, and the abortion ratio decreased 1% from 2015 to 2016, which, in combination with decreases that occurred during previous years (11–15), resulted in the lowest values for all three measures for the entire period of analysis. Among areas that reported by age every year of the analysis, women in their 20s accounted for the majority of abortions and had the highest abortion rates, whereas decreases in the abortion rate were greater for adolescents aged <20 years than for any other age group. In addition, throughout the period of analysis, ≤9% of abortions each year were performed after 13 weeks’ gestation; approximately two thirds of abortions were performed at ≤8 weeks’ gestation, and this percentage increased from 63.7% in 2007 to 65.3% in 2016. Among areas that included medical abortion on their reporting form every year, the percentage of all abortions performed by early medical abortion (a nonsurgical abortion at ≤8 weeks’ gestation) increased from 13.1% in 2007 to 27.9% in 2016.
These findings underscore important maternal age differences in abortion trends. Because of the high rate and proportion of abortions that occurred among women in their 20s, women in this age group have contributed substantially to overall changes. Conversely, during 2007–2016, women aged ≥40 years had consistently low abortion rates and accounted for a limited percentage of abortions (≤3.7%); therefore, they have had a much smaller contribution to overall abortion trends. Nonetheless, among women aged ≥40 years, the abortion ratio continues to be higher than among women aged 25–39 years, indicating that unintended pregnancy is a problem that women encounter throughout their reproductive years (54).
The adolescent abortion trends described in this report are important for monitoring progress that has been made toward reducing adolescent pregnancies in the United States. National birth data indicate the birth rate for adolescents aged 15–19 years in 2016 decreased 51% since 2007 (55,56), compared with a 43% decrease in the abortion rate for adolescents aged 15–19 years during the same period. These findings indicate that decreases in adolescent pregnancies in the United States have been accompanied by large decreases both in adolescent births and abortions and that the pattern of decline is continuing (56–58).
The findings in this report indicate that although the number, rate, and ratio of reported abortions have decreased across all race/ethnicity groups, well-documented disparities exist (3,4,19–24). In this report, abortion rates and ratios remained 1.8 and 1.4 times higher, respectively, for Hispanic women than for non-Hispanic white women, and 3.8 and 3.7 times higher, respectively, for non-Hispanic black women than for non-Hispanic white women. The comparatively high abortion rates and ratios among non-Hispanic black women have been attributed to higher unintended pregnancy rates and a greater percentage of unintended pregnancies ending in abortion (54).
The findings in this report indicate the majority of women obtaining abortions do so early in gestation (≤8 weeks), when the risks for complications are lowest (59–62). Among the areas that reported gestational age data every year during 2007–2016, the percentage of abortions performed at ≤8 weeks’ gestation increased 3%. Moreover, among the areas that reported abortions at ≤13 weeks’ gestation by individual week, the distribution continued to shift toward earlier weeks of gestation, with the percentage of early abortions performed at ≤6 weeks’ gestation increasing 8% from 2007 to 2016. Nonetheless, the overall percentage of abortions performed at ≤13 weeks’ gestation did not change appreciably from 2007–2016. Reports indicate that abortions at later gestational ages are more common among certain groups of women (63–65); among women in this report, the percentage of adolescents aged ≤19 years who obtained abortions at ≤8 weeks’ gestation was smaller than the percentage of women in other age groups who obtained abortions at the same gestational age. Because procedures performed at earlier gestational ages have a lower risk for complications, a better understanding of factors that influence the gestational age at which abortions are performed is needed (59–69).
The trend of obtaining abortions earlier in pregnancy has been facilitated by changes in abortion practices. Research conducted in the United States during the 1970s indicated that surgical abortion procedures performed at ≤6 weeks’ gestation, compared with 7–12 weeks’ gestation, were less likely to result in successful termination of the pregnancy (70). However, subsequent advances in technology (e.g., improved transvaginal ultrasonography and sensitive pregnancy tests) have allowed very early surgical abortions to be performed with completion rates exceeding 97% (71–73). Likewise, the development of early medical abortion regimens has allowed for abortions to be performed very early in gestation, with completion rates for regimens that combine mifepristone and misoprostol reaching 96%–98% (74–76). In 2016, 65.5% of all reported abortions were performed at ≤8 completed weeks’ gestation; thus, the women receiving these abortions were eligible for early medical abortion (a nonsurgical abortion at ≤8 weeks’ gestation) on the basis of gestational age. Among those abortions performed at ≤8 weeks’ gestation in 2016, 41.9% were reported as medical abortions. From 2007 to 2016, the proportion of all abortions reported as early medical abortion increased from 13.1% to 27.9%, respectively. Moreover, in addition to abortions meeting the definition of early medical abortion, the percentage of abortions at 9 completed weeks’ gestation that were reported as medical abortions has increased in recent years (from 5.0%–13.0% during 2011–2015 to 24.0% in 2016). On the basis of evidence that early medical abortion is safe and effective beyond 63 days’ gestation (46), professional clinical practice guidelines were updated midyear in 2013 and 2014 to extend the gestational age eligibility for early medical abortion from 63 to 70 days (≤9 completed weeks) (47,48). In early 2016, FDA updated its approval for use of mifepristone for early medical abortions, extending the gestational age limit to 70 days (49).
Because the annual number of deaths related to legal induced abortion is small and statistically unstable, case-fatality rates were calculated for consecutive 5-year periods during 1973–2007 and for a consecutive 8-year period during 2008–2015. The national legal induced abortion case-fatality rate for 2008–2015 was fewer than 1 per 100,000 abortions, as it was for all of the preceding 5-year periods since the late 1970s.
Limitations
The findings in this report are subject to at least four limitations. First, because reporting to CDC is voluntary and reporting requirements are established by the individual reporting areas (27), CDC is unable to obtain the total number of abortions performed in the United States. Although most reporting areas collect and send abortion data to CDC, three of the 52 reporting areas (California, Maryland, and New Hampshire) did not provide CDC data for 2007–2016, and one reporting area (DC) did not provide data to CDC for 2016. In 2016, abortions performed in California, DC, Maryland, and New Hampshire accounted for 20% of the abortions counted through the Guttmacher Institute’s national survey of abortion-providing facilities (18). During 2007–2016, the total numbers of abortions reported to CDC annually were 68%–71% of the total numbers of abortions reported by the Guttmacher Institute survey. In addition, whereas most reporting areas that send abortion data to CDC have laws requiring medical providers to submit a report for every abortion they perform to a central health agency, as of 2016, reporting to a central health agency was not required in DC or New Jersey, which affects the representativeness of annual reported estimates for these jurisdictions (26). Moreover, even in states that legally require medical providers to submit a report for all the abortions they perform, enforcement of this requirement varies, which might affect completeness from other reporting areas as well.††††† The accuracy of comparative data reported by Guttmacher might be affected by facility response rates, the accuracy of information reported by facilities, as well as the degree to which abortion counts were estimated from nonfacility data sources (18).
Second, because reporting requirements are established by the individual reporting areas, many states use reporting forms that differ from the technical standards and guidance that CDC developed in collaboration with the National Association for Public Health Statistics and Information Systems. Consequently, many reporting areas do not collect all the information CDC compiles on the characteristics of women obtaining abortions (e.g., maternal age, race, and ethnicity) or do not report the data in a manner consistent with this guidance (e.g., gestational age). Although missing demographic information can reduce the extent to which the statistics in this report represent all women in the United States, the most recent nationally representative survey of women obtaining abortions in 2014 (24) produced percentage distributions for most characteristics that are nearly identical to the percentage distributions reported by CDC. The exception is the percentage distribution of abortions by race/ethnicity. The percentage of abortions accounted for by non-Hispanic black women is higher and by Hispanic women is lower in this report than the percentages reported from a recent nationally representative survey of women obtaining abortions (24). Differences might be attributable to the fact that the number of states that report data to CDC by race/ethnicity continues to be somewhat lower than for other demographic variables. Certain reporting areas that have not reported to CDC or have not reported cross-classified race/ethnicity data (e.g., California, Florida, and Illinois) have sufficiently large populations of minority women that the absence of data from these areas reduces the representativeness of CDC data.
In addition, certain areas collect gestational age on the basis of estimated date of conception or collect probable postfertilization age or probable gestational age. Without medical guidance on how to report these data, the validity and reliability of gestational age for these reporting areas is uncertain.
Despite challenges in capturing medical abortions for reporting (8,16,26,77), a previous comparison of CDC data with mifepristone sales data§§§§§ suggests that CDC’s Abortion Surveillance System accurately describes trends in early medical abortion (78). However, because of recent changes in clinical practice guidelines for the use of mifepristone and misoprostol through 9 completed weeks of gestation, CDC’s definition of early medical abortion does not represent all abortions performed through this method. Nonetheless, for 2016, of the medical abortions reported at ≤9 weeks, 7.5% were performed at 9 completed weeks.
Third, abortion data are compiled and reported to CDC by the central health agency of the reporting area in which the abortion was performed rather than the reporting area in which the woman lived. Thus, the available population (34–43) and birth data (44), which are organized by the states in which women live, differ in certain cases from the population of women who undergo abortions in a given reporting area. This likely results in an overestimation of abortions for reporting areas in which a high percentage of abortions are obtained by out-of-state residents and an underestimation of abortions for states where residents frequently obtain abortions out of state. Limited abortion services, stringent regulatory requirements for obtaining an abortion, or geographic proximity to services in another state might influence where women obtain abortion services (79). To examine these reporting biases, CDC attempts to categorize abortions by residence in addition to geographic occurrence. However, in 2016, CDC was unable to identify the reporting area, territory, or country of residence for 12.4% of reported abortions.
Finally, the availability of demographic information is limited to what is collected on reporting forms. Therefore, performing stratified analyses by additional demographic variables (e.g., socioeconomic status) is not possible.
Public Health Implications
Ongoing surveillance of legal induced abortion is important for several reasons. First, abortion surveillance can be used to help evaluate the success of programs aimed at preventing unintended pregnancies. Although pregnancy intentions can be difficult to assess (80–85), abortion surveillance provides an important measure of pregnancies that are unwanted (86). Second, routine abortion surveillance is needed to assess trends in clinical practice patterns over time. Information in this report on the number of abortions performed through different methods (e.g., medical or surgical) and at different gestational ages provides the denominator data that are necessary for analyses of the relative safety of abortion practices (53). Finally, information on the number of pregnancies ending in abortion is needed in conjunction with data on births and fetal losses to estimate the number of pregnancies in the United States and determine rates for various outcomes of public health importance (e.g., adolescent pregnancies) (87).
Approximately 18% of all pregnancies in the United States end in induced abortion (18,88). Multiple factors influence the incidence of abortion, including access to health care services and contraception (89–92); the availability of abortion providers (8,9,16,93–96); state regulations, such as mandatory waiting periods (68), parental involvement laws (97), and legal restrictions on abortion providers (98–102); increasing acceptance of nonmarital childbearing (103,104); shifts in the race/ethnicity composition of the U.S. population (105,106); and changes in the economy and the resulting impact on fertility preferences and use of contraception (107). However, despite the multiple influences on abortion, because unintended pregnancy precedes nearly all cases of abortions (86), efforts to help women avoid pregnancies that they do not desire may reduce the number of abortions (89,91).
Recent data indicate that the proportion of pregnancies in the United States that were unintended decreased from 51% in 2008 to 45% during 2011–2013 (54). Changing patterns of contraception use might have contributed to this decrease in unintended pregnancy. The use of the most effective forms of reversible contraception (i.e., intrauterine devices and hormonal implants) (108) has recently increased among all women (109–112), and the use of contraception overall appears to be increasing among adolescents (113). Although the timing of these events is unknown, the majority of reported abortions in 2016 were among women with a previous birth, and a substantial proportion occurred among women with a previous induced abortion, events that also are opportunities for contraception counseling. Contraception provision in the immediate postpartum and postabortion settings might increase access to these methods at a time when women are receiving health services. In addition, providing contraception for women at no cost can increase use of these methods and reduce abortion rates (89–91,114–116). Level of provider reimbursement and training, inadequate client-centered counseling, lack of youth-friendly services, and low client awareness of available contraceptive methods also are barriers to accessing contraception (117–120). Removing these barriers might help improve contraceptive use, potentially reducing the number of unintended pregnancies and the number of abortions performed in the United States.
Corresponding author: Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. E-mail: [email protected].
1Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC; 2Oak Ridge Institute for Science and Education (ORISE) Fellow
Conflicts of Interest
All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.
* Hereafter, all abortions in this report are considered to be legally induced unless stated to be illegally induced.
† Includes aspiration curettage, suction curettage, manual vacuum aspiration, menstrual extraction, sharp curettage, and dilation and evacuation procedures.
§ CDC collects information only on the estimated number of weeks (not days) of gestation and acknowledges the conventional use of completed weeks of gestation to describe pregnancy duration. CDC’s category ≤8 weeks’ gestation thus includes abortions up through 8 weeks and 6 days. This closely corresponds to the performance measure for medical abortion proposed by the American College of Obstetricians and Gynecologists for 2014 (30).
¶ The cutoff of ≤12 weeks was selected on the basis of the implausibility of this procedure being performed at earlier gestational ages and on the basis of early research assessing the safety of intrauterine instillations starting at 13 weeks’ gestation (32,33).
** Excludes four reporting areas that did not report (California, DC, Maryland, and New Hampshire), and one (Florida) that did not report by maternal residence.
†† States that did not report for ≥1 year since 1998 include Alaska (1998–2000), California (1998–2015), Louisiana (2005), Maryland (2007–2015), New Hampshire (1998–2015), Oklahoma (1998–1999), and West Virginia (2003–2004).
§§ Excludes California, DC, Maryland, and New Hampshire.
¶¶ Comparisons do not include Wyoming, which reported <20 abortions.
*** Comparisons by residence status do not include California, DC, Florida, Maryland, or New Hampshire. Because these areas either did not report or did not report abortions by maternal residence, numbers are available only from other reporting areas where their residents obtained abortions, and as a consequence meaningful statistics cannot be reported.
††† Arkansas and Texas reported probable postfertilization age. 2 weeks were added to the probable postfertilization age to provide a corresponding measure to gestational age based on the clinician’s estimate. Virginia reported clinician’s estimate of gestational age based on conception, and West Virginia reported probable gestational age; no modifications were made to these data.
§§§ Excludes Alabama, California, DC, Florida, Georgia, Hawaii, Illinois, Kentucky, Louisiana, Maine, Maryland, Nevada, New Hampshire, New Mexico, Rhode Island, Tennessee, Vermont, Wisconsin, and Wyoming.
¶¶¶ Excludes Alabama, California, Connecticut, DC, Florida, Hawaii, Illinois, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Mississippi, Nebraska, New Hampshire, New Mexico, New York State, Pennsylvania, Tennessee, Vermont, Wisconsin, and Wyoming.
**** See Table 11 for list of reporting areas.
†††† Excludes Alaska, Arizona, California, Colorado, Connecticut, Delaware, DC, Florida, Hawaii, Illinois, Iowa, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Mississippi, Nebraska, Nevada, New Hampshire, New Mexico, New York State, North Carolina, North Dakota, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Vermont, Washington, Wisconsin, and Wyoming.
§§§§ Excludes Arizona, Arkansas, California, Connecticut, DC, Florida, Georgia, Hawaii, Louisiana, Maine, Maryland, Massachusetts, Nebraska, Nevada, New Hampshire, New York City, New York State, North Carolina, Ohio, Rhode Island, Vermont, Washington, and Wyoming.
¶¶¶¶ Excludes California, Connecticut, DC, Florida, Hawaii, Illinois, Maine, Maryland, Massachusetts, New Hampshire, New Mexico, New York State, North Carolina, Rhode Island, Vermont, Wisconsin, and Wyoming.
***** Excludes California, Connecticut, DC, Florida, Georgia, Hawaii, Illinois, Maine, Maryland, New Hampshire, New Mexico, New York City, New York State, North Carolina, Rhode Island, Vermont, Wisconsin, and Wyoming.
††††† In 2016, the abortion numbers CDC obtained for Wyoming were <5% of the numbers obtained for this state by the Guttmacher Institute through their national survey of abortion-providing facilities. CDC numbers for Colorado, Connecticut, Hawaii, Iowa, Louisiana, Missouri, New Jersey, Nevada, New Mexico, New York (city and state combined), Rhode Island, Virginia, and West Virginia were 51% to <90% of the Guttmacher Institute numbers. All other areas with legal reporting requirements that provided data to CDC obtained numbers that were at least 90% of the Guttmacher Institute numbers.
§§§§§ Because the sole distributor of mifepristone in the United States only sells this medication to licensed physicians, who must sign and return a prescriber’s agreement, sales data from this company are not limited by individual state reporting requirements or the difficulties of identifying smaller providers within the wider medical community.
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FIGURE 1. Number, rate,* and ratio† of abortions performed, by year — selected reporting areas,§ United States, 2007–2016
* Number of abortions per 1,000 women aged 15–44 years.
† Number of abortions per 1,000 live births.
§ Data are for 48 reporting areas; excludes California, District of Columbia, Maryland, and New Hampshire.
FIGURE 2. Percentage of total abortions, abortion rate,* and abortion ratio,† by age group of women who obtained a legal abortion — selected reporting areas,§ United States, 2016
* Number of abortions obtained by women in a given age group per 1,000 women in that age group. Women aged 13–14 years were used as the denominator for women aged <15 years, and women aged 40–44 years were used as the denominator for women aged ≥40 years. Women aged 15–44 years were used as the denominator for the overall rate. For each reporting area, abortions for women of unknown age were distributed according to the distribution of abortions among women of known age for that area.
† Number of abortions obtained by women in a given age group per 1,000 live births to women in that age group. For each reporting area, abortions for women of unknown age were distributed according to the distribution of abortions among women of known age for that area.
§ Data are for 46 reporting areas; excludes six areas (California, District of Columbia, Florida, Maryland, New Hampshire, and Wyoming) that did not report, did not report by age, or did not meet reporting standards.
FIGURE 3. Percentage* distribution of gestational ages at time of abortion, by age of woman — selected reporting areas,† United States, 2016
* Based on the total number of abortions reported with known weeks of gestation.
† Data from 40 reporting areas; excludes 12 reporting areas (California, District of Columbia, Florida, Illinois, Kentucky, Maryland, Massachusetts, New Hampshire, New York State, Pennsylvania, Wisconsin, and Wyoming) that did not report, did not report by age or gestational age, or did not meet reporting standards.
Suggested citation for this article: Jatlaoui TC, Eckhaus L, Mandel MG, et al. Abortion Surveillance — United States, 2016. MMWR Surveill Summ 2019;68(No. SS-11):1–41. DOI: http://dx.doi.org/10.15585/mmwr.ss6811a1.
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