This is Issue 19 in The American Reports Series. The paper may be viewed as a PDF here: U.S. Abortion Trends: 2019 and Preliminary 2020
Although accurate abortion data is vital for multiple public health and public policy purposes, U.S. abortion reporting remains dilatory and incomplete. States set their own reporting standards, and three states collect no abortion data at all, while others collect only limited data.[i] States voluntarily share their data with the U.S. Centers for Disease Control and Prevention (CDC) for inclusion in annual abortion surveillance reports, generally published two years after the data collection. Since not all states report abortions, and data quality varies from state to state, CDC abortion totals are well below – by 30 percent or more – independent estimates from the pro-abortion Guttmacher Institute.[ii]
Still, CDC reports are sufficient to gain a glimpse of abortion trends in recent years. In 2018, Charlotte Lozier Institute (CLI) noted a rise in the abortion rate after years of decline, which was borne out by the 2018 CDC abortion surveillance report.[iii] The CDC’s 2019 abortion surveillance report is unlikely to be available for several more months, but the available state reporting from 2019 indicates that the increase continued.
As of September 1, 2021, there were 39 states that had released abortion statistics for 2019. Seventeen states reported a decline in abortions from 2018, while 21 states reported that abortions increased. One state, Wyoming, published its first abortion report for the latter half of 2019.[iv]
In the 38 states that reported for both 2018 and 2019, abortions increased by 2.3 percent. This was the second year in a row that state data showed an increase in abortions. As in 2018, states that tend to be permissive of abortion reported a larger increase than states that are more protective of life.[v] In the 12 permissive states that released 2018 and 2019 abortion statistics, abortions increased by three percent, while in the 26 protective states, abortions increased by just two percent. The data shows an increase of 3,782 abortions from the prior year in the 12 permissive states that reported.
The largest percentage decreases were seen in Missouri and West Virginia, possibly impacted by pro-life policy. Because of Missouri’s safety regulations for chemical abortion, the state’s single abortion center referred most women seeking chemical abortions out-of-state.[vi] Additionally, plans to expand the number of abortion centers in Missouri were halted when a new abortion center failed a safety inspection. In November of 2018, West Virginia voters approved an amendment to the state constitution clarifying that the constitution contains no right to abortion; consequently, a court order requiring West Virginia Medicaid to fund abortions is no longer in effect, and West Virginia taxpayers do not pay for most abortions.[vii]
The largest percentage increase was reported in Iowa, where abortions rose by over 25 percent from the previous year. The sudden increase in Iowa abortions may have been the result of a rebound after an abrupt drop in 2018 following the closure of several abortion centers in late 2017 and early 2018.[viii] Delaware and Idaho also reported large increases.
However, because some of the states with the greatest percentage changes are low-volume abortion states, the overall change in abortions in the United States between 2018 and 2019 was driven by some of the larger states. Illinois reported an increase of over 4,000 abortions in 2019, while Georgia and Texas likewise reported increases of more than 2,000 abortions in each state. In Florida, abortions rose by nearly 1,700. Missouri claimed both the largest percentage and absolute decrease in abortions, with over 1,400 fewer abortions in 2019 than in 2018. Tennessee reported nearly 1,200 fewer abortions in 2019.
Table 1. Total abortions, 2018-2019 (39 states)
*Residents only. 2019 total excludes Wyoming
Out of 39 states that released 2019 abortion statistics, 33 states reported chemical abortions for 2018 and 2019. Georgia, Louisiana, and Tennessee did not report chemical abortion data for either year, Oregon and Virginia have not yet published chemical abortion data for 2019, and Wyoming reported only for the second half of 2019. Among the 33 states, chemical abortions jumped by 11.8 percent from 2018 to 2019, representing 44 percent of total abortions in 2019, up from 41 percent the previous year. In 11 states, chemical abortions composed half or more of all reported abortions.
Twenty-eight states reported that chemical abortions increased from 2018, with 16 states reporting increases in chemical abortions of more than 10 percent. Only five states reported that chemical abortions declined from the previous year. Chemical abortions increased by nearly 14 percent in the permissive states, compared to an increase of 11 percent in the states that tend to be protective of life.
This trend is very likely to continue into the future. Due to the COVID-19 pandemic, a federal court suspended a critical element of the Risk Evaluation and Mitigation Strategy (REMS) that the U.S. Food and Drug Administration (FDA) maintains for mifepristone, waiving the requirement that mifepristone be distributed in person. The FDA then voluntarily lifted the in-person requirement for the duration of the pandemic.[ix] Immediately, abortion pill websites began distributing mifepristone through the mail, and mail-order abortion is now advertised in half the states.[x] Although the change was originally supposed to be temporary, the FDA is now considering making this revision to the REMS permanent or perhaps even eliminating the REMS entirely. This could lead to an increase in both abortions and abortion-related complications, as chemical abortions have a higher complication rate than surgical abortions at the same gestational age.[xi] Among the few states that report the types of abortion procedures that lead to complications, almost all report a disproportionate share of complications from chemical abortions. This same pattern is demonstrated by large-scale studies, including some in countries with more complete abortion reporting than the United States. Without the in-person requirement, complications would no doubt increase.[xii] With no physical examination, the abortion provider will not have the opportunity to screen for ectopic pregnancy, and abortion pills could inadvertently be prescribed dangerously late in pregnancy. Additionally, the lack of an in-person requirement could lead to increased coercion and abuse.[xiii]
In addition to an increase in chemical abortions and abortion complications, this will almost certainly result in even worse abortion reporting, as many health departments of the states to which online distributors are mailing pills have informed CLI that they are unable to track abortion pills sent from outside the state. If a provider in California or another state that does not require abortion reporting mailed abortion pills to a woman in a different state, the abortion could go unreported.
Table 2. Chemical abortions and percent of total, 2019 (34 states)
The Impact of the COVID-19 Pandemic
Abortion reporting for 2020 is still incomplete, with only 15 states having released 2020 abortion statistics as of September 2021. While numbers are preliminary, available 2020 reporting suggests that the COVID-19 pandemic accelerated the trends noted in 2018 and 2019, although states were impacted in different ways. In some states, abortions dropped precipitously as a result of the pandemic, with Oklahoma abortions falling by 24 percent and South Dakota abortions dropping by 69 percent after abortions in these states were suspended for part of 2020. Conversely, Nebraska and Colorado abortions each jumped by 15 percent in 2020. Overall, abortions in the states that have reported 2020 data increased by 2.3 percent.
The increase was largely driven by chemical abortion. In every single state that reported chemical abortions for all of 2019 and 2020 (13 states), chemical abortions made up a larger percentage of the state total in 2020 than they did the previous year. Among the states that have released 2020 abortion statistics so far, chemical abortions jumped by 26 percent. The rollback of the in-person requirement for mifepristone may have contributed to this rapid increase.
This preliminary look at 2019 abortion data, as well as early numbers from states that have released 2020 statistics, shows that abortions in the United States have continued to increase and that chemical abortion is playing a major role. It is likely that these patterns will continue in 2021 due to mail-order mifepristone, with chemical abortion rates rising and abortions increasingly going unreported. In response, some states have recently taken steps to address both issues by enacting legislation to better regulate chemical abortion and improve chemical abortion reporting. As the FDA relaxes its chemical abortion regulations, state-level abortion restrictions are likely to have an increasing impact on abortion trends in the United States.
[i] Charlotte Lozier Institute. FDA decision to relax chemical abortion rule ignores the science, neglects women, places them in danger. https://lozierinstitute.org/fda-decision-to-relax-chemical-abortion-rule-ignores-the-science-neglects-women-places-them-in-danger/ Published April 13, 2021. Accessed July 12, 2021.
[iii] Longbons T. The abortion pill’s significant complications must not be buried or ignored. Live Action. https://www.liveaction.org/news/abortion-pill-complications-buried-ignored/ Published July 3, 2021. Accessed July 12, 2021.
[iv] Skop Ingrid. The “no-test medication abortion” protocol: experimenting with women’s health. Charlotte Lozier Institute. On Point Series Issue 49, July 2020. https://lozierinstitute.org/the-no-test-medication-abortion-protocol-experimenting-with-womens-health/
[v] Howard H. Medical and social risks associated with unmitigated distribution of mifepristone: a primer. Charlotte Lozier Institute. On Point Series Issue 51, October 2020. https://lozierinstitute.org/medical-and-social-risks-associated-with-unmitigated-distribution-of-mifepristone-a-primer/
[vi] Kortsmit K, Jatloui TC, Mandel MG, et al. Abortion Surveillance – United States, 2018. MMWR Surveill Summ 2020;69(No. SS-7):1-29. DOI: http://dx.doi.org/10.15585/mmwr.ss6907a1*Residents only. 2019 total excludes Wyoming
[viii] Longbons T. New abortion trends in the United States: a first look. Charlotte Lozier Institute. American Reports Series Issue 16, September 2020. https://lozierinstitute.org/new-abortion-trends-in-the-united-states-a-first-look/
[ix] Longbons T. Abortion reporting: Wyoming (2019). Charlotte Lozier Institute. https://lozierinstitute.org/abortion-reporting-wyoming-2019/ Published November 3, 2020. Accessed July 20, 2021.
[x] These groupings were determined by the abortion legislation in place in each state in 2019, the states’ political environments, and the overall trend of their policies. All protective states except for Florida, Iowa and West Virginia scored in the top 25 of Americans United for Life’s Defending Life 2019 report, and all permissive states except for Virginia scored in the lower 25. Florida, Iowa, West Virginia, and Virginia were categorized based on their political environments and the shift in their policies that has taken place over the past decade. See: Americans United for Life. Defending Life 2019. Arlington, VA: Americans United for Life, 2019.
[xi] See Longbons T. Abortion reporting: Missouri (2018). Charlotte Lozier Institute. https://lozierinstitute.org/abortion-reporting-missouri-2018/ Published March 10, 2020. Accessed July 12, 2021.
[xii] West Virginia Bureau for Medical Services. Revised public notice regarding West Virginia Constitutional Amendment 1. Issued November 9, 2018. https://dhhr.wv.gov/bms/Public%20Notices/Pages/Public%20Notice%20regarding%20West%20Virginia%20Constitutional%20Amendment%201%20is%20now%20available.aspx Amended November 13, 2018. Accessed July 12, 2021.
[xiii] Longbons T. Abortion reporting: Iowa (2019). Charlotte Lozier Institute. https://lozierinstitute.org/abortion-reporting-iowa-2019/ Published December 16, 2020. Accessed July 12, 2021.