Abortion Surveillance — United States, 2018

A CDC Surveillance Summary covering 2018 (abortion-related deaths for 2017), since corrected by two errata. California, Maryland and New Hampshire did not report.

How the surveillance works

Since 1969 CDC has documented the number and characteristics of women obtaining legal induced abortions in the United States. Each year it asks the central health agencies of the 50 states, the District of Columbia and New York City for aggregate data; reporting is voluntary, and many areas collect only some of the information CDC requests.

For surveillance, a legal induced abortion is an intervention by a licensed clinician, within state law, intended to end a suspected or known intrauterine pregnancy that does not result in a live birth. The report uses:

• the rate — abortions per 1,000 women aged 15–44;
• the ratio — abortions per 1,000 live births.

For 2018, 49 areas reported (47 states, the District of Columbia and New York City). Trends use the 48 areas that reported every year from 2009 to 2018. Areas are counted where the abortion took place, not where the woman lived.

Totals and trends

The 49 areas reported 619,591 abortions for 2018; 614,820 of them came from the 48 continuously reporting areas.

All three measures fell to historic lows for the period in 2017, then rose 1–2 percent in 2018.

Rates and ratios varied widely by area: the rate ranged from 2.4 per 1,000 women in South Dakota to 26.8 in New York City, and the ratio from 32 per 1,000 live births in South Dakota to 518 in the District of Columbia. The share of abortions obtained by out-of-state residents ranged from 0.4 percent in Arizona to 65.4 percent in the District of Columbia.

Who obtained abortions

Age. Women in their 20s obtained 57.7 percent of abortions and had the highest rates: 19.1 per 1,000 at ages 20–24 and 18.5 at 25–29. Girls under 15 and women 40 and over had the smallest shares (0.2 and 3.6 percent) and lowest rates (0.4 and 2.6). Ratios, however, were lowest among women aged 25–39.

• From 2009 to 2018 rates fell in every age group, most for adolescents: 64 percent for those under 15 and 55 percent for ages 15–19. Over the same years the birth rate for 15–19-year-olds fell 54 percent — declines in adolescent births have come with large declines in adolescent abortions.
• From 2017 to 2018, rates held steady or fell among women 24 and under and 40 and over, but rose among women aged 25–39.
• Among adolescents, 18- and 19-year-olds accounted for 69.7 percent of adolescent abortions; the ratio was highest for those under 15 (833 per 1,000 live births).

Race and ethnicity (31 areas). Non-Hispanic White women accounted for 38.7 percent of abortions, non-Hispanic Black women 33.6 percent, Hispanic women 20.0 percent and women of other races 7.7 percent. Non-Hispanic White women had the lowest rate (6.3 per 1,000) and ratio (110); non-Hispanic Black women had the highest (21.2 and 335) — 3.4 and 3.0 times the White figures, while Hispanic women's were 1.7 and 1.4 times higher. The report attributes the higher figures among Black women to higher rates of unintended pregnancy and a greater share of unintended pregnancies ending in abortion, and calls for identifying the complex factors behind the differences so family planning services can be equitable.

Marital status (42 areas). 14.8 percent were married and 85.2 percent unmarried; the ratio was 44 per 1,000 live births for married and 378 for unmarried women.

Previous births and abortions. 40.7 percent had no previous live births, 24.8 percent one, 19.8 percent two and 14.7 percent three or more. 59.9 percent had no previous abortion, 23.9 percent one, 9.9 percent two and 6.4 percent three or more.

Timing and method

Gestation (42 areas). 77.7 percent of abortions took place at 9 weeks or earlier and 92.2 percent at 13 weeks or earlier; 6.9 percent were at 14–20 weeks and 1.0 percent at 21 weeks or later. From 2009 to 2018 the share at 13 weeks or earlier barely changed, but shifted earlier: the share at 6 weeks or less rose from 33.6 to 36.2 percent. Abortions after 13 weeks stayed at 9.0 percent or less. Adolescents were more likely to obtain abortions after 13 weeks (21.7 percent of those under 15 and 10.3 percent of those 15–19, against 7.3–8.0 percent for older women).

Method (45 areas):

Medication abortion was the majority only at 6 weeks or earlier (54.9 percent). Of abortions at 9 weeks or earlier — all eligible for early medical abortion — half were medical, and the share of all abortions done by early medical abortion rose 120 percent from 2009 to 2018. Improved ultrasound and pregnancy tests now let very early surgical abortions succeed more than 97 percent of the time, and mifepristone-misoprostol regimens 96–98 percent.

Deaths

Through its Pregnancy Mortality Surveillance System, CDC identified two abortion-related deaths in 2017, both related to legal abortion. Because the yearly numbers are small and unstable, CDC calculates case-fatality rates over five-year periods: for 2013–2017 the rate was 0.44 deaths per 100,000 legal abortions, lower than in any earlier period and, like every period since the late 1970s, under 1 per 100,000.

Limitations

• Reporting is voluntary, so CDC cannot report the national total. California, Maryland and New Hampshire — about 19 percent of U.S. abortions in 2017, by the Guttmacher Institute's facility survey — did not report, and the District of Columbia and New Jersey had no central reporting requirement. Enforcement of reporting laws varies.
• Many areas' forms do not follow CDC's guidance, so some characteristics are missing; race and ethnicity came from only 31 areas.
• Data are counted where abortions occur, while population and birth data are by residence, overstating rates in areas that serve many out-of-state residents and understating them elsewhere.
• Only variables on the areas' forms can be analysed; socioeconomic status, for example, cannot.

Why it matters

Surveillance helps evaluate programmes to prevent unintended pregnancy — up to 42 percent of which end in abortion — tracks clinical practice and safety, and, with birth and fetal-loss data, lets the nation estimate pregnancies. About 18 percent of U.S. pregnancies end in induced abortion. Many factors affect abortion rates, including access to health care and contraception, the availability of providers, state regulations such as waiting periods, parental-involvement laws and restrictions on providers, attitudes toward childbearing outside marriage, and the economy.

The share of pregnancies that were unintended fell from 51 percent in 2008 to 45 percent in 2011–2013, possibly helped by growing use of long-acting reversible contraception (intrauterine devices and implants). Providing contraception right after birth or abortion, and at low or no cost, reduces unintended and repeat pregnancies. The report concludes that increasing access to and use of effective contraception can reduce unintended pregnancies and the number of abortions, and that barriers — inadequate provider reimbursement and training, too little client-centred counselling, few youth-friendly services and low awareness of methods — should be reduced.

Sources

• Kortsmit K, Jatlaoui TC, Mandel MG, Reeves JA, Oduyebo T, Petersen E, Whiteman MK. Abortion Surveillance — United States, 2018. MMWR Surveillance Summaries, CDC (corrected).