Abortion’s Downward Spiral Appears to be Over
It’s but a slight uptick, yet an uptick nonetheless, considering that abortion numbers have been on the decline in this country since 2009.
For the first time since then, the number of abortions is climbing. By 2018, the number rose to 619,591, according to the CDC. From 2009 to 2018, the number of abortions had dropped 22%, from 786,621. The rate of abortions, meaning the number of abortions per 1,000 women, and the ratio, meaning the number of abortions per 1,000 live births, went up 1% and 2%, respectively.
These numbers do not include figures from California, Maryland and New Hampshire. Other women’s health researchers, like Carol Joffe of the University of California, San Francisco, did not consider the increase significant.
To put the numbers in context: in 2011, there were 1.06 million abortions in this country. And that figure was a drop by 13% from three years prior.
The question, of course, is why the number has started to creep up. Longtime researchers aren’t sure why.
“We don’t know the exact reason for this increase,” Ushma Upadhyay, PhD, MPH told Medical Daily. “ Reductions in funding for family planning programs under the Trump Administration occurred only in 2019. There may have been increased state laws banning state funding for family planning programs. I have not seen any research on this documenting the reasons.” Dr. Upadhyay is director of the University of California’s San Francisco, women’s health, gender and empowerment center.
Clinics closing, access to better contraception methods and to abortion methods, legislative restrictions and changes in sex education curriculum have all been cited as reasons influencing abortion numbers, regardless of direction. What still remains to be seen is the impact of the Supreme Court’s recent decision that reversed an appellate court ruling from July regarding access to early-term medical abortions, which increasingly is becoming the abortion method of choice.
Abortion number influencers
Abortion clinics. Between 2011 and 2014, the number of abortion clinics decreased by 17%, and have continued to drop in number. The Daily Beast reported that 755 clinics were still open in 2019.
Dr. Upadhyay said her research showed that nearly 90% of US counties have no abortion provider; women living in 27major cities, so-called abortion deserts, are at minimum 100 miles away from an abortion provider.
Dr. Joffe,* professor in the Advancing New Standards in Reproductive Health at UCSF, attributed the decrease in abortion numbers from the last decade to better contraception.
“Unintended pregnancy is a major contributor to induced abortion,” said Dr. Upadhyay. “Increasing access to and use of effective contraception can reduce unintended pregnancies and further reduce the number of abortions performed in the United States.”
A 2019 policy paper by the Guttmacher Institute looked at reasons for the decline in abortions between 2011 and 2017. Researchers found that abortion restrictions placed on providers, which in turn shut down clinics, helped contribute to the decline in abortions. But the biggest reason for the consistent drop, Guttmacher researchers found, was the overall decline in births and pregnancies between 2011 and 2017.
Medical abortion, Part 1. Two medications combined that can terminate a pregnancy within a few weeks of conception have impacted early abortion figures.
In 2000 the FDA approved the use of mifepristone in combination with another pill called misoprostol. The first pill restricts production of the hormone progesterone; the second was already approved for inducing labor. both are available as generics. Misoprostol, its generic name, became that way in 2012 and mifepristone in 2019. Together, these pills can terminate a pregnancy well before the first trimester is over. Misoprostol, used by itself, can be used to terminate a pregnancy.
The FDA put restrictions on immediate access to these pills, requiring that healthcare providers become certified in their use and only allowing these medications to be given in hospitals, clinics and medical offices by these certified providers.
Medical abortions, Part II. As for their impact:
- Use of pills to terminate a pregnancy early on increased 9% from 2017 to 2018 (from 34.7% of abortions to 37.7%)
- From 2009 to 2018, the increase was 120% (from 17.1% of abortions to 37.7%)
- By 2018, 77.7% of all abortions occurred earlier than 9 weeks’ gestation.
Legislative restrictions. Researchers do not see legislation that bans certain abortion procedures per se as a direct influence on abortion numbers. One recent study that contradicts that view looked at the impact of an executive order in Texas. The order stopped elective surgeries from March 22, 2020 to April 21, 2020. The study found that once the executive order was lifted, more abortions occurred at 12 weeks’ gestation than in the same period in 2019. The researchers suspect the subsequent increase was due to backlogs created during the banned period.
While researchers might not see a direct link to outright legislative-imposed restrictions, they do point to indirect restrictions, such as physicians needing operating privileges in the hospital where they want to perform the procedure, as having some effect.
States also have made restrictions regarding medical abortion. States, more than half of them, require that no one but a doctor — not other prescribers, like nurse practitioners and physician’s assistants — can prescribe the abortion combination.
Guttmacher found that these types of terminations increased to 39% of all abortions in 2017 from 5% in 2001, even though the overall rate of abortion was dropping.
Recently the FDA reported a shortage of misoprostol. Both UC Davis and UCSF hospitals reported that there had been a shortage in the spring of last year but that none of their patients had been affected, and they are currently unaware of any shortage.
Dr. Joffe wrote in an email that women manage their own abortion with misoprostol and without medical assistance. It is estimated that 7% of women in the US will self-manage their abortion during their lifetime.
The combination mifepristone and misoprostol is the standard of care in abortion clinics, Dr. Joffe said. However, “Using misoprostol alone is not quite as effective and can take longer than with both medications.”
The World Health Organization states medical abortion care is crucial to providing access to safe, effective and acceptable abortion care for all women seeking an abortion.
Culture. One possible abortion-figure influencer are cultural mores. During the 2010s, abstinence became the primary message to young people, replacing birth control information. In 2018, among the areas that reported age by individual year, 18- and 19 year-old-teens had the majority (69.7%) of abortions and the highest adolescent abortion rates, meaning the number of abortions per 1000 teens the same age — 8.6 and 12.2 abortions per 1,000. Between 2014 and 2018, the only age group that did not have rising abortion figures were women 35 and older. Women in their 20s had the most abortions among all other women.
“At the societal level,” wrote researchers in 2011 regarding sex education, “deeply rooted cultural and religious norms around adolescent sexuality have shaped federal and state policies and practices, driving restrictions on comprehensive sexual and reproductive health information, and service delivery in schools and elsewhere.”
The CDC report said decreases in adolescent births in the United States, between 2009 and 2018, have been accompanied by large decreases in adolescent abortions — the birth rate for adolescents dropped 54%, and the abortion rate dropped 55%.
In July 2020 Judge Theodore D. Chuang, of the Federal District Court, Maryland, ruled that requiring an in-person visit during a pandemic to obtain a medical abortion prescription was unnecessary. Mifepristone became available by mail in all but 19 states.
Dr. Upadhyay told Medical Daily that following the July decision many telehealth clinics had opened to provide these medications by mail. Misoprostol was already available by mail. That all came to a halt January 12 with the Supreme Court ruling that mifepristone is available only if a woman appears in person to get the prescription from her provider.
Even approved prescriptions ready for shipment cannot be mailed out.
* Dr. Joffe is the co-author (with David S. Cohen) of Obstacle Course: The everyday struggle to get an abortion in America. (University of California Press, 2020.)
Yvonne Stolworthy MSN, RN graduated from nursing school in 1984 and has spent many years in critical care and as an educator in a variety of settings, including clinical trials.
Christine Bahls is an editor with MedicalDaily.com.