abortion in the united states essay

Abortion in the US: What you need to know

Subscribe to the center for economic security and opportunity newsletter, isabel v. sawhill and isabel v. sawhill senior fellow emeritus - economic studies , center for economic security and opportunity @isawhill kai smith kai smith research assistant - the brookings institution, economic studies.

May 29, 2024

Key takeaways:

One in every four women will have an abortion in their lifetime.

• The vast majority of abortions (about 95%) are the result of unintended pregnancies.
• Most abortion patients are in their twenties (61%), Black or Latino (59%), low-income (72%), unmarried (86%), between six and twelve weeks pregnant (73%), and already have given birth to one or more children (55%).
• Despite state bans, U.S. abortion totals increased in the first full year after the Supreme Court overturned Roe v. Wade.

Introduction

Two years after the Supreme Court overturned Roe v. Wade, abortion remains one of the most hotly contested issues in American politics. The abortion landscape has become highly fractured, with some states implementing abortion bans and restrictions and others increasing protections and access. The Supreme Court heard two more cases on abortion this term and will likely release those decisions in June. Beyond the Supreme Court, pro-choice and pro-life advocates are fiercely battling it out in the voting booths, state legislatures, and courts. If the 2022 midterm elections are any indication , abortion will be one of the most influential issues of the 2024 election. So what are the basic facts about abortion in America? This primer is designed to tell you most of what you need to know.

What are the different types of abortion?

There are two main types of abortion: procedural abortions and medication abortions. Procedural abortions (also called in-clinic or surgical abortions) are provided by health care professionals in a clinical setting. Medication abortions (also called medical abortions or the abortion pill) typically involve the oral ingestion of two drugs in succession, mifepristone and misoprostol.

Most women discover they are pregnant in the first five to six weeks of pregnancy, but about a third of women do not learn they are pregnant until they are beyond six weeks of gestation. 1 Women with unintended pregnancies detect their pregnancies later than women with intended pregnancies, between six and seven weeks of gestation on average. Even if a woman discovers she is pregnant relatively early, for many it takes time to decide what to do and how to arrange for an abortion if that is her preference.

Why do women have abortions?

The vast majority of abortions (about 95%) are the result of unintended pregnancies. That includes pregnancies that are mistimed as well as those that are unwanted.

Women’s reasons for not wanting a child—or not wanting one now—include finances, partner-related issues, the need to focus on other children, and interference with future education or work opportunities.

In short, if there were fewer unintended pregnancies, there would be fewer abortions.

How common are abortions?

About two in every five pregnancies are unintended (40% in 2015). Roughly the same share of these unintended pregnancies end in abortion (42% in 2011). About one in every five pregnancies are aborted (21% in 2020).

How have abortion totals changed over time?

The number of abortions occurring in the U.S. jumped up after the Roe v. Wade decision in 1973. After peaking in 1990, the number of abortions declined steadily for two and a half decades until reaching its lowest point since 1973 in 2017. 2 Possible contributing factors explaining this long-term decline include delays in sexual activity amongst young people, improvements in the use of effective contraception , and overall declines in pregnancy rates , including those that are unintended . In addition, state restrictions which became more prevalent beginning in 2011 prevented at least some individuals in certain states from having abortions.

In 2018 (four years before the Supreme Court overturned Roe v. Wade), the number of abortions in the U.S. began to increase. The causes of this uptick are not yet fully understood, but researchers have identified multiple potential contributing factors. These include greater coverage of abortions under Medicaid that made abortions more affordable in certain states, regulations issued by the Trump administration in 2019 which decreased the size of the Title X network and therefore reduced the availability of contraception to low-income individuals, and increased financial support from privately-financed abortion funds to help pay for the costs associated with getting an abortion.

Another contributing factor, whose importance bears emphasizing, is the surging popularity of medication abortions .

The use of medication abortions has increased steadily since becoming available in the U.S. in 2000. However, in 2016, the FDA increased the gestational limit for the use of mifepristone from seven to ten weeks and thereby doubled the share of abortion patients eligible for medication abortions from 37% to 75%.

Later, during the COVID-19 pandemic, the FDA revised its policy in 2021 so that clinicians are no longer required to dispense medication abortion pills in person. Patients can now have medication abortion pills mailed to their homes after conducting remote consultations with clinicians via telehealth. In January 2023, the FDA issued another change which allows retail pharmacies like CVS and Walgreens to dispense medication abortion pills to patients with a prescription. Previously only doctors, clinics, or some mail-order pharmacies could dispense abortion pills.

Although access varies widely by state , medication abortions are now the most commonly used abortion method in the U.S. and account for nearly two-thirds of all abortions (63% in 2023). 3

This is why the Supreme Court’s upcoming decision in the Mifepristone case (FDA v. Alliance for Hippocratic Medicine) is so consequential. Among other issues, at stake is whether access to medication abortion will be sharply curtailed and whether regulations regarding medication abortions will revert to pre-2016 rules when abortion pills were not authorized for use after seven weeks of pregnancy and could not be prescribed via telemedicine, sent to abortion patients by mail, or dispensed by retail pharmacies.

Who has abortions?

Most abortion patients are in their twenties (61%), Black or Latino  (59%), low-income (72%), unmarried (86%), and between six and twelve weeks pregnant (73%). 4

The majority of abortion patients have already given birth to one or more children (55%) and have not previously had an abortion (57%). 5 Among abortion patients twenty years old or older, most had attended at least some college (63%). The vast majority of abortions occur during the first trimester of pregnancy (91%). So-called “late-term abortions” performed at or after 21 weeks of pregnancy are very rare and represent less than 1% of all abortions in the U.S.

The abortion rate per 1,000 women of reproductive age is disproportionately high for certain population groups. Among women living in poverty, for example, the abortion rate was 36.6 abortions per 1,000 women of reproductive age in 2014, compared to 14.6 abortions per 1,000 women among all women of reproductive age.

How much does an abortion cost?

The cost of an abortion varies depending on what kind of abortion is administered, how far along the patient is in their pregnancy, where the patient lives, where the patient is seeking an abortion, and whether health insurance or financial assistance is available. In 2021, the median self-pay cost for abortion services was $625 for a procedural abortion in the first trimester of pregnancy and $568 for a medication abortion.

Since 1977, the Hyde Amendment has banned the use of federal funds to pay for abortions except in cases of rape, incest, or life endangerment. Today, among the 36 states that have not banned abortion, fewer than half (17 as of March 2024) allow the use of state Medicaid funds to pay for abortions. 6 Many insurance plans do not cover abortions, often due to state limitations. Most abortion patients pay for abortions out of pocket (53%). State Medicaid funding is the second-most-commonly used method of payment (30%), followed by financial assistance (15%) and private insurance (13%). 7

Whether state law allows state Medicaid funds to cover abortions has a very large impact on the difficulty of paying for abortions and the methods used by women to pay for them. In the year before the Dobbs Supreme Court decision, 50% of women residing in states where state Medicaid funds did not cover abortion reported it was very or somewhat difficult to pay for their abortions, compared to only 17% of women residing in states where abortions were covered.

How has the Supreme Court handled abortion?

In Roe v. Wade (1973), the Supreme Court established that states could not ban abortions before fetal viability, the point at which a fetus can survive outside the womb. Under the three-trimester framework established by Roe, states were not allowed to ban abortions during the first two trimesters of pregnancy but were allowed to regulate or prohibit abortions in the third trimester, except in cases where abortions were necessary to protect the life or health of a pregnant person. The Court ruled that the fundamental right to have an abortion is included in the right to privacy implicit in the “liberty” guarantee of the Due Process Clause of the Fourteenth Amendment.

Since it was decided, Roe v. Wade has faced legal criticism. Notwithstanding these critiques, the Court upheld Roe multiple times over the next half-century including in Planned Parenthood v. Casey (1992). But after former President Trump appointed three new Justices to the Supreme Court, a new conservative supermajority overturned Roe v. Wade in Dobbs v. Jackson Women’s Health Organization (2022) and established that there is no Constitutional right to have an abortion.

In his Dobbs majority opinion , Justice Alito concluded “Roe was egregiously wrong from the start.” Writing for the majority, he underscored that “[t]he Constitution makes no reference to abortion,” and while he recognized there are constitutional rights not expressly enumerated in the Constitution, he concluded the right to have an abortion is not one of them. Justice Alito reasoned that the only legitimate rights not explicitly stated in the Constitution are those “deeply rooted in the nation’s history and traditions,” and he found no evidence of this for abortion.

Because the Court determined there is no Constitutional right to abortion, it allowed the Mississippi state law which banned abortion after 15 weeks of pregnancy with limited exceptions to go into effect. The Court ruled that states have the authority to restrict access to abortion or ban it completely and that the power to regulate or prohibit abortions would be “returned to the people and their elected representatives.”

The Court’s three liberal Justices criticized the majority’s decision in a withering joint dissent . The dissenting Justices argued the right to abortion established in Roe and upheld in Casey is necessary to respect the autonomy and equality of women and prevent the government from controlling “a woman’s body or the course of a woman’s life.” They lamented “one result of today’s decision is certain: the curtailment of women’s rights, and of their status as free and equal citizens.”

How did the states respond to the overturning of Roe v. Wade?

Since Roe v. Wade was overturned, many states have implemented abortion bans or restrictions, while others have added protections and expanded access. The abortion landscape in America is now fractured and highly variegated .

As of May 2024, abortion is banned completely in almost all circumstances in 14 states. In 7 states, abortion is banned at or before 18 weeks of gestation. Many states with abortion bans do not include exceptions in cases where the health of the pregnant person is at risk, the pregnancy is the result of rape or incest, or there is a fatal fetal anomaly.

Access to abortion varies widely even among states without bans since many states have restrictions such as waiting periods, gestational limits, or parental consent laws making it more difficult to get an abortion.

Many state bans and restrictions are still being litigated in court. The interjurisdictional issues and legal questions arising from the post-Dobbs abortion landscape have not been fully resolved.

Despite the Supreme Court’s stated intention in Dobbs to leave the abortion issue to elected officials, the Court will likely hear more cases on abortion in the near future. This term, in addition to the case about Mifepristone, the Court will decide in Moyle v. United States whether a federal law called the Emergency Medical Treatment and Labor Act (EMTLA) can require hospitals in states with abortion bans to perform abortions in emergency situations that demand “stabilizing treatment” for the health of pregnant patients.

What are the trends in abortion statistics post-Dobbs?

In 2023, the first full year since the Dobbs Supreme Court decision, states with abortion bans experienced sharp declines in the number of abortions occurring within their borders. But these declines were outweighed by increases in abortion totals in states where abortion remained legal. Nearly all states without bans witnessed increases in 2023. Taken together, abortions in non-ban states increased by 26% in 2023 compared to 2020 levels.

As a result, the nationwide abortion statistics from 2023 represent the highest total number (1,037,000 abortions) and abortion rate (15.9 abortions per 1,000 women of reproductive age) in the U.S. in over a decade. The 2023 U.S. total represents an 11% increase from 2020 levels.

It’s unclear why, despite Dobbs, abortions have continued to rise . It may be because of the increased use of medication abortions , especially after the FDA liberalized regulations related to telehealth and in-person visits. In addition, multiple states where abortion remains legal have implemented shield laws and other new protections for abortion patients and providers, increased insurance coverage, or otherwise expanded access . Abortion funds provided greater financial and practical assistance . Interstate travel for abortions doubled after the Dobbs decision.

In short, the impacts of Dobbs are being felt unevenly. Although most women who want abortions are still able to obtain them, a significant minority are instead carrying their pregnancies to term. In the first six months of 2023, state abortion bans led between one-fifth and one-fourth of women living in ban states who may have otherwise gotten an abortion not to have one.

Young, low-income, and minority women will be most affected by state bans and restrictions because they are disproportionately likely to have unintended pregnancies and less able to overcome economic and logistical barriers involved in travelling across state lines or receiving medication abortion pills through out-of-state networks.

What are the effects of expanding or restricting abortion access on women and their families?

Effects of abortion restrictions on women.

Abortion bans jeopardize the lives and health of women. The impacts on their health can be especially troublesome. Pregnancies can go wrong for many reasons—fetal abnormalities, complications of a miscarriage, ectopic pregnancies—and without access to emergency care, some women could face serious threats to their own health and future ability to bear children. Abortion restrictions can place doctors in difficult situations and undermine women’s health care.

Although medication abortions are safe and effective, abortion bans could also increase the number of women who use unsafe methods to induce self-managed abortions, thereby endangering their own health or even their lives. State abortion legalizations in the years before Roe reduced maternal mortality among non-white women by 30-40%.

Enforcement of state laws that restricted access to abortion in the years before Dobbs has even been associated with increases in intimate partner violence-related homicides of women and girls.

In addition, lack of access to abortion leads to worse economic outcomes for women. After a conservative group suggested that such effects have not been well documented, a group of economists filed an amicus brief to the Supreme Court in the Dobbs case, noting that in recent years methods for establishing the causal effects of abortion have shown that they do affect women’s life trajectories. Although there has been some difficulty in separating the effects of access to abortion from access to the Pill or other forms of birth control, an extensive literature shows that reducing unintended pregnancies increases educational attainment , labor force participation , earnings , and occupational prestige for women. These trends are especially pronounced for Black women .

One example that focuses solely on abortion is the Turnaway study, in which researchers compared the outcomes for women who were denied abortions on the basis of just being a little beyond the gestational cutoff for eligibility to the outcomes of otherwise similar women who were just under that cutoff. The study along with subsequent related research has shown that women who are denied abortions are nearly four times more likely to be living in poverty six months after being denied an abortion, a difference that persists through four years after denial. They are also more likely to be unemployed , rely on public assistance , and experience financial distress such as bankruptcies, evictions and court judgements.

Finally, increased access to abortion results in lower rates of single and teen parenthood. State abortion legalizations in the years before Roe reduced the number of teen mothers by 34%. The effects were especially large for Black teens.

Effects of abortion restrictions on children

Along with contraception, access to abortion reduces unplanned births. That means fewer children dying in infancy, growing up in poverty, needing welfare, and living with a single parent. One study suggests that if all currently mistimed births were aligned with the timing preferred by their mothers, children’s college graduation rates would increase by about 8 percentage points (a 36% increase), and their lifetime incomes would increase by roughly $52,000.

Despite this evidence that the denial of abortions to women who want them would be harmful to women and to children once born, those who are pro-life argue that these costs are well worth the price to save the lives of the unborn. As of April 2024, 36% of Americans believe abortion should be illegal in all (8%) or most (28%) cases, while 63% of Americans believe abortion should be legal in all (25%) or most (28%) cases.

Looking ahead

The abortion landscape in America is continually evolving. Whereas pro-choice advocates will seek to expand access and add additional protections for abortion patients and providers, opponents of abortion will continue to criminalize abortions and further restrict availability.

Abortion will be one of the top issues of the 2024 elections in November. Democratic candidates in particular believe abortion is a winning issue for them and will broadcast their pro-choice stance on the campaign trail. Some evidence suggests the overturning of Roe has galvanized a new class of abortion-rights voters. Multiple states will have abortion referenda on the ballot .

The Supreme Court’s Dobbs decision will not prevent women and other citizens from affecting the legislative process by voting, organizing, influencing public opinion, or running for office. What they do with that power in November remains to be seen.

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The Brookings Institution is financed through the support of a diverse array of foundations, corporations, governments, individuals, as well as an endowment. A list of donors can be found in our annual reports published online  here . The findings, interpretations, and conclusions in this report are solely those of its author(s) and are not influenced by any donation.

• We recognize people of all genders become pregnant and have abortions, including about 1% of abortion patients who do not identify as women or female. For concision, we use “women” and female pronouns in this piece when discussing individuals who become pregnant.
• The Guttmacher and CDC data produced in this primer only represent legal abortions that occur within the formal US healthcare system. They do not include self-managed which occur outside of the formal US healthcare system.
• As of March 2024, 29 states have laws that restrict access to medication abortion, for example by requiring ultrasound, counseling, or multiple in-person appointments.
• We define low-income as earnings below 200% of the federal poverty level.
• The CDC abortion data is less complete than the Guttmacher Institute data and omits abortion data from states which account for approximately one-fourth of all abortions in the U.S.
• Today, roughly 35% of women of reproductive age covered by Medicaid (5.5 million women) are living in states where abortion is legal but state funds are not allowed to cover abortions beyond the Hyde exceptions of rape, incest, or life endangerment.
• Respondents could indicate multiple payment methods.

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Key Facts on Abortion in the United States

Usha Ranji , Karen Diep , and Alina Salganicoff Published: Nov 21, 2023

Note: This brief was updated on January 4, 2024 to correct the description of the data collected by the federal CDC Abortion Surveillance System. On June 24, 2022, the Supreme Court issued a ruling in Dobbs v. Jackson Women’s Health Organization that overturned the constitutional right to abortion as well as the federal standards of abortion access, established by prior decisions in the cases Roe v. Wade and Planned Parenthood v. Casey . Prior to the Dobbs ruling, the federal standard was that abortions were permitted up to fetal viability. That federal standard has been eliminated, allowing states to set policies regarding the legality of abortions and establish limits. Access to and availability of abortions varies widely between states , with some states banning almost all abortions and some states protecting abortion access.

This issue brief answers some key questions about abortion in the United States and presents data collected before and new data that was published shortly after the overturn of Roe v. Wade .

What is abortion?

How safe are abortions, how often do abortions occur, who gets abortions, at what point in pregnancy do abortions occur, where do people get abortion care, how much do abortions cost, does private insurance or medicaid cover abortions, what are public opinions about abortion.

Abortion is the medical termination of a pregnancy. It is a common medical service that many women obtain at some point in their life. There are different types of abortion methods, which the National Academy of Sciences, Engineering, and Medicine (NASEM ) places in four categories:

• Medication Abortion – Medication abortion, also known as medical abortion or abortion with pills, is a pregnancy termination protocol that involves taking oral medications. There are two widely accepted protocols for medication abortion. In the U.S., the most common protocol involves taking two different drugs, Mifepristone and Misoprostol. Typically, an individual using medication abortion takes Mifepristone first, followed by misoprostol 24-48 hours later. In the U.S., the Food and Drug Administration (FDA) has approved this protocol of medication abortion for use up to the first 70 days (10 weeks) of pregnancy, and its use has been rising for years. Another medication abortion protocol uses misoprostol alone . Patients can take 800 µg (4 pills) of misoprostol sublingually or vaginally every three hours for a total of 12 pills. The regimen is also recommended for up to 70 days (10 weeks) of pregnancy, but it is not currently approved by the FDA and is more commonly used in other countries.

Guttmacher Institute estimates that in 2020, medication was used for more than half (53%) of all abortions. While medication abortion has been available in the U.S. for more than 20 years, studies have found that many adults and women of reproductive age have not heard of medication abortion. Many have confused emergency contraception ( EC ) pills with medication abortion pills, but EC does not terminate a pregnancy. EC works by delaying or inhibiting ovulation and will not affect an established pregnancy.

• Aspiration , a minimally invasive and commonly used gynecological procedure, is the most common form of procedural abortion. It can be used to conduct abortions up to 14-16 weeks of gestation. Aspiration is also commonly used in cases of early pregnancy loss (miscarriage).
• Dilation and evacuation abortions (D&E) are usually performed after the 14th week of pregnancy. The cervix is dilated, and the pregnancy tissue is evacuated using forceps or suction.
• Induction abortions are rare and conducted later in pregnancy. They involve the use of medications to induce labor and delivery of the fetus.

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Decades of research have shown that abortion is a very safe medical service.

Despite its strong safety profile, abortion is the most highly regulated medical service in the country and is now banned in several states. In addition to bans on abortion altogether and telehealth, many states impose other limitations on abortion that are not medically indicated, including waiting periods, ultrasound requirements, gestational age limits, and parental notification and consent requirements. These restrictions typically delay receipt of services.

• NASEM completed an exhaustive review on the safety and effectiveness of abortion care and concluded that complications from abortion are rare and occur far less frequently than during childbirth.
• NASEM also concluded that safety is enhanced when the abortion is performed earlier in the pregnancy. State level restrictions such as waiting periods, ultrasound requirements, and gestational limits that impede access and delay abortion provision likely make abortions less safe.
• When medication abortion pills, which account for the majority of abortions, are administered at 9 weeks’ gestation or less, the pregnancy is terminated successfully 99.6% of the time, with a 0.4% risk of major complications, and an associated mortality rate of less than 0.001 percent (0.00064%).
• Medication abortion pills can be provided in a clinical setting or via telehealth (without an in-person visit). Research has found that the provision of medication abortion via telehealth is as safe and effective as the provision of the pills at an in person visit.
• Studies on procedural abortions, which include aspiration and D&E, have also found that they are very safe. Research on aspiration abortions, the most common procedural method, have found the rate of major complications of less than 1%.

There are three major data sources on abortion incidence and the characteristics of people who obtain abortions in the U.S: the Centers for Disease Control and Prevention (CDC), the Guttmacher Institute, and most recently, the Society of Family Planning’s (SFP) #WeCount project.

The federal CDC Abortion Surveillance System requests data from the central health agencies of the 50 states, DC, and New York City to document the number and characteristics of women obtaining abortions. Most states collect data from facilities where abortions are provided on the demographic characteristics of patients, gestational age, and type of abortion procedure. Reporting these data to the CDC is voluntary and not all states participate in the surveillance system. Notably, California, Maryland, and New Hampshire have not reported data on abortions to the CDC system for years. CDC publishes available data from the surveillance system annually.

Guttmacher Institute , an independent research and advocacy organization, is another major source of data on abortions in the U.S. Prior to the Dobbs ruling, Guttmacher conducted the Abortion Provider Census (APC) periodically which has provided data on abortion incidence, abortion facilities, and characteristics of abortion patients. Data from this Census are based primarily on questionnaires collected from all known facilities that provide abortion in the country, information obtained from state health departments, and Guttmacher estimates for a small portion of facilities. The most recent APC reports data from 2020.

The CDC and Guttmacher data differ in terms of methods, timeframe, and completeness, but both have shown similar trends in abortion rates over the past decade. One notable difference is that Guttmacher’s study includes continuous reporting from California, D.C., Maryland, and New Hampshire, which explains at least in part the higher number of abortions in their data.

Since the Dobbs ruling, the Guttmacher Institute has established the Monthly Abortion Provision Study to track abortion volume within the formal United States health care system. This ongoing effort collects data on and provides national and state-level estimates on procedural and medication abortions while also tracking the changes in abortion volume since 2020. The Monthly Abortion Provision Study was designed to complement Guttmacher’s APC along with other data collection efforts to allow for quick snapshots of the changing abortion landscape in the United States.

Society of Family Planning’s (SFP) #WeCount is another national reporting effort that measures changes in abortion access following the Dobbs ruling. The project reports on the number of abortions per month by state and includes data on abortions provided through clinics, private practices, hospitals, and virtual-only providers. The report does not include data on self-managed abortions that are performed without clinical supervision. The most recent #WeCount report analyzes data from April 2022 to data from June 2023, marking one full year of abortion data since Dobbs. The effort represents 83% of all providers known to #WeCount who agreed to participate in their research.

This KFF issue brief uses data from the CDC, Guttmacher, and SFP as well as other research organizations.

How has the abortion rate changed over time?

For most of the decade prior to the Dobbs ruling, there was a steady decline in abortion rates nationally, but there was a slight increase in the years just before the ruling.

In their most recent national data, Guttmacher Institute reported 930,160 abortions in 2020 and a rate of 14.4 per 1,000 women. CDC reported 622,108 abortions in 2021 and a rate of 11.6 abortions per 1,000 women (excludes CA, DC, MD, NH). Guttmacher’s study showed an upward trend in abortion from 2017 to 2020 whereas CDC’s report showed an increase in abortions from 2017 to 2021 except for a slight decrease in 2020.

While most attribute the long-term decline in abortion rates to increased use of more effective methods of contraception , several states had reduced access to low- or no-cost contraceptive care as a result of reductions in the Title X network under the Trump Administration, which may have contributed to the slight rise in abortions prior to the Dobbs ruling. Other factors that may have contributed to the increase could include greater coverage under Medicaid that subsequently made abortions more affordable in some states and broader financial support from abortion funds to help individuals pay for the costs of abortion care.

Even prior to the Dobbs ruling, abortion rates varied widely between states.

National averages can mask local and more granular differences. Lower state-level abortion rates do not reflect less need. Some of the variation has been due to the wide differences in state policies, with some states historically placing restrictions on abortion that make access and availability to nearly out of reach and, on the other side, some states enshrining protections in state Constitutions and legislation.

• In 2020, the abortion rate (per 1,000 women ages 15-44) ranged from 0.1 in Missouri to 48.9 in the District of Columbia (DC). Trends also varied between states. While the national rate of abortion increased between 2017 and 2019, some states saw declines, with particularly sharp drops in states where heavy restrictions were put into place.

While the number of abortions in the U.S. dropped immediately following the Dobbs decision, new data show that the number of abortions increased overall one year following the ruling. However, the upswing obscures the declines in abortion care in states with bans.

SFP’s #WeCount estimates there were 2,200 cumulative more abortions in the year following Dobbs (July 2022 to June 2023) compared to the pre- Dobbs period (April 2022 and May 2022). Nationally, the number of abortions varied month-by-month, with the largest decrease observed in November 2022 (73,930 abortions; 8,185 fewer abortions than pre- Dobbs period ) and the largest increase in March 2023 (92,680 abortions; 10,565 more abortions than pre- Dobbs period). The states with the largest cumulative increases in the total number of abortions provided by a clinician during the 12-month period include Illinois, Florida, North Carolina, California, and New Mexico. States with abortion bans experienced the largest cumulative decreases in the number of abortions, including Texas, Georgia, Tennessee, and Louisiana (data varies by month in each state; data not shown).

States without abortion bans experienced an increase of abortions following the Dobbs ruling likely due to a combination of reasons: increased interstate travel for abortion access, expanded in-person and virtual/telehealth capacity to see patients, increased measures to protect and cover abortion care for residents and out-of-state patients, and potentially reduced abortion-related stigma as a result of community mobilization around abortion care.

However, the overall national increase in the number of abortions masks the absence and/or scarcity of abortion care in states with total abortion bans or severe restrictions. States with total bans experienced observed 94,930 fewer clinician-provided abortions a year following the ruling (data not shown). Note, this figure is an underestimate due several state policies that restricted abortion access during the pre- Dobbs period. These estimates do not include abortions that may have been performed through self-managed means.

Most of the information about people who receive abortions comes from data prior to the Dobbs ruling. In 2021, women across a range of age groups, socioeconomic status, and racial and ethnic backgrounds obtained abortions, but the majority were obtained by women who were in their twenties, low-income, and women of color.

• Women in their twenties accounted for more than half (57%) of abortions. Nearly one-third (31%) were among women in their thirties and a small share were among women in their 40s (4%) and teens (8%).
• Seven in ten abortion patients were of women of color. Black women comprised 42% of abortion recipients, White women 30% , Hispanic women 22%, and 7% women of other races/ethnicities.
• Many women who sought abortions have children. More than six in 10 (61%) abortion patients in 2021 had at least one previous birth.

The vast majority (94%) of abortions occur during the first trimester of pregnancy according to data available from before the Dobbs decision.

Before the 2022 ruling in Dobbs, there was a federal constitutional right to abortion before the pregnancy is considered to be viable, that is, can survive outside of a pregnant person’s uterus. Viability is generally considered around 24 weeks of pregnancy. Most abortions, though, occur well before the point of fetal viability.

• Data from 2021 found that more than four in ten (45%) abortions occurred by six weeks of gestation, a third (36%) occurred between seven and nine weeks, and 13% at 10-13 weeks. Just 7% of abortions occurred after the first trimester.
• Prior to the decision in the Dobbs case, almost half of states (22) had enacted laws that ban abortion at a certain gestational age. Most of these limits are in the second trimester, but some are in the first trimester, well before fetal viability. Many of these laws were blocked because they violated the federal standard established by Roe v Wade. Some states have enacted laws banning abortions after fetal cardiac activity can be detected, or around 6 weeks of pregnancy, which is often before a person knows they are pregnant. In addition to banning abortion, states can now establish pre-viability gestational restrictions because the federal standard has been overturned.

Just over half of abortions were provided at clinics that specialize in abortion care in 2020. Others were provided at clinics that offer abortion care in addition to other family planning services.

Guttmacher Institute estimated that 96% of abortions were provided at clinics and just 4% were provided in doctors’ offices or hospitals in 2020. Most clinic-based abortions were provided at clinics that specialize in providing abortion care, but many were provided at clinics that offer a wide range of other sexual and reproductive health services like contraception and STI care. Most abortions are provided by physicians. However, in 19 states and D.C., Advanced Practice Clinicians (APCs) such as Nurse Practitioners and midwives may provide medication abortions. Conversely, 31 states prohibit clinicians other than physicians from providing abortion care.

Even prior to the ruling in Dobbs , access to abortion services was very uneven across the country though. The proliferation of restrictions in many states, particularly in the South, had greatly shrunk the availability of services in some areas. In the wake of overturning Roe v. Wade , these geographic disparities are likely to widen as more states ban abortion services altogether.

Telehealth has grown as a delivery mechanism for abortion services.

While procedural abortions must be provided in a clinical setting, medication abortion can be provided in a clinical setting or via telehealth. Access to medication abortion via telehealth had been limited for many years by a Food and Drug Administration (FDA) restriction that had permitted only certified clinicians to dispense mifepristone in a health care setting. The drug could not be mailed or picked up at a retail pharmacy. However, in December 2021, the FDA permanently revised its policy and no longer requires clinicians to dispense the drug in person. Additionally, in January 2023, the FDA finalized a change that allows retail pharmacies to dispense medication abortion pills to patients with a prescription.

While some states are regulating the use of mifepristone as an abortion method, the Biden Administration has asserted that the FDA has regulatory power over all drugs, including mifepristone. This could result in future legal action as the authority of the state to regulate health care will be pitted against the authority of the federal government to regulate drugs through the FDA will be contested.

• In a telehealth abortion, the patient typically completes an online questionnaire to assess (1) confirmation of pregnancy, (2) gestational age and (3) blood type. If determined eligible by a remote clinician, the patient is mailed the medications. This model does not require an ultrasound for pregnancy dating if the patient has regular periods and is sure of the date of their last menstrual period (in line with  ACOG ’s guidelines for pregnancy dating). If the patient has irregular periods or is unsure how long they have been pregnant, they must obtain an ultrasound to confirm gestational age and rule out an ectopic pregnancy 3 and send in the images for review before receiving their medications. If the patient does not know their blood type or has Rh negative blood, the  provider  may prompt the patient to visit a nearby clinic for an injection to prevent adverse reactions between maternal and fetal blood ( RhoGAM ), The follow-up visit with a clinician can also happen via a telehealth visit.
• However, even in some of the states that have not banned abortion altogether, telehealth may not be available. Many states had established restrictions prior to the Dobbs ruling that limit the use of telehealth abortions by either requiring abortion patients to take the pills at a physical clinic, require ultrasounds for all abortions, set their own policies regarding the dispensing of the medications used for abortion care, or directly ban the use of telehealth for abortion care. As of November 2022, of the 33 states that have not banned abortion, eight had at least one of these restrictions, effectively prohibiting telehealth for medication abortion.
• Medication abortion has emerged as a major legal front in the battle over abortion access across the nation. Multiple cases have been filed in federal courts regarding aspects of the FDA’s regulation of medication abortion as well as the mailing of medications. One notable ongoing case is Alliance for Hippocratic Medicine v. FDA , where the plaintiffs are challenging the FDA’s authority and approval process for mifepristone. The plaintiffs also contend that an 1873 anti-obscenity law, the Comstock Act, prohibits the mailing of any medication used for abortion. In April 2023, a US Supreme Court ruling allowed current FDA rules to remain in effect as the case proceeds through the courts. This means that mifepristone remains available for medication abortion either in a clinic or via telehealth where state law permits.

Data from SFP’s October 2023 #WeCount report show that abortions provided by virtual-only clinics represent approximately 5% of all abortions post- Roe . The number of telehealth abortions increased 72% from a monthly average of 4,045 abortions in April and May 2022 to 6,950 abortions per month in the 12 months post- Dobbs . Nearly all of these abortions occurred in states that permit abortions.

Self-managed abortions are provided without a clinician visit.

Self-managed abortions typically involve obtaining medication abortion pills from an online pharmacy that will send the pills by mail or by purchasing the pills from a pharmacy in another country. This does not typically involve a direct consultation with a clinician either in person or via telehealth.

Research has found that prior to Dobbs , more than one in ten patients who obtained abortions at clinics had considered self-managing their abortions. This is likely to increase going forward since abortion care is not available in many states, and there have already been reports of people ordering pills from online markets outside the U.S. medical system. Tracking information on these online orders can help fill in gaps in abortion count estimates but can also be difficult. Some companies may not share data on purchases, and it would also be unclear whether patients take the abortion medication after receiving it in the mail.

The median costs of abortion services exceed $500.

Obtaining an abortion can be costly. On average, the costs are higher for abortions in the second trimester than in the first trimester. State restrictions can also raise the costs, as people may have to travel if abortions are prohibited or not available in their area. Many people pay for abortion services out of pocket, but some people can obtain assistance from local abortion funds.

• In 2021, the median costs for people paying out of pocket in the first trimester were $568 for a medication abortion and $625 for a procedural abortion. The Federal Reserve estimates that nationally about one-third of people do not have $400 on hand for unexpected expenses. For low-income people, who are more likely to need abortion care, these costs are often unaffordable.
• The costs of abortion are higher in the second trimester compared to the first, with median self-pay of $775. In the second trimester, more intensive procedures may be needed, more are likely to be conducted in a hospital setting (although still a minority), and local options are more limited in many communities that have fewer facilities. This results in additional nonmedical costs for transportation, childcare, lodging, and lost wages. nonmedical costs for transportation, childcare, lodging, and lost wages.
• Abortion funds are independent organizations that help some people pay for the costs of abortion services. Most abortion funds are regional and have connections to clinics in their area. Funds vary, but they typically provide assistance with the costs of medical care, travel, and accommodations if needed. However, they do not reach all people seeking services, and many people are not able to afford the costs of obtaining an abortion because they cannot pay for the abortion itself or cover the costs of travel, lodging or missed work.

Insurance coverage for abortion services is heavily restricted in certain private insurance plans and public programs like Medicaid and Medicare.

Private insurance covers most women of reproductive age, and states have the responsibility to regulate fully insured private plans in their state, whereas the federal government regulates self-funded plans under the Employee Retirement Income Security Act (ERISA). States can choose whether abortion coverage is included or excluded in private plans that are not self-insured.

• Prior to the Dobbs ruling, several states had enacted private plan restrictions and banned abortion coverage from ACA Marketplace plans. Currently, there are 11 states that have policies restricting abortion coverage in private plans and 26 that ban coverage in any Marketplace plans. Since the Dobbs ruling, some of these states have also banned the provision of abortion services altogether.
• A handful of states ( 9 ), however, have enacted laws that require private plans to cover abortion.
• The Medicaid program covers approximately one in five women of reproductive age and four in ten who are low-income. For decades, the Hyde Amendment has banned the use of federal funds for abortion in Medicaid and other public programs unless the pregnancy is a result of rape, incest, or it endangers the woman’s life.
• States have the option to use state-only funds to cover abortions under other circumstances for women on Medicaid, which 16 states do currently. However, more than half (56% ) of women covered by Medicaid live in Hyde states.
• According to a Guttmacher Institute survey of patients in the year prior to the Dobbs ruling, a quarter (26%) of abortion patients in the study used Medicaid to pay for abortion services, 11% used private insurance, and 60% paid out of pocket. People in states with more restrictive abortion policies were less likely to use Medicaid or private insurance and more likely to pay out of pocket compared to people living in less restrictive states.
• Federal law also restricts abortion funding under the Indian Health Service, Medicare, and the Children’s Health Insurance Program. Over the years, language similar to that in the Hyde Amendment has been incorporated into a range of other federal programs that provide or pay for health services to women including: the military’s TRICARE program, federal prisons, the Peace Corps, and the Federal Employees Health Benefits Program.

National polls have consistently found that a majority of the public did not want to see Roe v . Wade overturned and that most people feel that abortion is a personal medical decision. The public also strongly opposes the criminalization of abortion both among people who get abortion and the clinicians who provide abortion services. Nearly three quarters of adults (74%) and 79% of reproductive age women say that obtaining an abortion should be a personal choice rather than regulated by law (data not shown). For example, two-thirds of the public are concerned that bans on abortion may lead to unnecessary health problems for people experiencing pregnancy complications.

Additional KFF resources:

Abortion in the US Dashboard

Access and Coverage of Abortion Services

Issue Brief: Abortion at SCOTUS: Dobbs v. Jackson Women’s Health

Issue Brief: State Actions to Protect and Expand Access to Abortion Services

Policy Watch: A Year After Dobbs: Policies Restricting Access to Abortion in States Even Where It’s Not Banned

Policy Watch: Employer Coverage of Travel Costs for Out-of-State Abortion

Issue Brief: Exclusion of Abortion Coverage from Employer-Sponsored Health Plans

Interactive: How State Policies Shape Access to Abortion Coverage

Medication Abortion

Issue Brief: Legal Challenges to the FDA Approval of Medication Abortion Pills

Infographic: The Availability and Use of Medication Abortion Care

Fact Sheet: The Availability and Use of Medication Abortion

Issue Brief: The Intersection of State and Federal Policies on Access to Medication Abortion Via Telehealth

Public Opinion on Abortion

Web Event: Americans’ Knowledge and Attitudes About Abortion Access and The Pending Supreme Court Ruling

KFF Health Tracking Poll: Early 2023 Update On Public Awareness On Abortion and Emergency Contraception

KFF Health Tracking Poll: Views on and Knowledge about Abortion in Wake of Leaked Supreme Court Opinion

Other Resources on Women’s Health

Interactive: State Profiles for Women’s Health

Interactive: State Health Facts on Women’s Health Indicators

Homepage: Women’s Health Policy

• Women's Health Policy
• Access to Care

Also of Interest

• The Availability and Use of Medication Abortion
• State Actions to Protect and Expand Access to Abortion Services
• Legal Challenges to State Abortion Bans Since the Dobbs Decision
• Legal Challenges to the FDA Approval of Medication Abortion Pills
• Employer Coverage of Travel Costs for Out-of-State Abortion
• Abortion in the United States Dashboard

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How the Right to Legal Abortion Changed the Arc of All Women’s Lives

By Katha Pollitt

I’ve never had an abortion. In this, I am like most American women. A frequently quoted statistic from a recent study by the Guttmacher Institute, which reports that one in four women will have an abortion before the age of forty-five, may strike you as high, but it means that a large majority of women never need to end a pregnancy. (Indeed, the abortion rate has been declining for decades, although it’s disputed how much of that decrease is due to better birth control, and wider use of it, and how much to restrictions that have made abortions much harder to get.) Now that the Supreme Court seems likely to overturn Roe v. Wade sometime in the next few years—Alabama has passed a near-total ban on abortion, and Ohio, Georgia, Kentucky, Mississippi, and Missouri have passed “heartbeat” bills that, in effect, ban abortion later than six weeks of pregnancy, and any of these laws, or similar ones, could prove the catalyst—I wonder if women who have never needed to undergo the procedure, and perhaps believe that they never will, realize the many ways that the legal right to abortion has undergirded their lives.

Legal abortion means that the law recognizes a woman as a person. It says that she belongs to herself. Most obviously, it means that a woman has a safe recourse if she becomes pregnant as a result of being raped. (Believe it or not, in some states, the law allows a rapist to sue for custody or visitation rights.) It means that doctors no longer need to deny treatment to pregnant women with certain serious conditions—cancer, heart disease, kidney disease—until after they’ve given birth, by which time their health may have deteriorated irretrievably. And it means that non-Catholic hospitals can treat a woman promptly if she is having a miscarriage. (If she goes to a Catholic hospital, she may have to wait until the embryo or fetus dies. In one hospital, in Ireland, such a delay led to the death of a woman named Savita Halappanavar, who contracted septicemia. Her case spurred a movement to repeal that country’s constitutional amendment banning abortion.)

The legalization of abortion, though, has had broader and more subtle effects than limiting damage in these grave but relatively uncommon scenarios. The revolutionary advances made in the social status of American women during the nineteen-seventies are generally attributed to the availability of oral contraception, which came on the market in 1960. But, according to a 2017 study by the economist Caitlin Knowles Myers, “The Power of Abortion Policy: Re-Examining the Effects of Young Women’s Access to Reproductive Control,” published in the Journal of Political Economy , the effects of the Pill were offset by the fact that more teens and women were having sex, and so birth-control failure affected more people. Complicating the conventional wisdom that oral contraception made sex risk-free for all, the Pill was also not easy for many women to get. Restrictive laws in some states barred it for unmarried women and for women under the age of twenty-one. The Roe decision, in 1973, afforded thousands upon thousands of teen-agers a chance to avoid early marriage and motherhood. Myers writes, “Policies governing access to the pill had little if any effect on the average probabilities of marrying and giving birth at a young age. In contrast, policy environments in which abortion was legal and readily accessible by young women are estimated to have caused a 34 percent reduction in first births, a 19 percent reduction in first marriages, and a 63 percent reduction in ‘shotgun marriages’ prior to age 19.”

Access to legal abortion, whether as a backup to birth control or not, meant that women, like men, could have a sexual life without risking their future. A woman could plan her life without having to consider that it could be derailed by a single sperm. She could dream bigger dreams. Under the old rules, inculcated from girlhood, if a woman got pregnant at a young age, she married her boyfriend; and, expecting early marriage and kids, she wouldn’t have invested too heavily in her education in any case, and she would have chosen work that she could drop in and out of as family demands required.

In 1970, the average age of first-time American mothers was younger than twenty-two. Today, more women postpone marriage until they are ready for it. (Early marriages are notoriously unstable, so, if you’re glad that the divorce rate is down, you can, in part, thank Roe.) Women can also postpone childbearing until they are prepared for it, which takes some serious doing in a country that lacks paid parental leave and affordable childcare, and where discrimination against pregnant women and mothers is still widespread. For all the hand-wringing about lower birth rates, most women— eighty-six per cent of them —still become mothers. They just do it later, and have fewer children.

Most women don’t enter fields that require years of graduate-school education, but all women have benefitted from having larger numbers of women in those fields. It was female lawyers, for example, who brought cases that opened up good blue-collar jobs to women. Without more women obtaining law degrees, would men still be shaping all our legislation? Without the large numbers of women who have entered the medical professions, would psychiatrists still be telling women that they suffered from penis envy and were masochistic by nature? Would women still routinely undergo unnecessary hysterectomies? Without increased numbers of women in academia, and without the new field of women’s studies, would children still be taught, as I was, that, a hundred years ago this month, Woodrow Wilson “gave” women the vote? There has been a revolution in every field, and the women in those fields have led it.

It is frequently pointed out that the states passing abortion restrictions and bans are states where women’s status remains particularly low. Take Alabama. According to one study , by almost every index—pay, workforce participation, percentage of single mothers living in poverty, mortality due to conditions such as heart disease and stroke—the state scores among the worst for women. Children don’t fare much better: according to U.S. News rankings , Alabama is the worst state for education. It also has one of the nation’s highest rates of infant mortality (only half the counties have even one ob-gyn), and it has refused to expand Medicaid, either through the Affordable Care Act or on its own. Only four women sit in Alabama’s thirty-five-member State Senate, and none of them voted for the ban. Maybe that’s why an amendment to the bill proposed by State Senator Linda Coleman-Madison was voted down. It would have provided prenatal care and medical care for a woman and child in cases where the new law prevents the woman from obtaining an abortion. Interestingly, the law allows in-vitro fertilization, a procedure that often results in the discarding of fertilized eggs. As Clyde Chambliss, the bill’s chief sponsor in the state senate, put it, “The egg in the lab doesn’t apply. It’s not in a woman. She’s not pregnant.” In other words, life only begins at conception if there’s a woman’s body to control.

Indifference to women and children isn’t an oversight. This is why calls for better sex education and wider access to birth control are non-starters, even though they have helped lower the rate of unwanted pregnancies, which is the cause of abortion. The point isn’t to prevent unwanted pregnancy. (States with strong anti-abortion laws have some of the highest rates of teen pregnancy in the country; Alabama is among them.) The point is to roll back modernity for women.

So, if women who have never had an abortion, and don’t expect to, think that the new restrictions and bans won’t affect them, they are wrong. The new laws will fall most heavily on poor women, disproportionately on women of color, who have the highest abortion rates and will be hard-pressed to travel to distant clinics.

But without legal, accessible abortion, the assumptions that have shaped all women’s lives in the past few decades—including that they, not a torn condom or a missed pill or a rapist, will decide what happens to their bodies and their futures—will change. Women and their daughters will have a harder time, and there will be plenty of people who will say that they were foolish to think that it could be otherwise.

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By Jia Tolentino

By Isaac Chotiner

By Margaret Talbot

A Brief History of Abortion in the U.S.

Abortion wasn’t always a moral, political, and legal tinderbox. What changed?

A bortion laws have never been more contentious in the U.S. Yet for the first century of the country’s existence—and most of human history before that—abortion was a relatively uncontroversial fact of life.

“Abortion has existed for pretty much as long as human beings have existed,” says Joanne Rosen, JD, MA , a senior lecturer in Health Policy and Management who studies the impact of law and policy on access to abortion.

Until the mid-19th century, the U.S. attitude toward abortion was much the same as it had often been elsewhere throughout history: It was a quiet reality, legal until “quickening” (when fetal motion could be felt by the mother). In the eyes of the law, the fetus wasn’t a “separate distinct entity until then,” but rather an extension of the mother, Rosen explains.

What changed?

America’s first anti-abortion movement wasn’t driven primarily by moral or religious concerns like it is today. Instead, abortion’s first major foe in the U.S. was physicians on a mission to regulate medicine.

Until this point, abortion services had been “women’s work.” Most providers were midwives, many of whom made a good living selling abortifacient plants. They relied on methods passed down through generations, from herbal abortifacients and pessaries—a tampon-like device soaked in a solution to induce abortion—to catheter abortions that irritate the womb and force a miscarriage, to a minor surgical procedure called dilation and curettage (D&C), which remains one of the most common methods of terminating an early pregnancy.

The cottage abortion industry caught the attention of the fledgling American Medical Association, which was established in 1847 and, at the time, excluded women and Black people from membership. The AMA was keen to be taken seriously as a gatekeeper of the medical profession, and abortion services made midwives and other irregular practitioners—so-called quacks—an easy target. Their rhetoric was strategic, says Mary Fissell, PhD , the J. Mario Molina professor in the Department of the History of Medicine at Johns Hopkins University. “You have to link those midwives to providing abortion as a way of kind of getting them out of business,” Fissell says. “So organized medicine very much takes the anti-abortion position and stays with that for some time.”

Early 19th century and before

Abortion is legal in the U.S. until “quickening”

AMA campaigns to end abortion

At least 40 anti-abortion statutes are enacted in the U.S.

Comstock Act makes it illegal to sell or mail contraceptives or abortifacients

Late 19th century

OB-GYN emerges as a specialty

Griswold v. Connecticut decision finds that the Constitution guarantees a right to privacy, specifically in prescribing contraceptives, paving the way for Roe v. Wade

Supreme Court decision in Roe v. Wade enshrines abortion as a constitutional right

Planned Parenthood of Southeastern Pennsylvania v. Casey protects a woman's right to have an abortion prior to  fetal viability

Four states pass trigger laws making it a felony to perform, procure, or prescribe an abortion if Roe is ever overturned

Roe v. Wade and Planned Parenthood v. Casey overturned; 13 states ban abortion by October 2022

In 1857, the AMA took aim at unregulated abortion providers with a letter-writing campaign pushing state lawmakers to ban the practice. To make their case, they asserted that there was a medical consensus that life begins at conception, rather than at quickening.

The campaign succeeded. At least 40 anti-abortion laws went on the books between 1860 and 1880.

And yet some doctors continued to perform abortions in the late 19th and early 20th centuries. By then, abortion was illegal in almost all states and territories, but during the Depression era, “doctors could see why women wouldn’t want a child,” and many would perform them anyway, Fissell says. In the 1920s and through the 1930s, many cities had physicians who specialized in abortions, and other doctors would refer patients to them “off book.”

That leniency faded with the end of World War II. “All across America, it’s very much about gender roles, and women are supposed to be in the home, having babies,” Fissell says. This shift in the 1940s and ’50s meant that more doctors were prosecuted for performing abortions, which drove the practice underground and into less skilled hands. In the 1950s and 1960s, up to 1.2 million illegal abortions were performed each year in the U.S., according to the Guttmacher Institute . In 1965, 17% of reported deaths attributed to pregnancy and childbirth were associated with illegal abortion.

A rubella outbreak from 1963–1965 moved the dial again, back toward more liberal abortion laws. Catching rubella during pregnancy could cause severe birth defects, leading medical authorities to endorse therapeutic abortions . But these safe, legal abortions remained largely the preserve of the privileged. “Women who are well-to-do have always managed to get abortions, almost always without a penalty,” says Fissell. “But God help her if she was a single, Black, working-class woman.”

Women who could afford it brought their cases to court to fight for access to hospital abortions. Other women gained approval for abortions with proof from a physician that carrying the pregnancy would endanger her life or her physical or mental health. These cases set off a wave of abortion reform bills in state legislatures that helped set the stage for Roe v. Wade . By the time Roe was decided in 1973, legal abortions were already available in 17 states—and not just to save a woman’s life.

But raising the issue to the level of the Supreme Court and enshrining abortion rights for all Americans also galvanized opposition to it and mobilized anti-abortion groups. “ Roe was under attack virtually from the moment it was decided,” says Rosen.  

In 1992 another Supreme Court case, Planned Parenthood of Southeastern Pennsylvania v. Casey posed the most significant existential threat to Roe . Rosen calls it “the case that launched a thousand abortion regulations,” upholding Roe but giving states far greater scope to regulate abortion prior to fetal viability. However, defining that nebulous milestone a became a flashpoint for debate as medical advancements saw babies survive earlier and earlier outside the womb. Sonograms became routine around the same time, making fetal life easier to grasp and “putting wind in the sails of the ‘pro-life’ movement,” Rosen says. Then in June, the Supreme Court overturned both Roe and Casey .

For many Americans, that meant the return to the conundrum that led Norma McCorvey—a.k.a. Jane Roe—to the Supreme Court in 1971: being poor and pregnant, and seeking an abortion in a state that had banned them in all but the narrowest of circumstances.

The history of abortion in the U.S. suggests the tides will turn again. “We often see periods of toleration followed by periods of repression,” says Fissell. The current moment is unequivocally marked by the latter. What remains to be seen is how long it will last.

From Public Health On Call Podcast

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Understanding why women seek abortions in the US

M antonia biggs.

1 Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, University of California, San Francisco, Oakland, California, USA

Heather Gould

Diana greene foster.

The current political climate with regards to abortion in the US, along with the economic recession may be affecting women’s reasons for seeking abortion, warranting a new investigation into the reasons why women seek abortion.

Data for this study were drawn from baseline quantitative and qualitative data from the Turnaway Study , an ongoing, five-year, longitudinal study evaluating the health and socioeconomic consequences of receiving or being denied an abortion in the US. While the study has followed women for over two full years, it relies on the baseline data which were collected from 2008 through the end of 2010. The sample included 954 women from 30 abortion facilities across the US who responded to two open ended questions regarding the reasons why they wanted to terminate their pregnancy approximately one week after seeking an abortion.

Women’s reasons for seeking an abortion fell into 11 broad themes. The predominant themes identified as reasons for seeking abortion included financial reasons (40%), timing (36%), partner related reasons (31%), and the need to focus on other children (29%). Most women reported multiple reasons for seeking an abortion crossing over several themes (64%). Using mixed effects multivariate logistic regression analyses, we identified the social and demographic predictors of the predominant themes women gave for seeking an abortion.

Conclusions

Study findings demonstrate that the reasons women seek abortion are complex and interrelated, similar to those found in previous studies. While some women stated only one factor that contributed to their desire to terminate their pregnancies, others pointed to a myriad of factors that, cumulatively, resulted in their seeking abortion. As indicated by the differences we observed among women’s reasons by individual characteristics, women seek abortion for reasons related to their circumstances, including their socioeconomic status, age, health, parity and marital status. It is important that policy makers consider women’s motivations for choosing abortion, as decisions to support or oppose such legislation could have profound effects on the health, socioeconomic outcomes and life trajectories of women facing unwanted pregnancies.

While the topic of abortion has long been the subject of fierce public and policy debate in the United States, an understanding of why women seek abortion has been largely missing from the discussion [ 1 ]. In an effort to maintain privacy, adhere to perceived social norms, and shield themselves from stigma, the majority of American women who have had abortions— approximately 1.21 million women per year [ 2 ]– do not publicly disclose their abortion experiences or engage in policy discussions as a represented group [ 3 - 5 ].

A review of several international and a handful of US qualitative and quantitative articles considered reasons for abortion among women in 26 “high-income” countries [ 6 ]. Of these, four studies (two primarily quantitative, one primarily qualitative and one that used mixed methods) were conducted in the US [ 7 - 10 ]. This review found that, despite methodological differences among the studies, a consistent picture of women’s reasons for abortion emerged, that could be encapsulated in three categories: 1) “Women-focused” reasons, such as those related to timing, the woman’s physical or mental health, or completed family size; 2) “Other-focused” reasons, such as those related to the intimate partner, the potential child, existing children, or the influences of other people, and 3) “Material” reasons, such as financial and housing limitations. These categories were not mutually exclusive; women in nearly all of the studies reported multiple reasons for their abortion.

The largest of the US studies included in the review, by Finer and colleagues [ 9 ], utilized data from a structured survey conducted in 2004 with 1,209 abortion patients across the US, as well as open-ended, in-depth interviews conducted with 38 patients from four facilities, nearly half of whom were in their second trimester of pregnancy. Quantitative data from this study were compared to survey data collected from nationally representative samples in 1987 [ 11 , 12 ] and 2000 [ 13 ]. The most commonly reported reasons for abortion in 2004 (selected from a researcher-generated list of possible reasons with write-in options for other reasons) were largely similar to those found in the 1987 study [ 11 ]. The top three reason categories cited in both studies were: 1) “Having a baby would dramatically change my life” (i.e., interfere with education, employment and ability to take care of existing children and other dependents) (74% in 2004 and 78% in 1987), 2) “I can’t afford a baby now” (e.g., unmarried, student, can’t afford childcare or basic needs) (73% in 2004 and 69% in 1987), and 3) “I don’t want to be a single mother or am having relationship problems” (48% in 2004 and 52% in 1987). A sizeable proportion of women in 2004 and 1987 also reported having completed their childbearing (38% and 28%), not being ready for a/another child (32% and 36%), and not wanting people to know they had sex or became pregnant (25% and 33%). Considering all of the reasons women reported, the authors observed that the reasons described by the majority of women (74%) signaled a sense of emotional and financial responsibility to individuals other than themselves, including existing or future children, and were multi-dimensional. Greater weeks of gestation were found to be related with citing concerns about fetal health as reasons for abortion. The authors did not examine associations between weeks of gestation with some of the other more frequently mentioned reasons for abortion.

While the US abortion rate appears to have stabilized after a national decline, this decline has been slower among low-income women and in certain states, suggesting possible disparities in access to effective contraceptive methods and/or economic challenges preventing women from feeling they are able to care for a child [ 2 , 13 ]. According to national estimates for 2005 and 2008, changes in the abortion rate varied by region, with the South and West seeing small declines, and the Northwest and Midwest seeing no change over that period [ 2 ].

Furthermore, the changing political climate and increasing restrictive legislation with regards to abortion in this country [ 14 ], in conjunction with the economic recession, may be affecting women’s reasons for seeking abortion, warranting a fresh investigation into these issues. This study builds upon and extends the small body of literature that documents US women’s reasons for abortion [ 6 ]. While two other papers using data from the Turnaway Study (see below) describe how women who indicate partner related reasons or reasons related to their own alcohol, tobacco and/or drug use, differ from those who do not mention these reasons [ 15 , 16 ] this study presents all of the reasons women from the Turnaway Study gave for seeking abortion, as described in their own words.

Ethics statement

This study was approved by the University of California, San Francisco, Committee on Human Research. Written and oral consent was obtained from all participants.

Study design

Data for this study were drawn from baseline quantitative and qualitative data from the Turnaway Study, an ongoing, five-year, longitudinal study evaluating the health and socioeconomic consequences of receiving or being denied an abortion in the US. While the study has followed women for two full years, this analysis relies on the baseline data which were collected from 2008 through the end of 2011. The study design, recruitment and research methods and some findings from this study have been published elsewhere [ 15 , 17 - 19 ]. This study overcomes several limitations of previous studies on this topic. Most importantly, we interviewed a large sample of both adult and adolescent women, including many women who sought abortions at later gestations of pregnancy. We asked women about their reasons for abortion using an open-ended question, rather than relying on a checklist of researcher-generated reasons.

This paper draws on baseline data from interviews conducted one week after receiving or being denied an abortion at the recruitment facility.

Recruitment

Women seeking abortion care at 30 US facilities (abortion clinics, other clinics and hospitals) between January 2008 and December 2010 were recruited to participate in the study. Facilities were identified using the National Abortion Federation membership directory, as well as through professional contacts in the abortion research community. While the gestational limits of the recruitment facilities varied (from 10 weeks to the end of the second trimester), they each had the latest gestational limit for providing abortion of any facility within 150 miles. These sites were selected because we thought that women denied an abortion would be unlikely to get one elsewhere. The facilities performed an average of 2,400 abortions annually (range 440–8,000) and were located in 21 states throughout the US representing every US region [ 17 ].

Abortion patients were eligible to participate in the study if they were English- or Spanish-speaking, aged 15 years or older, had no fetal diagnoses or demise, and were within the gestational age range of one of three study groups. At each facility, a designated point person was trained by Turnaway study researchers to oversee and conduct site recruitment activities. After assessing potential participants’ eligibility based on their age, language and gestational age, the facility point person or facility staff briefly informed potential participants about the study. Participants were usually approached in a private exam room after receiving an ultrasound and were told that the purpose of the study was to learn more about how unintended pregnancy affects women’s lives. Participants who expressed willingness to learn more about the study were led to a private location within the clinic, where they were given additional study information, the informed consent documents, and human subjects’ Bill of Rights a .

Facility staff then connected interested prospective participants to Turnaway study researchers by telephone. Facility staff dialed and introduced participant by first name then passed the phone to the woman to speak with the interviewer. During the recruitment call, research staff explained the study in greater detail, screened for eligibility and obtained informed consent. After verbally agreeing to participate, each woman signed a written consent form, which was faxed by facility staff to a private, dedicated fax machine in the UCSF Project Director’s office. Parental consent was obtained from women under the age of 18 living in states where parental notification or consent for an abortion is required. In states without parental involvement laws, women under the age of 18 were screened for their ability to understand the risks and benefits of the study and, those who were determined to be able provided informed consent on their own behalf. For all patients who completed the recruitment call and consented to enroll, Turnaway study researchers scheduled their first telephone interview to take place eight days later. These baseline interviews lasted approximately 40 minutes. The study is ongoing, with follow-up phone interviews being conducted every six months for five years.

All interviewers were female, fluent in English and/or Spanish, and experienced in reproductive health research and interviewing techniques. The interviewer training covered general interviewing guidelines, handling sensitive issues, confidentiality, data collection protocols, question-by-question reviews of both English and Spanish versions of the interview guide, role playing, and record-keeping. During the data collection period, research staff worked closely with the interviewers to ensure data quality. Quality assurance strategies included making sure that interviewers understood the meaning of every question, how to ask the question and how to record answers, observation of live interviews, monitoring the data for missing values, and periodic inter-rater reliability tests. All data from the interviews were entered manually. The interviewers simultaneously collected and entered data into a password-protected, computer database using CASES (Computer Assisted Survey Execution System). Qualitative responses in Spanish were translated to English by bilingual research staff. Women were mailed a $50 gift card for a major retail store after completing each interview.

Participants

Overall, 37.5% of eligible women agreed to complete semi-annual telephone interviews for a period of five years. For the purposes of the larger study, participants were recruited into three distinct study groups: women who were denied an abortion because they were just over the pregnancy gestational age limit for the clinic (n=231), women who received an abortion and were just under the gestational age limit (n=452), and women who received a first trimester procedure (n=273). For the purposes of this analysis, all three groups are combined and analyzed by gestational age.

The structured interview guide included questions on participant socio-demographic characteristics, experiences becoming pregnant, pregnancy planning, and the abortion decision-making process. The interview guide and study protocols were all first pilot tested among 64 women receiving or being denied an abortion at a local abortion facility.

Demographic characteristics

We examine age, race/ethnicity (White, Black, Hispanic/Latina and other), education (more than high school versus high school graduation or less than high school), whether they received public assistance (i.e. Women Infant and Children (WIC), food stamps, disability payments, or Temporary Assistance for Needy Families (TANF)) in the past month and employment status (part/full time versus not employed).

Pregnancy-related characteristics

We also considered parity, and gestational age at recruitment (13 weeks or less, 14 to 19 weeks, and 20 weeks or more). Pregnancy intentions were measured with the London Measure of Unplanned Pregnancy. The London Measure is a validated measure of pregnancy intentions that assesses contraceptive use, intentions to become pregnant, extent to which women wanted to become pregnant and partner interest in becoming pregnant in the month before becoming pregnant as well as changes women may have made in preparation for pregnancy and women’s perceptions of the timing of the pregnancy [ 20 ]. It is a continuous scale ranging from 1–12, with 0–3 indicating unplanned pregnancies, 4–9 ambivalent pregnancies and 10–12 planned pregnancies.

Health care and health

“ Has healthcare provider” was a dichotomous variable defined as having a doctor or nurse practitioner one usually goes to when sick or wanting health advice. Self-rated health is a dichotomous variable of rating health prior to pregnancy as good or very good versus fair, poor or very poor. History of depression or anxiety diagnosis is a dichotomous variable indicating whether the participant has ever been told by a health professional if she suffers from a major depressive or anxiety disorder.

Reasons for abortion

All participants were asked two open-ended questions about their reasons for seeking an abortion. The first question asked “What are the reasons that you decided to have an abortion?” followed by a prompt asking for any other reasons until the respondent says that is all. The second questions asked “What would you say was the main reason you decided to have an abortion?” Generally participants were not able to narrow their answers to one reason and sometimes even gave additional reasons to this last question making it difficult to discern a “main” reason. Therefore, the answers to both questions were combined to identify all reasons given by respondents for seeking abortion.

Data analysis

Qualitative analysis.

The analytic team was comprised of two of the study authors. A non-hierarchical list of themes was generated and agreed upon by both researchers after reviewing an initial 100 responses. The next set of 100 responses was coded using the agreed upon themes and were revised iteratively, as appropriate. The list of themes was finalized after review of all responses. Once the final set of themes was generated, both researchers recoded all the responses until reaching consensus on all items. Occasionally the underlying reasons that motivated a particular response were not evident. For example some women may have responded that they sought abortion due to “bad timing”, which may have been due to a number of factors (e.g. being financially unprepared or not having found the right partner) but unless these underlying reasons were explicitly stated, her reason was coded only as “bad timing.” Often the reasons were interrelated with other reasons, (e.g. “bad timing because I’m unemployed”) in which case the response was coded under all themes mentioned (e.g. “bad timing” and “unemployed”). Respondents could also be coded under multiple subthemes within an overarching theme (e.g. “unemployed and don’t want government assistance.” All coding was done in Excel.

Quantitative analysis

Once all of the codes were finalized, the reasons for abortion were analyzed quantitatively using Stata Version 12. Multivariable mixed effects logistic regression was used to assess the characteristics associated with having higher odds of reporting each of the major themes as a reason for seeking abortion. Continuous predictors included age, pregnancy intentions and parity. Dichotomous predictors included high school education and above (yes/no), employed (yes/no), has health care provider (yes/no), history of depression or anxiety (yes/no), and rates health as good/very good (yes/no). Additional categorical predictors included a four-part race variable, a three-part marital status variable, and a three-part gestational age variable. Our quantitative analysis approach accounted for clustering by recruitment site.

Description of the sample

Two women did not answer either question on reason for seeking an abortion, leaving a final sample of 954. A description of study participants is presented in Table  1 . Approximate 37% of participants were white, 36% between the ages of 20 and 24 (36%), and 38% were nulliparous. The majority were single and never married (79%), had less than a high school education (53%) and enough money to meet basic living needs (60%).

Participant characteristics (n=954)

a This age category includes one participant aged 14 who was recruited early in the study before the minimum enrollment age was changed to 15.

Women gave a wide range of responses to explain why they had chosen abortion. The reasons were comprised of 35 themes which were categorized under a final set of 11 overarching themes (Table  2 ). While most women gave reasons that fell under one (36%) or two (29%) themes, 13% mentioned four or more themes. Many women reported multiple reasons for seeking an abortion crossing over several themes. As one 21 year-old woman describes, “ This is how I described it [my reasons for abortion] to my doctor 'social, economic’, I had a whole list, I don’t feel like I could raise a child right now and give the child what it deserves. ”A 19-year old explains “[There are] so many of them [reasons]. I already have one baby, money wise, my relationship with the father of my first baby, relationship with my mom, school. ” A 27-year old enumerates the reasons that brought her to the decision to have an abortion “ My relationship is newer and we wanted to wait. I don’t have a job, I have some debt, I want to finish school and I honestly am not in the physical shape that I would want to be to start out a pregnancy .”

Major themes and reasons women gave for seeking abortion (n=954)

Note: Respondents gave reasons under multiple themes and subthemes.

Financial reasons

A financial reason (40%) was the most frequently mentioned theme. Six percent of women mentioned this as their only reason for seeking abortion. Most women (38%) cited general financial concerns which included responses such as “ financial problems ,” “ don’t have the means ,” “It all boils down to money ” and “ can’t afford to support a child .” As one unemployed 42-year-old woman with a monthly household income of a little over $1,000 describes “[It was] all financial, me not having a job, living off death benefits, dealing with my 14 year old son. I didn't have money to buy a baby spoon. ”

A small proportion of women (4%) stated that lack of employment or underemployment was a reason for seeking an abortion. A 28-year old college educated woman, receiving $1,750 a month in government assistance, looking for work, and living alone with her two children while her husband was away in the Air Force explains “ [My husband and I] haven't had jobs in awhile and I don't want to go back to living with other people. If we had another child it would be undue burden on our financial situation. ” Six (0.6%) women stated that their lack of insurance and/or inability to get government assistance contributed to their desire to terminate their pregnancies.

“I’m unemployed, no health insurance, and could not qualify for any government-assisted aid, and even if my fiancé decided to hurry up and get married, I still wouldn't have been covered under his health insurance for that.”-- 32-year-old, in school full-time.

Four respondents (0.4%) said that their desire to have an abortion stemmed from their inability to provide for the child without relying on government assistance. “I don't have enough money to support a child and I don't want to have to get support from the government. ”

Not the right time for a baby

Over one third (36%) of respondents stated reasons related to timing. Many women (34%) used phrasing such as “ I wasn’t ready ”, and “ wasn’t the right time. ” A 21-year old pointed to a number of reasons why she felt the timing of her pregnancy was wrong “ Mainly I didn't feel like I was ready yet - didn't feel financially, emotionally ready. Due date was at the same time as my externship at school. Entering the workforce with a newborn would be difficult - I just wasn't ready yet .” A small proportion of women described not having enough time or feeling too busy to have a baby (2%). A 25-year old looking for work, already raising a child, and who reported “rarely” having enough money to meet her basic living needs explains how she has “ So many things going on now-physically,emotionally, financially, pretty busy and can't handle anymore right now. ” Similarly, a 19-year old describes how she “ didn't have time to go to the doctor to make sure everything is OK like I wanted to. So busy with school and work I felt it [having an abortion] would be the right thing to do until I really have time to have one [a child]. ” Fewwomen described being too old to have a baby (2%). A 43-year old illustrates how timing and her age are the primary reasons for seeking abortion “ Because I'm too old to have a child. It's like starting over and my nerves are bad. My son…he's going to be 2b0 next month and I don't want to start over. It's just bad timing .”

Partner-related reasons

Nearly one third (31%) of respondents gave partner-related reasons for seeking an abortion. Six percent mentioned partners as their only reason for seeking abortion. Partner related reasons included not having a “good” or stable relationship with the father of the baby (9%), wanting to be married first (8%), not having a supportive partner (8%), being with the “wrong guy” (6%), having a partner who does not want the baby (3%), and having an abusive partner (3%). For a more extensive analysis of partner-related reasons for seeking an abortion see Chibber et al. [ 17 ].

Need to focus on other children

The need to focus on other children was a common theme, mentioned by 29% of women. Six percent of women mentioned only this theme. The majority of these reasons (67%) were related to feeling overextended with current children “ I already had 2 kids and it would be really overwhelming. It's kind of hard to raise 2 kids by yourself ,” that the pregnancy was too soon after a previous child “ I have a 3-month-old already. If I had had that baby, he wouldn't even be one [year old by the time the baby came] ”, or simply not wanting any more children “I just felt inadequate-I have a teenager and 2 pre-teens and I couldn't see starting over again.” A small proportion (5%) of women felt that having a baby at this time would have an adverse impact on her other children. “I already have 5 kids; their quality of life would go down if I had another. ” A 31-year-old with three children spoke of the need to focus on her sick child as a reason for seeking abortion “My son was diagnosed with cancer. His treatment requires driving 10 hours and now we found out we need to go to New York for some of his treatment. The stress of that and that he relies on me. ”

A new baby would interfere with future opportunities

One in five women (20%) reported that they chose abortion because they felt a baby at this time would interfere with their future goals and opportunities in general (5%) or, more specifically, with school (14%) or career plans (7%). Usually the reasons were related to the perceived difficulty of continuing to advance educational or career goals while raising a baby: “I didn't think I'd be able to support a baby and go to college and have a job. ” states an 18-year old respondent in high school. A 21-year-old woman in college with no children explains that she “ Still want[s] to be able to do things like have a good job, finish school, and be stable. ” Similarly , a 26-year old desiring to go back to college explains “ I wanted to finish school. I'd been waiting a while to get into the bachelor's program and I finally got it. ” Another woman explains “ I feel like I need to put myself first and get through college and support myself. ” As a 21-one-year old seeking a college degree points out, “I’m trying to graduate from college and I’m going to cooking school in August and I have a lot of things going for me and I can’t take care of a kid by myself .” Others spoke to the inability to take time off work to raise the child.” A 21-one-year old holding two part-time jobs and raising two children states: “I wouldn't be able to take the time off work. My work doesn't offer maternity leave and I have to work [to afford to live] here. If I took time off I would lose my job so there's just no way.”

Some women, particularly younger women, expressed the feeling that having a baby at this time would negatively impact multiple aspects of their future lives.

“It is hard to get in school. If I had the baby it would be tough to do school work, thinking about my future. I know that I wouldn't be able to do what I want to do. I still want to be free and have my youth. I don't want to have it all gone because of one experience. I still want to study abroad. I don't want to ruin that.” -- 20-year-old in college with no children

Not emotionally or mentally prepared

Nineteen percent of respondents (19%) described feeling emotionally or mentally unprepared to raise a child at this time. Respondents in this category were characterized by a feeling of exasperation and an inability to continue the pregnancy— “I can't go through it” , “ I just felt inadequate ”— or feeling a lack of mental strength to have the baby— “[I am] not mentally stable to take that on”, “emotionally, I couldn't take care of another baby, ” and “I couldn’t handle it.” A 19-year old mother reporting a history of depression and physical abuse describes seeking an abortion because, “ I have a lot of problems-serious problems and so I'm not prepared for another baby. ” Another woman explained her rationale for seeking abortion, “ I would say a mental reason, in the sense that it would really be a burden because then I would have to watch three, my hands are already full.”

Health-related reasons

Twelve percent of respondents (12%) mentioned health-related reasons ranging from concern for her own health (6%), health of the fetus (5%), drug, tobacco, or alcohol use (5%), and/or non-illicit prescription drug or birth control use (1%). Maternal health concerns included physical health issues that would be exacerbated by the pregnancy or due to the pregnancy itself, “ My bad back and diabetes, I don't think the baby would have been healthy. I don't think I would have been able to carry it to term” as well as mental health concerns. Five percent of women (5%) chose abortion because they were concerned about the effects of their drug and/or alcohol use on the health of the fetus or on their ability to raise the child. For a more extensive analysis of substance use as reasons for seeking an abortion see Roberts et al. [ 16 ]. Other women (5%) voiced concern for the health of the fetus because they had been using contraceptives (n=4), psychotropic drugs (n=3) or medications (such as antibiotics, blood thinners, and narcotics) to treat other health conditions (n=7). As one woman explains, she and her partner chose abortion “ because I had been doing drinking and the medication I’m on for bipolar disorder is known to cause birth defects and we decided it’s akin to child abuse if you know you’re bringing your child into the world with a higher risk for things. ”

Want a better life for the baby than she could provide

Twelve percent of women gave reasons for choosing abortion related to their desire to give the child a better life than she could provide. Responses related to generally wanting to give the child a better life (7%) were characterized by a concern for the child “I'm afraid my kid will be suffering in this world” and “ wouldn't have been good for me or the child,” or a feeling of inadequacy to parent the child: “I can't take care of a kid because I can barely take care of myself and I don't want to bring a child into the world when I'm unmarried and not ready. ” As reflected in this previous quote, sometimes statements stemmed from a desire for the baby to have a father, or the feeling that the father of the baby was not suitable. “I didn't want to do it by myself. I couldn't and the man was abusive and horrible… I didn't want my kid to grow up with a father like that (knowing his father had left). ” For one woman, the decision to terminate her pregnancy was a moral one. “I've been unemployed it’s not a decision I can face morally without being able to raise it properly. An abortion was the best option. ”

Approximately 5% of respondents explained that their living or housing context was not suitable for a baby and mentioned this as one of the reasons they chose abortion. According to a 22-year old who described herself as being unable to work, on welfare, and rarely having enough money to meet basic living needs: “My mom pays my rent for me and where I live I can't have kids. I can't get anyone to rent to me because I have had an eviction and haven't had a steady job. ”

While never mentioned as the only reason for choosing abortion, 13 respondents said that lack of help to care for the baby was one reason they chose abortion. Responses included “I wouldn't have a babysitter for school,” “family isn't close by to help”, and “My grandma passed away and she was the one who was going to help.” Another subcategory of this theme included choosing abortion because of the desire not to repeat their childhood (n=5). An 18-year old who frequently smoked marijuana explained that she chose abortion “Because I did do drugs and my mom used drugs with me and my sister and I swore to myself I wouldn't bring a child into this world like that. ” Another respondent in her teens and who had a history of physical and sexual abuse and neglect remarked “my childhood was less than awesome, if I do have a child I want to give it the best possible life that I can and I am not in a place to do that right now. ”

Lack of maturity or independence

Less than 7% of women explained that their reliance on others or lack of maturity was a reason for choosing abortion. Some women felt they were too young (5%), unable to take care of themselves (1%), or too reliant on others to raise this baby (1%). “I'm not grown up enough to take care of another person. I can't take care of myself yet, let alone another person. I wouldn't want to bring a baby into this world with parents who aren't ready to be parents. ”

Influences from friends and/or family

Around 5% of women described a concern for, or influences from family or friends as a reason for seeking abortion. Two percent feared that having a baby would negatively impact their family or friends “It would have been a strain on my family ” and a similar proportion (2%) didn’t want others to know about their pregnancy or feared judgment or reaction from others. A 19-year old explains that the reason she chose abortion was because “I was scared to go to my parents .” Another woman feared what the family would think about her having a biracial child. A small minority reported influences or pressure from family or friends (n=11) as a reason for seeking abortion. “Because my mother convinced me to get one, ” explains one 17-year old. A 23-year old describes her rationale for seeking abortion “because my dad thinks I should finish school first, not financially ready for a baby, gonna have to move out when I have the baby. ” Similarly, a 25-year old explained that she wanted an abortion because of, “the negative feedback I was getting from my family. ”

Don’t want a baby or place baby for adoption

Four percent (4%) of women gave reasons falling under the theme not wanting a baby or not wanting to place a baby for adoption. Three percent (3%) explained succinctly that they do not want a baby or don’t want children “I just didn't want any kids”, “It [a baby] is something I just didn't want.” A small number (n=7) mentioned adoption was not an option for them. As one 25-year old describes “We are not really sure if we ever want kids. I don't think that I would be strong enough to give it up for adoption. ” Another respondent states that “adoption isn't an option for me-so it was kind of a no brainer decision. ”

Other reasons

Eleven women (1%) gave other reasons for seeking abortion that didn’t easily fall into one of the major themes, including going through legal issues (n=3) and fear of giving birth (n=2).

Factors related to reasons for abortion

Using mixed effects multivariate logistic regression analyses, we examined the social and demographic predictors of the predominant themes women gave for seeking an abortion (Table  3 ). Significant predictors of reporting financial reasons for seeking an abortion included marital status, education level, and not having enough money to meet basic living needs. Women who gave financial reasons for seeking an abortion were more likely to have a higher level of education [Odds Ratio (OR) 1.41, 95% Confidence Interval (CI), 1.05-1.90], less likely to be separated, divorced or widowed (OR, 0.54, CI, 0.34-0.86) than to be single/never married, and less likely to have enough money to meet basic needs (OR 0.54 CI, 0.41-0.72). Approximately 82% of women who reported this as a reason were single/never married.

Multivariate mixed effects logistic analyses predicting reasons for abortion

*p<.05; **p<.01; ***p<.001; OR Odds Ratios; CI=95% Confidence Intervals.

Women who reported reasons related to the need to focus on other children now were significantly more likely to have a lower pregnancy intentions score (OR 0.79, CI 0.71-0.88), and, to have a greater number of children (OR 2.31, CI 1.97-2.72). All women who reported this as a reason had one or more children.

Women who reported that this is not the right time for a baby as a reason for seeking abortion had a lower pregnancy intentions score (OR 0.86, CI 0.78-0.94) and lower parity (OR 0.71, CI 0.61-0.82). Over half (51%) of women who reported this as a reason had no children.

Women who gave partner related reasons were significantly more likely to be African American (OR 0.66, CI 0.45-0.99) and to have higher parity (OR, 0.78, CI 0.67-0.90). Older women (OR 1.03, 1.0-1.07), women who were separated, divorced or widowed (OR 2.22, CI 1.40-3.53), and women with higher pregnancy intention scores (OR 1.11, CI 1.01-1.21), had increased odds of giving partner related reasons.

Women who chose abortion because they felt having a baby would interfere with her future plans were more likely to be younger (OR 0.94, CI 0.90-0.98), to have more than a high school education (OR 2.43, CI 1.66-3.56), self-rated good health (OR 1.81, CI 1.08-3.04), and lower scores on the pregnancy intentions scale (OR 0.89, CI 0.80-0.99). Among those who reported this as a reason, over half (52%) were in college or getting their Associates or technical degree.

Predictors of reporting being emotionally or mentally unprepared as a reason for seeking abortion included race/ethnicity and having enough money to meet basic living needs. Women who were African American (OR 0.47, CI 0.29-0.75) were less likely than white women to report this as a reason. Women who reported having sufficient money to meet basic needs (OR 0.55, CI 0.38-0.78) were at a reduced odds of reporting this as a reason for seeking abortion.

Women with a history of depression or anxiety (OR 3.29, CI 2.07-5.23) had sharply elevated odds of mentioning physical or mental health factors as reasons for seeking abortion. Women who rated their health as good (OR 0.61, CI 0.37-0.99) and were employed (OR 0.50, CI 0.32-0.80) had reduced odds of mentioning physical or mental health reasons for seeking abortion.

Women who chose abortion because they wanted to give the baby a better life than they could provide were significantly more likely to have more than a high school education (OR 1.61, CI 1.0-2.5), have lower parity (OR 0.65, CI 0.5-0.8), and to lack a usual health care provider (OR 0.63, CI 0.4-1.0). Over half of women who gave this as a reason were nulliparous (55%).

Women who gave lack of independence or immaturity as a reason for seeking abortion were more likely to be younger (OR 0.83, CI 0.7-0.9) and lower parity (OR 0.38, CI 0.2-0.7). All women who gave this reason were under age 31, 48% were in their teens and 83% were nulliparous. Marital status was excluded in the model because of problems with collinearity with the outcome. Nearly all (97%) women who gave this as a reason were single/never married.

Reporting influences from friends and family as a reason for seeking abortion was significantly predicted by age and pregnancy intentions. Women who report this reason were more likely to be younger (OR 0.87, CI 0.8-1.0) and to have a higher pregnancy intentions score (OR 1.20, CI 1.0-1.4). Over three quarters (85%) of women who gave this as a reason were ages 24 and under. Their average pregnancy intentions score was higher when compared to women giving other reasons (3.2 vs. 2.7, p=.03).

The two significant predictors of “don’t want a baby or place baby for adoption” were lower parity (OR 0.67, CI 0.46-0.96) and a lower pregnancy intentions score (OR 0.77, CI 0.60-0.99). Over two thirds (68%) who reported this reason were nulliparous.

The findings from this study demonstrate that the reasons women seek abortion are complex and interrelated. Unlike other studies [ 6 ], this study asked women entirely open-ended questions regarding the reasons they sought to terminate their pregnancies, ensuring that all women’s reasons could be fully captured. This methodology enabled us to get a wide range of responses that otherwise would not have been gathered. While some women stated only one factor that contributed to their desire to terminate their pregnancies, others pointed to a myriad of factors that, cumulatively, resulted in their seeking an abortion.

As indicated by the differences we observed among women’s reasons by individual characteristics, women seek abortion due to their unique circumstances, including their socioeconomic status, age, health, parity and marital status. Even with changes in the climate surrounding abortion and the shifting demographics of the women having abortions, the predominant reasons women gave for seeking abortion reflected those of previous studies [ 6 ]. Reasons related to timing, partners, and concerns for the ability to support the child and other dependents financially and emotionally were the most common reasons women gave for seeking an abortion, suggesting that abortion is often a decision driven by women’s concerns for current and future children, family, as well as existing commitments and responsibilities. Some women held the belief that her unborn child deserves to be raised under better circumstances than she can provide at this time; in an environment where the child is financially secure and part of a stable and loving family. This intersection between abortion and motherhood is described qualitatively in a study by Jones and colleagues where women indicate that their abortion decisions are influenced by the idea that children deserve “ideal conditions of motherhood” [ 21 ]. Some women also seem to have internalized gendered norms that value women as self-denying and always thinking in the best interest of her children, over making self-interested decisions. Experiences of stigma, fear of experiencing stigma, or internalized stigma around her abortion may have prompted women to give more socially desirable responses to make her appear or feel selfless, to justify her abortion decision. Other studies have reported abortion-seeking women’s fear of being judged as having made a selfish decision [ 22 ]. At the same time, some of the women seeking abortion in this study were aiming to secure themselves a better life and future- chances for a better job and a good education. These women may be more stigmatized than the former since they don’t fall into a discourse of the selfless and all-sacrificing woman. In an effort not to further contribute to the abortion stigma in our culture, we must be careful not to use women’s reasons for abortion as a way to rationalize or justify their abortions, but rather to better understand their experiences [ 23 ].

Denying women an abortion, which occurred among one quarter of the women interviewed in this study, may have a significant negative impact on her health, her existing children and other family members, and her future. Policies that restrict access to abortion must acknowledge that such women will need added support (e.g. financial, emotional, educational, health care, vocational support) to appropriately care for their children, other children, and themselves. In some cases, where women are struggling with abuse or health issues, continuing an unwanted pregnancy to term may be associated with even greater than normal risks of childbirth.

This study should be viewed in light of its limitations. Fewer than 40% of women who were eligible and approached agreed to participate. Many women may have been deterred from enrolling because participation required bi-annual interviews for a period of 5 years. Nonetheless, our sample demographics, with the exception of our overrepresentation of women beyond the first trimester, closely mirror the national estimates of women seeking abortion in the US, suggesting that our results are generalizable [ 24 , 25 ]. The greater proportion of women in our sample seeking abortions at later gestational ages and without fetal anomalies allows us to make inferences about a previously understudied group. Gestational age at the time of the interview was unrelated to any of the major themes mentioned. Other studies have found that late gestational age was an important predictor of termination because of concerns about the health of the fetus [ 9 ]. In this study, we have excluded women seeking abortion for fetal anomaly and found that seeking a later abortion was unrelated to women’s reasons for seeking an abortion. Thus, among women without fetal anomalies, reasons for seeking abortion are not different whether women sought abortion early or late in pregnancy. This suggests that factors other than the reasons for desiring an abortion play a role in seeking later abortions.

A small number of women stated that concern for the fetus while using contraception or other medications was a reason for seeking abortion pointing to an area for intervention. The general consensus in the literature is that birth control use during pregnancy is unlikely to have negative consequences for the development of the fetus [ 26 - 29 ]. A better understanding of the potential impact of the contraceptive methods and other medications on a developing fetus can help women be better informed when deciding whether nor not to have an abortion.

Laws requiring waiting periods, mandated counseling, and parental involvement for adolescents are motivated in part by a desire to protect women from making uninformed decisions and from being coerced into having an abortion. Prior research suggests that, women who feel the abortion decision is not completely their own have more difficulty coping following an abortion [ 30 ]. Our study, like most studies of women seeking abortions [ 9 ], finds that few women report pressure from others as a reason for seeking abortion. About 1% of women in this study described being influenced by others to have an abortion. Our study design, however, did not allow us to assess the level of pressure women experienced. The pressure women felt may have varied in degree from statements of a mild lack of support for continuing a pregnancy to strong and specific statements about a lack of future emotional or financial support for the pregnancy or potential child. While these women’s pregnancy intention scores are somewhat higher than those who gave other reasons for abortion, their scores were still in the unintended/ambivalent range. Health care providers should continue to assess and confirm that women are able to make their own decision about whether or not to continue or end a pregnancy. Women who experience pressure may benefit from additional emotional support if they choose to proceed with abortion.

In recent years, politicians, advocacy organizations and the media have extensively debated issues related to the funding, provision, utilization, and morality of abortion, and legislation restricting abortion access has increased dramatically. The Guttmacher Institute documented that 92 new provisions restricting abortion were enacted in 2011, almost three times the previous record of 34 provisions enacted six years earlier [ 31 ]. Despite the proliferation of proposed legislation that would restrict access to abortion, the public discourse concerning why women seek abortions has been limited. It is important that policy makers consider women’s motivations for choosing abortion, as decisions to support or oppose such legislation could have profound effects on the health, socioeconomic outcomes and life trajectories of women facing unwanted pregnancies.

As found in previous literature, the findings from this study demonstrate that women are motivated to seek abortion for a wide range of reasons that are driven by their unique circumstances and stage of life. Women expressed lacking the financial, emotional, and physical resources to adequately provide for a/another child, yet many were denied access to a wanted abortion. Supporters of policies that continue to further restrict women’s access to abortion need to recognize the potential impact on the financial, emotional, and physical well-being of these women and their families. Women who carry an unwanted pregnancy to term because they are denied access to a wanted abortion may require financial assistance, support handling an abusive partner, access to mental health services prenatal care and, potentially, specialized health care for high risk pregnancies. By better understanding women’s decisions when faced with an unintended pregnancy and destigmatizing abortion seeking we can better support women’s reproductive decisions and provide them with the resources they may need.

a Bill of Rights can be downloaded at: http://www.research.ucsf.edu/chr/Guide/chrB_BoR.asp .

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

MAB’s role in this paper included conceptualizing the analyses for this paper, leading the quantitative and qualitative analyses and drafting the manuscript. HG was responsible for reviewing the literature, assisting in the qualitative coding, and drafting and editing the manuscript. DGF conceptualized and led the overall Turnaway study design and assisted in drafting and editing the manuscript. All authors approved the final manuscript.

Pre-publication history

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1472-6874/13/29/prepub

Acknowledgements

The authors thank Tracy Weitz for reviewing parts of the manuscript; Rana Barar and Sandy Stonesifer for study coordination and management; Janine Carpenter, Undine Darney, Ivette Gomez, Selena Phipps, Claire Schreiber and Danielle Sinkford for conducting interviews; Michaela Ferrari and Elisette Weiss for project support; Jay Fraser and John Neuhaus for statistical and database assistance and all the participating providers for their assistance with recruitment. This study was supported by research and institutional grants from the Wallace Alexander Gerbode Foundation, the David and Lucile Packard Foundation, the William and Flora Hewlett Foundation and an anonymous foundation.

• Herold S. The new public face of abortion: connecting the dots between abortion stories. RH Reality Check. 2012. Available at: http://rhrealitycheck.org/article/2012/07/08/new-public-face-abortion-connecting-dots-between-abortion-stories/
• Jones RK, Kooistra K. Abortion incidence and access to services in the United States, 2008. Perspect Sex Reprod Health. 2011; 43 (1):41–50. doi: 10.1363/4304111. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kumar A, Hessini L, Mitchell EM. Conceptualising abortion stigma. Cult Health Sex. 2009; 11 (6):625–639. doi: 10.1080/13691050902842741. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Norris A, Bessett D, Steinberg JR, Kavanaugh ML, De Zordo S, Becker D. Abortion stigma: a reconceptualization of constituents, causes, and consequences. Women's Health Issues. 2011; 21 (3 Suppl):S49–S54. [ PubMed ] [ Google Scholar ]
• Shellenberg KM, Moore AM, Bankole A, Juarez F, Omideyi AK, Palomino N, Sathar Z, Singh S, Tsui AO. Social stigma and disclosure about induced abortion: results from an exploratory study. Glob Public Health. 2011; 6 (Suppl 1):S111–S125. [ PubMed ] [ Google Scholar ]
• Kirkman M, Rowe H, Hardiman A, Mallett S, Rosenthal D. Reasons women give for abortion: a review of the literature. Arch Womens Ment Health. 2009; 12 (6):365–378. doi: 10.1007/s00737-009-0084-3. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Santelli JS, Speizer IS, Avery A, Kendall C. An exploration of the dimensions of pregnancy intentions among women choosing to terminate pregnancy or to initiate prenatal care in New Orleans, Louisiana. Am J Public Health. 2006; 96 (11):2009–2015. doi: 10.2105/AJPH.2005.064584. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Glander SS, Moore ML, Michielutte R, Parsons LH. The prevalence of domestic violence among women seeking abortion. Obstet Gynecol. 1998; 91 (6):1002–1006. doi: 10.1016/S0029-7844(98)00089-1. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Finer LB, Frohwirth LF, Dauphinee LA, Singh S, Moore AM. Reasons U.S. women have abortions: quantitative and qualitative perspectives . Perspect Sex Reprod Health. 2005; 37 (3):110–118. doi: 10.1363/3711005. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Ehrlich JS. Choosing abortion: teens who make the decision without parental involvement. Gender Issues. 2003; 21 (2):3–39. doi: 10.1007/s12147-003-0014-z. [ CrossRef ] [ Google Scholar ]
• Torres A, Forrest JD. Why do women have abortions? Fam Plann Perspect. 1988; 20 (4):169–176. doi: 10.2307/2135792. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Jones RK, Darroch JE, Henshaw SK. Patterns in the socioeconomic characteristics of women obtaining abortions in 2000–2001. Perspect Sex Reprod Health. 2002; 34 (5):226–235. doi: 10.2307/3097821. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• GuttmacherInstitute. State Policies in Brief: An Overview of Abortion Laws . 2013. p. 2013. 2013.
• Roberts SC, Avalos LA, Sinkford D, Foster DG. Alcohol, tobacco and drug use as reasons for abortion . Alcohol Alcohol. 2012; 47 (6):640–648. doi: 10.1093/alcalc/ags095. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Chibber K, Gould H, Biggs MA, Roberts S, Foster DG. Partner reasons for seeking an abortion . Under review.
• Gould H, Perrucci A, Barar R, Sinkford D, Foster DG. Patient education and emotional support practices in abortion care facilities in the United States . Womens Health Issues. 2012; 22 (4):359–364. doi: 10.1016/j.whi.2012.04.003. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Foster DG, Kimport K, Gould H, Roberts SC, Weitz TA. Effect of abortion protesters on women's emotional response to abortion . Contraception. 2013; 87 (1):81–87. doi: 10.1016/j.contraception.2012.09.005. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Rocca CH KK, Gould H, Foster DG. Women’s emotional responses to unintended pregnancy, abortion and being denied an abortion in the United States . Perspect Sex Reprod Health. 2013. In Press. [ PubMed ]
• Barrett G, Smith SC, Wellings K. Conceptualisation, development, and evaluation of a measure of unplanned pregnancy . J Epidemiol Community Health. 2004; 58 (5):426–433. doi: 10.1136/jech.2003.014787. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Jones RK, Frohwirth LF, Moore AM. “I would want to give my child, like, everything in the world” - how issues of motherhood influence women who have abortions . J Fam Issues. 2008; 29 (1):79–99. [ Google Scholar ]
• Ellison MA. Authoritative knowledge and single women's unintentional pregnancies, abortions, adoption, and single motherhood: social stigma and structural violence . Med Anthropol Q. 2003; 17 (3):322–347. doi: 10.1525/maq.2003.17.3.322. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Cockrill K, Nack A. “I’m not that type of person”: managing the stigma of having an abortion . Deviant Behavior. 2013. In Press.
• Jones RK, Kavanaugh ML. Changes in abortion rates between 2000 and 2008 and lifetime incidence of abortion . Obstet Gynecol. 2011; 117 (6):1358–1366. doi: 10.1097/AOG.0b013e31821c405e. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Jones RK, Finer LB. Who has second-trimester abortions in the United States? . Contraception. 2012; 85 (6):544–551. doi: 10.1016/j.contraception.2011.10.012. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Simpson JL. Do contraceptive methods pose fetal risks? . Res Front Fertil Regul. 1985; 3 (6):1–11. [ PubMed ] [ Google Scholar ]
• Waller DK, Gallaway MS, Taylor LG, Ramadhani TA, Canfield MA, Scheuerle A, Hernandez-Diaz S, Louik C, Correa A. Use of oral contraceptives in pregnancy and major structural birth defects in offspring . Epidemiology. 2010; 21 (2):232–239. doi: 10.1097/EDE.0b013e3181c9fbb3. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Pardthaisong T, Yenchit C, Gray R. The long-term growth and development of children exposed to Depo-Provera during pregnancy or lactation . Contraception. 1992; 45 (4):313–324. doi: 10.1016/0010-7824(92)90053-V. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Barash A, Shoham Z, Borenstein R, Nebel L. Development of human embryos in the presence of a copper intrauterine device . Gynecol Obstet Invest. 1990; 29 (3):203–206. doi: 10.1159/000293380. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kimport K, Foster K, Weitz TA. Social sources of women's emotional difficulty after abortion: lessons from women's abortion narratives . Perspect Sex Reprod Health. 2011; 43 (2):103–109. doi: 10.1363/4310311. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Guttmacher Institute. Laws affecting reproductive health and rights: 2011 state policy review . New York: Guttmacher Institute; 2012. [ Google Scholar ]

• HISTORY & CULTURE

How U.S. abortion laws went from nonexistent to acrimonious

Most scholars say that at the nation's founding ending a pregnancy wasn’t illegal—or even controversial. Here’s a look at the complex early history of abortion in the United States.

There’s no more hot-button issue in the United States than that of abortion. And every time the divisive battle flares up, someone is bound to invoke the historical legacy of abortion in America.

But what is that history? Though interpretations differ, most scholars who have investigated the complex history of abortion argue that terminating a pregnancy wasn’t always illegal—or even controversial. Here’s what they say about the nation’s long, complicated relationship with abortion.

Before abortion law  

In colonial America and the early days of the republic, there were no abortion laws at all. Church officials frowned on the practice, writes Oklahoma University of Law legal historian Carla Spivack in the William & Mary Journal of Race, Gender, and Social Justice , but they treated the practice as evidence of illicit or premarital sex—not as murder.

Some localities prosecuted cases involving abortions. In 1740s Connecticut, for example, prosecutors tried both a doctor and a Connecticut man for a misdemeanor in connection with the death of Sarah Grosvenor, who had died after a botched abortion. However, the case centered around the men’s role in the woman’s death, not abortion per se, and such prosecutions were rare.

In fact, says Lauren MacIvor Thompson , a historian of women’s rights and public health and an assistant professor at Kennesaw State University, “abortion in the first trimester would have been very, very common.”

That’s in part because of society’s understanding of conception and life.

For Hungry Minds

Many historians agree that in an era long before reliable pregnancy tests, abortion was generally not prosecuted or condemned up to the point of quickening—the point at which a pregnant woman could feel the fetus’ first kicks and movements . At the time quickening might be the only incontrovertible evidence of pregnancy; indeed, one 1841 physician wrote that many women didn’t even calculate their due dates until they had felt the baby kick, which usually takes place during the second trimester, as late as 20 weeks into the pregnancy. That’s when the fetus was generally recognized as a baby or person.

Until the mid-19th century, writes University of Illinois historian Leslie J. Reagan in her book When Abortion Was a Crime, “What we would now identify as an early induced abortion was not called an ‘abortion’ at all. If an early pregnancy ended, it had ‘slipp[ed] away,’ or the menses had been ‘restored.’”

How early abortion worked

At the time, women who did not wish to remain pregnant had plenty of options. Herbs like savin, tansy, and pennyroyal were common in kitchen gardens, and could be concocted and self-administered to, in the parlance of the time, clear “obstructions” or cause menstruation.

“It was really a decision that a woman could choose in private,” MacIvor Thompson says.

A pregnant woman might consult with a midwife, or head to her local drug store for an over-the-counter patent medicine or douching device. If she owned a book like the 1855   Hand-Book of Domestic Medicine , she could have opened it to the section on “emmenagogues,” substances that provoked uterine bleeding. Though the entry did not mention pregnancy or abortion by name, it did reference “promoting the monthly discharge from the uterus.”

Though reasons varied, a lack of reliable contraception, the disgrace of bearing a child outside of marriage, and the dangers of childbirth were the main reasons women terminated their pregnancies. Though birth rates were high—in 1835, the average woman would give birth more than six times during her lifetime—many women wanted to limit the number of times they would have to carry and bear a child. In an era before modern medical procedures, the grave dangers of childbirth were widely understood. In the words of historian Judith Walzer Leavitt, “Women knew that if procreation did not kill them or their babies, it could maim them for life.”

( Women's health concerns are dismissed more, studied less .)

As a result, the deliberation termination of pregnancy was widely practiced, and by some estimates , up to 35 percent of 19th-century pregnancies ended in abortion.

For enslaved women, abortion was more tightly regulated because their children were seen as property. In the Journal of American Studies , historian Liese M. Perrin writes that many slaveholders were paranoid about abortion on their plantations; she documents that at least one slaveholder locked an enslaved woman up and stripped her of privileges because he suspected she had self-induced a miscarriage. Still, bondswomen’s medical care was usually left to Black midwives who practiced folk medicine.   And at least some enslaved women are known to have used abortifacients, chewing cotton roots or ingesting substances like calomel or turpentine.

Middle- and upper-class white women, however, had an advantage when it came to detecting and treating unwanted pregnancies in the 19th century. Their strictly defined roles in society held that the home—and issues of reproductive health—were a woman’s realm.   And so women, not doctors, were the ones who held and passed down knowledge about pregnancy, childbirth, and reproductive control. “It gave them a space to make their own decisions about their reproductive health,” MacIvor Thompson says.

Criminalizing abortion

That would slowly change throughout the century as the first abortion laws slowly made their ways onto the books. Most were focused on unregulated patent medicines and abortions pursued after quickening. The first , codified in Connecticut in 1821, punished any person who provided or took poison or “other noxious and destructive substance” with the intent to cause “the miscarriage of any woman, then being quick with child.”

Patent medicines were a particular concern; they were available without prescriptions, and their producers could manufacture them with whatever ingredients they wished and advertise them however they liked. Many such medicines were abortifacients and were advertised as such—and they were of particular concern to doctors.

As physicians professionalized in the mid-19th century, they increasingly argued that licensed male doctors, not female midwives, should care for women throughout the reproductive cycle. With that, they began to denounce abortion.

Gynecologist Horatio Storer led the charge. In 1857, just a year after joining the barely decade-old American Medical Association, Storer began pushing the group to explore what he called “criminal abortion.”   Storer argued that abortion was immoral and caused “derangement” in women because it interfered with nature. He lobbied for the association to think of abortion not as a medical act, but a grave crime, one that lowered the profession as a whole.

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A power player within the association, he gathered fellow physicians into a crusade called the Physicians Campaign Against Abortion. The doctors’ public stance helped serve as justification for an increasing number of criminal statutes.

For its opponents, abortion was as much a social evil as a moral one. The influx of immigrants, the growth of cities, and the end of slavery prompted nativist fears that white Americans were not having enough babies to stave off the dominance of groups they found undesirable. This prompted physicians like Storer to argue that white women should have babies for the “future destiny of the nation.”

A nation of outlaws

By 1900, writes University of Oregon historian James C. Mohr in his book Abortion in America , “the United States completed its transition from a nation without abortion laws of any sort to a nation where abortion was legally and officially proscribed.” Just 10 years later, every state in the nation had anti-abortion laws—although many of these laws included exceptions for pregnancies that endangered the life of the mother.

With the help of a U.S. postal inspector named Anthony Comstock, it had also become harder to access once-common information on how to end an unwanted pregnancy. The 1873 Comstock Act made it illegal to send “obscene” materials—including information about abortion or contraception—through the mail or across state lines.

“Americans understood that abortion and birth control went hand in hand,” MacIvor Thompson says.

The combination of anti-obscenity laws, criminal statutes, and the 1906 Pure Food and Drug Act , which made it unlawful to make, sell, or transport misbranded or “deleterious” drugs or medicines, made it increasingly difficult for women to access safer forms of abortion.

“The legal punishments in place absolutely had a chilling effect,” says MacIvor Thompson. “And yet, just like a hundred years earlier, women still sought them frequently.”

As the 20th century dawned, under-the-table surgical abortions became more common, discreetly practiced by physicians who advertised by word-of-mouth to those who could afford their services. Those who could not used old herbal recipes, drank creative concoctions, douched with substances like Lysol, or attempted to remove the fetuses on their own.

Advocates of the growing birth control movement even used now-illegal abortion to argue for legal contraception. Birth control pioneer Margaret Sanger said that she was inspired to make teaching women about contraceptives her career after treating a woman who died from a self-induced abortion—a practice she called a “disgrace to a civilized community.”

( How the first birth control pill was designed .)

It’s still up for debate how frequently women sought abortions in the 20th century—and how often they died from self-induced or botched, “back-alley” abortions. In 1942, the question vexed the Bureau of the Census’ chief statistician, Halbert Dunn, who noted that, despite the lack of accurate reporting, “abortion is evidently still one of the greatest problems to be met in lowering further the maternal mortality rate for the country.”

The modern battle over abortion

By 1967, abortion was a felony in nearly every state, with few provisions for the health of the mother or pregnancies arising from rape.

But all that changed in the 1970s. States across the country had begun to reconsider their laws and loosen their restrictions on abortion, and in 1973, the Supreme Court seemingly settled the question with two landmark rulings— Roe v. Wade and the lesser-known but equally important Doe v. Bolton— that made terminating a pregnancy a legal right nationwide.

( The tumultuous history that led to the landmark   Roe v. Wade ruling. )

The country has debated the merits of those rulings ever since. In June 2022, the Supreme Court made the momentous decision to overturn Roe . Now, generations of women who have never known life before Roe   face yet another shift in the landscape of the nation’s contentious history of abortion.

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• America’s Abortion Quandary

2. Social and moral considerations on abortion

Table of contents.

• Abortion at various stages of pregnancy 
• Abortion and circumstances of pregnancy 
• Parental notification for minors seeking abortion
• Penalties for abortions performed illegally 
• Public views of what would change the number of abortions in the U.S.
• A majority of Americans say women should have more say in setting abortion policy in the U.S.
• How do certain arguments about abortion resonate with Americans?
• In their own words: How Americans feel about abortion 
• Personal connections to abortion 
• Religion’s impact on views about abortion
• Acknowledgments
• The American Trends Panel survey methodology

Relatively few Americans view the morality of abortion in stark terms: Overall, just 7% of all U.S. adults say abortion is morally acceptable in all cases, and 13% say it is morally wrong in all cases. A third say that abortion is morally wrong in  most  cases, while about a quarter (24%) say it is morally acceptable most of the time. About an additional one-in-five do not consider abortion a moral issue.

There are wide differences on this question by political party and religious affiliation. Among Republicans and independents who lean toward the Republican Party, most say that abortion is morally wrong either in most (48%) or all cases (20%). Among Democrats and Democratic leaners, meanwhile, only about three-in-ten (29%) hold a similar view. About four-in-ten Democrats say abortion is morally  acceptable  in most (32%) or all (11%) cases, while an additional 28% say abortion is not a moral issue. 

White evangelical Protestants overwhelmingly say abortion is morally wrong in most (51%) or all cases (30%). A slim majority of Catholics (53%) also view abortion as morally wrong, but many also say it is morally acceptable in most (24%) or all cases (4%), or that it is not a moral issue (17%). And among religiously unaffiliated Americans, about three-quarters see abortion as morally acceptable (45%) or not a moral issue (32%).

There is strong alignment between people’s views of whether abortion is morally wrong and whether it should be illegal. For example, among U.S. adults who take the view that abortion should be illegal in all cases without exception, fully 86% also say abortion is always morally wrong. The prevailing view among adults who say abortion should be legal in all circumstances is that abortion is not a moral issue (44%), though notable shares of this group also say it is morally acceptable in all (27%) or most (22%) cases. 

Most Americans who say abortion should be illegal with some exceptions take the view that abortion is morally wrong in  most  cases (69%). Those who say abortion should be legal with some exceptions are somewhat more conflicted, with 43% deeming abortion morally acceptable in most cases and 26% saying it is morally wrong in most cases; an additional 24% say it is not a moral issue. 

The survey also asked respondents who said abortion is morally wrong in at least some cases whether there are situations where abortion should still be legal  despite  being morally wrong. Roughly half of U.S. adults (48%) say that there are, in fact, situations where abortion is morally wrong but should still be legal, while just 22% say that whenever abortion is morally wrong, it should also be illegal. An additional 28% either said abortion is morally acceptable in all cases or not a moral issue, and thus did not receive the follow-up question.

Across both political parties and all major Christian subgroups – including Republicans and White evangelicals – there are substantially more people who say that there are situations where abortion should still be  legal  despite being morally wrong than there are who say that abortion should always be  illegal  when it is morally wrong.

Asked about the impact a number of policy changes would have on the number of abortions in the U.S., nearly two-thirds of Americans (65%) say “more support for women during pregnancy, such as financial assistance or employment protections” would reduce the number of abortions in the U.S. Six-in-ten say the same about expanding sex education and similar shares say more support for parents (58%), making it easier to place children for adoption in good homes (57%) and passing stricter abortion laws (57%) would have this effect. 

While about three-quarters of White evangelical Protestants (74%) say passing stricter abortion laws would reduce the number of abortions in the U.S., about half of religiously unaffiliated Americans (48%) hold this view. Similarly, Republicans are more likely than Democrats to say this (67% vs. 49%, respectively). By contrast, while about seven-in-ten unaffiliated adults (69%) say expanding sex education would reduce the number of abortions in the U.S., only about half of White evangelicals (48%) say this. Democrats also are substantially more likely than Republicans to hold this view (70% vs. 50%). 

Democrats are somewhat more likely than Republicans to say support for parents – such as paid family leave or more child care options – would reduce the number of abortions in the country (64% vs. 53%, respectively), while Republicans are more likely than Democrats to say making adoption into good homes easier would reduce abortions (64% vs. 52%).

Majorities across both parties and other subgroups analyzed in this report say that more support for women during pregnancy would reduce the number of abortions in America.

More than half of U.S. adults (56%) say women should have more say than men when it comes to setting policies around abortion in this country – including 42% who say women should have “a lot” more say. About four-in-ten (39%) say men and women should have equal say in abortion policies, and 3% say men should have more say than women. 

Six-in-ten women and about half of men (51%) say that women should have more say on this policy issue. 

Democrats are much more likely than Republicans to say women should have more say than men in setting abortion policy (70% vs. 41%). Similar shares of Protestants (48%) and Catholics (51%) say women should have more say than men on this issue, while the share of religiously unaffiliated Americans who say this is much higher (70%).

Seeking to gauge Americans’ reactions to several common arguments related to abortion, the survey presented respondents with six statements and asked them to rate how well each statement reflects their views on a five-point scale ranging from “extremely well” to “not at all well.” 

The list included three statements sometimes cited by individuals wishing to protect a right to abortion: “The decision about whether to have an abortion should belong solely to the pregnant woman,” “If legal abortions are too hard to get, then women will seek out unsafe abortions from unlicensed providers,” and “If legal abortions are too hard to get, then it will be more difficult for women to get ahead in society.” The first two of these resonate with the greatest number of Americans, with about half (53%) saying each describes their views “extremely” or “very” well. In other words, among the statements presented in the survey, U.S. adults are most likely to say that women alone should decide whether to have an abortion, and that making abortion illegal will lead women into unsafe situations.

The three other statements are similar to arguments sometimes made by those who wish to restrict access to abortions: “Human life begins at conception, so a fetus is a person with rights,” “If legal abortions are too easy to get, then people won’t be as careful with sex and contraception,” and “If legal abortions are too easy to get, then some pregnant women will be pressured into having an abortion even when they don’t want to.” 

Fewer than half of Americans say each of these statements describes their views extremely or very well. Nearly four-in-ten endorse the notion that “human life begins at conception, so a fetus is a person with rights” (26% say this describes their views extremely well, 12% very well), while about a third say that “if legal abortions are too easy to get, then people won’t be as careful with sex and contraception” (20% extremely well, 15% very well).

When it comes to statements cited by proponents of abortion rights, Democrats are much more likely than Republicans to identify with all three of these statements, as are religiously unaffiliated Americans compared with Catholics and Protestants. Women also are more likely than men to express these views – and especially more likely to say that decisions about abortion should fall solely to pregnant women and that restrictions on abortion will put women in unsafe situations. Younger adults under 30 are particularly likely to express the view that if legal abortions are too hard to get, then it will be difficult for women to get ahead in society.

In the case of the three statements sometimes cited by opponents of abortion, the patterns generally go in the opposite direction. Republicans are more likely than Democrats to say each statement reflects their views “extremely” or “very” well, as are Protestants (especially White evangelical Protestants) and Catholics compared with the religiously unaffiliated. In addition, older Americans are more likely than young adults to say that human life begins at conception and that easy access to abortion encourages unsafe sex.

Gender differences on these questions, however, are muted. In fact, women are just as likely as men to say that human life begins at conception, so a fetus is a person with rights (39% and 38%, respectively).

Analyzing certain statements together allows for an examination of the extent to which individuals can simultaneously hold two views that may seem to some as in conflict. For instance, overall, one-in-three U.S. adults say that  both  the statement “the decision about whether to have an abortion should belong solely to the pregnant woman” and the statement “human life begins at conception, so the fetus is a person with rights” reflect their own views at least somewhat well. This includes 12% of adults who say both statements reflect their views “extremely” or “very” well. 

Republicans are slightly more likely than Democrats to say both statements reflect their own views at least somewhat well (36% vs. 30%), although Republicans are much more likely to say  only  the statement about the fetus being a person with rights reflects their views at least somewhat well (39% vs. 9%) and Democrats are much more likely to say  only  the statement about the decision to have an abortion belonging solely to the pregnant woman reflects their views at least somewhat well (55% vs. 19%).

Additionally, those who take the stance that abortion should be legal in all cases with no exceptions are overwhelmingly likely (76%) to say only the statement about the decision belonging solely to the pregnant woman reflects their views extremely, very or somewhat well, while a nearly identical share (73%) of those who say abortion should be  illegal  in all cases with no exceptions say only the statement about human life beginning at conception reflects their views at least somewhat well.

When asked to describe whether they had any other additional views or feelings about abortion, adults shared a range of strong or complex views about the topic. In many cases, Americans reiterated their strong support – or opposition to – abortion in the U.S. Others reflected on how difficult or nuanced the issue was, offering emotional responses or personal experiences to one of two open-ended questions asked on the survey. 

One open-ended question asked respondents if they wanted to share any other views or feelings about abortion overall. The other open-ended question asked respondents about their feelings or views regarding abortion restrictions. The responses to both questions were similar. 

Overall, about three-in-ten adults offered a response to either of the open-ended questions. There was little difference in the likelihood to respond by party, religion or gender, though people who say they have given a “lot” of thought to the issue were more likely to respond than people who have not. 

Of those who did offer additional comments, about a third of respondents said something in support of legal abortion. By far the most common sentiment expressed was that the decision to have an abortion should be solely a personal decision, or a decision made jointly with a woman and her health care provider, with some saying simply that it “should be between a woman and her doctor.” Others made a more general point, such as one woman who said, “A woman’s body and health should not be subject to legislation.” 

About one-in-five of the people who responded to the question expressed disapproval of abortion – the most common reason being a belief that a fetus is a person or that abortion is murder. As one woman said, “It is my belief that life begins at conception and as much as is humanly possible, we as a society need to support, protect and defend each one of those little lives.” Others in this group pointed to the fact that they felt abortion was too often used as a form of birth control. For example, one man said, “Abortions are too easy to obtain these days. It seems more women are using it as a way of birth control.” 

About a quarter of respondents who opted to answer one of the open-ended questions said that their views about abortion were complex; many described having mixed feelings about the issue or otherwise expressed sympathy for both sides of the issue. One woman said, “I am personally opposed to abortion in most cases, but I think it would be detrimental to society to make it illegal. I was alive before the pill and before legal abortions. Many women died.” And one man said, “While I might feel abortion may be wrong in some cases, it is never my place as a man to tell a woman what to do with her body.” 

The remaining responses were either not related to the topic or were difficult to interpret.

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Reproductive rights in America

6 key facts about abortion laws and the 2024 election.

Selena Simmons-Duffin

Elissa Nadworny

In the nearly two years since the Supreme Court overturned Roe v. Wade, abortion access has been in an almost constant state of flux.

State laws keep changing – with new bans taking effect in some places while new protections are enacted in others. And there have been a slew of lawsuits and ballot measures that may motivate voters come November.

Here are 6 facts about where things currently are with abortion and the election.

1. About half of states restrict abortion.

In 14 states, there are total bans on abortion, with very limited exceptions in cases such as rape or to save the life or health of the mother. A few more states – including Florida – have six-week bans, and often that's so early in a pregnancy most people don't yet know they're pregnant. Another half dozen states have restrictions that limit abortion after 12, 15, 18 or 22 weeks of pregnancy.

In the states that ban or severely restrict abortion access, the number of abortions has dropped drastically.

But legal challenges and ballot initiatives mean the map could keep shifting. So far, voters will be weighing in on the right to an abortion in four states: Colorado, Florida, Maryland and South Dakota. Six more states are in the process of getting it on the ballot, including Missouri, Nebraska, Nevada, Arizona, Arkansas and Montana.

2. Bans are affecting where doctors work.

Idaho illustrates how abortion bans can affect a state's broader health care system. Doctors are leaving the state, and three maternity wards have closed since the abortion ban took effect there.

"We lost 58 obstetricians either to moving out of state or retiring, and in that same time period, only two OB-GYNs moved into Idaho," says Dr. Sara Thomson, an OB-GYN in Boise. "That is not really a sustainable loss-to-gain ratio."

It's not just Idaho – a lot of hospital systems in states with abortion bans are having recruiting problems. The Association of American Medical Colleges earlier this month reported a decrease in medical students applying to residencies in states that limit abortion access. Essentially, these early career doctors are saying they don't want to practice medicine with the threat of fines, jail time, and the loss of their medical license.

3. Abortions are actually increasing nationally.

Since the Supreme Court overturned Roe v. Wade, the number of abortions in the U.S. has continued to grow.

"We are seeing a slow and small, steady increase in the number of abortions per month and this was completely surprising to us," says Ushma Upadhyay, who co-leads the Society of Family Planning's WeCount project. According to their recent report, in 2023 there were, on average, 86,000 abortions per month compared to 2022, when there were about 82,000 abortions per month. "Not huge," says Upadhyay, "but we were expecting a decline."

A major factor in the uptick in abortions nationwide is the rise of telehealth, made possible in part by regulations first loosened during the coronavirus pandemic. Telehealth abortions now make up nearly 1 in 5 of all abortions in the U.S. Patients don't need to take off work and go to a clinic, they can connect with providers over text messages, phone calls or video, no matter where they live. Abortion medication is then mailed to them at home.

John Seago, president of Texas Right To Life, is concerned with the rise of abortions and increased access through telehealth.

"I'm afraid that we are going to wake up in 20 years and just kind of realize that we won in Dobbs , and then we've been losing ever since," Seago says. He told NPR his group is currently working on how to bring criminal and civil challenges to tamp down on the number of abortions.

4. Some states have moved to make abortion access easier.

Abortion was heavily regulated even while Roe v. Wade was the law of the land, and states like Michigan, Colorado, California, Minnesota and others have made moves to undo some of those regulations.

They are passing laws to get rid of waiting periods and gestational limits, and they are allowing more types of providers like nurse practitioners, for instance, to perform abortions. Some states have stockpiled mifepristone, one of the medicines that can be used for abortion, in case access is curtailed federally in the future.

New York City made an abortion hub as part of its health department, including a hotline and chat for people to find out where to get an abortion and how to get funding to cover the costs.

5. "Shield laws" create new access in untested legal terrain.

Another way some states have expanded abortion access is by passing "shield laws." These are laws that say doctors and nurses in states where abortion is legal can't be prosecuted by another state if they provide abortion across state lines. They apply if a woman travels to another state for an abortion or if the abortion provider mails pills to someone in a state with restrictions.

Lauren, who is 33 and lives in Utah, got a telehealth abortion from a provider in a state with shield laws. Lauren got pregnant on birth control and decided quickly that she couldn't afford another child. (NPR is not using her last name because she's worried about professional repercussions.)

Abortion is technically legal in Utah until 18 weeks, but Lauren chose an online company called Aid Access, that provides telehealth abortion for people in all 50 states.

"In my situation, I felt more at ease than I would in a physician's office and more comfortable, to be honest," she explains. "Especially with a provider within the state of Utah – I feel like there's always a judgmental indication or undertone."

She filled out a form online with questions about how far along she was and her medical history, connected with a doctor via email and text messages, and received abortion medication in the mail. She had her abortion at home.

Some anti-abortion rights groups are hoping to test the legality of shield laws by bringing charges against a doctor, but that hasn't happened yet.

6. The Supreme Court could shake things up again.

There are two major decisions on abortion pending right now before the Supreme Court.

One is about the abortion pill mifepristone. The Court could restrict this drug for the whole country and totally change access to medication abortion through telemedicine. Court watchers think it won't go that way, but no one knows for sure.

The other case is about abortion in emergency situations and it centers on Idaho's medical exception. It's a fight over whether federal or state law should have priority. The oral arguments left legal analysts unsure about which way the Court was leaning.

Both of these decisions are expected in late June or early July, just a few months before the election. Regardless of what the justices decide, it's going to catapult abortion back into the headlines a few months before the election.

Correction May 28, 2024

A previous version of this story said that a law in Utah required abortions to be performed in a hospital. That was incorrect. The law was temporarily blocked a day before it would have gone into effect, and then repealed by lawmakers in 2024 . Clinics providing abortions are open in Utah.

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How Abortion’s Legal Landscape Post-Roe is Causing Fear and Confusion

We spoke with seven reproductive rights organizations — here’s what we found..

This is The Marshall Project’s Closing Argument newsletter, a weekly deep dive into a key criminal justice issue. Want this delivered to your inbox? Subscribe to future newsletters .

For years before the Supreme Court upended Roe v. Wade, the landmark precedent protecting abortion access, a network of conservative Christians was slowly and methodically stacking the courts through political means. “[W]hat Trump and his Republican allies had done was to change the country by leveraging political force to conquer the courts,” Elizabeth Dias and Lisa Lerer wrote in their recent recounting of the network’s maneuvering for The New York Times Magazine.

“Their policy arms churned out legal arguments and medical studies. Their lawyers argued their cases, and their judges ruled on them,” Dias and Lerer explained.

This strategy helps to decode the ever-changing post-Roe legal landscape. With Roe out of the way, and with many courts stacked in their favor, conservative state legislatures have continued to pass increasingly restrictive and punitive abortion laws. At least 14 states have banned abortion with limited exceptions since the Dobbs v. Jackson Women’s Health Organization decision ended Roe in 2022. Another seven states have banned the procedure before 18 weeks, according to the Guttmacher Institute , a research organization that advocates for reproductive rights, including abortion.

Nearly two years after Dobbs, the legality of abortion in the United States is still being debated in court. A total of 40 cases have challenged abortion bans in 23 states as of January, according to the think tank Brennan Center for Justice.

The Marshall Project has been tracking the ripple effects of these laws and lawsuits, particularly in Southern states in which most pregnancy-related prosecutions are concentrated. We wanted to understand how reproductive rights lawyers, advocacy groups, abortion providers and their patients are responding to this new legal reality and what new risks they face. Over the course of several weeks, we heard from seven organizations in Alabama, Mississippi, North Carolina and South Carolina.

The end of Roe ushered in a climate of fear and confusion, many of the organizations told us. New laws and novel prosecutorial tactics have raised critical questions about free speech, interstate travel, telemedicine and more. All while the reproductive rights legal community has scrambled to keep up.

Here are other important takeaways:

A set of lawsuits in Alabama, where abortion is banned, illustrates the new dynamics. State Attorney General Steve Marshall threatened to prosecute anyone helping residents get an out-of-state abortion. The threat extends to organizations, such as Yellowhammer Fund, that provide information about where to go and what to consider when seeking an abortion in a state where the procedure is legal.

Yellowhammer Fund and another organization filed suit, questioning the constitutionality of the state ban. Such prosecutions would violate Alabamians’ right to free speech, they argued.

Marshall “has threatened to criminalize in a way calculated to chill the speech, expressive conduct, and association of helpers, and to isolate pregnant people — a known tactic of abusers — to make it more difficult for them to travel and access needed medical care,” lawyers for the case explained in their initial complaint .

Marshall moved to dismiss the lawsuit, arguing the state could prosecute people using its anti-conspiracy laws . But earlier this month a federal judge ruled the lawsuit can proceed.

Many of the reproductive rights organizations we spoke to across the South said they’ve also struggled with what information they can legally share. Most lawyers won’t give them guidance, one group told us, saying the laws are too untested and too risky.

Many of the recent state laws take aim at people helping someone seeking an abortion or those looking to leave a state where abortion is illegal. Several states have focused on aid to minors.

Take, for example, a soon-to-be-enacted law in Tennessee that would punish adults for taking minors across state lines to end a pregnancy. A law in Idaho that did the same has been temporarily put on hold by a federal court. These laws are copycats of Texas’ S.B. 8, which allows anyone to sue people aiding or abetting an abortion.

In her ruling blocking the Idaho law from taking effect, U.S. District Magistrate Debora K. Grasham wrote that the case was about much more than abortion. “Namely, long-standing and well recognized fundamental rights of freedom of speech, expression, due process, and parental rights,” she wrote. “These are not competing rights, nor are they at odds.”

Challenging these laws legally is complex because there is limited legal precedent. Last year, the Department of Justice sought to clarify the constitutionality of the travel bans. “The right to travel from one state to another is firmly embedded in the Supreme Court’s jurisprudence and the Constitution,” the department noted.

Even before the Dobbs decision, labor and delivery wards in rural hospitals were shutting down , citing costs and financial uncertainty. By 2020, half of rural community hospitals stopped providing obstetrics care, according to the American Hospital Association. About 60 million , or 1 in 5, Americans live in rural areas.

Adding to the strain, rural hospitals are also experiencing a “brain drain.” Some doctors, wary of restrictive abortion laws, are leaving in droves . That has created maternity care deserts — where access to reproductive health care, including abortions, is nearly impossible. Women in these regions often have to travel hundreds of miles to find care , if they can afford to do so at all.

For people in states with abortion restrictions, and where health care is scarce, access to telehealth medicine is also up for legal debate.

In Ohio , the ACLU and Planned Parenthood are suing the state Department of Health because of laws that make it hard to get abortion medications using telehealth services. A court there previously recognized telehealth medication abortion services as a safe and effective option.

Now, the fight has grown bigger as the ACLU and Planned Parenthood challenge more Ohio laws, including those that prevent certain health care professionals, like nurse practitioners, from providing medication abortions.

The case extends beyond Ohio; it shows how people in rural areas, already facing limited health care, are hit hardest by these restrictions. This is even more true for low-income women, who are six times more likely to have an abortion and twice as likely to lack health insurance compared to higher-income women, per a Guttmacher Institute study .

“So many people across the country had questions,” said Clara Spera, senior counsel at the National Women’s Law Center, where she helps lead the Abortion Access Legal Defense Fund. “What can I do? What can I not do? What’s different today than it was yesterday? There was just a real need to navigate the chaos.”

The laws are not only changing rapidly — so that legal guidance that is relevant today could be out-of-date only weeks later — but these laws often change locally . For example, in Texas last year, Lubbock County passed an ordinance that would bar pregnant people from driving through Lubbock County to get an abortion in another state. Meanwhile, the city council of neighboring Amarillo has yet to approve the travel ban .

To solve this issue — and provide legal expertise to attorneys navigating the uncertainty — nonprofit legal organizations have banded together to form coalitions. One such example is the Abortion Defense Network , launched last year by several organizations, including the Lawyering Project, the ACLU and the National Women’s Law Center.

“The Abortion Defense Network leverages the resources and expertise of six leading reproductive rights organizations, and a number of very well respected nationwide law firms, to provide legal help, assistance and support to those who provide abortion care, those who help people obtain abortion care, or want to do one of those things,” Spera explained.

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The Safety and Quality of Abortion Care in the United States (2018)

Chapter: 5 conclusions, 5 conclusions.

This report provides a comprehensive review of the state of the science on the safety and quality of abortion services in the United States. The committee was charged with answering eight specific research questions. This chapter presents the committee’s conclusions by responding individually to each question. The research findings that are the basis for these conclusions are presented in the previous chapters. The committee was also asked to offer recommendations regarding the eight questions. However, the committee decided that its conclusions regarding the safety and quality of U.S. abortion care responded comprehensively to the scope of this study. Therefore, the committee does not offer recommendations for specific actions to be taken by policy makers, health care providers, and others.

1. What types of legal abortion services are available in the United States? What is the evidence regarding which services are appropriate under different clinical circumstances (e.g., based on patient medical conditions such as previous cesarean section, obesity, gestational age)?

Four legal abortion methods—medication, 1 aspiration, dilation and evacuation (D&E), and induction—are used in the United States. Length of gestation—measured as the amount of time since the first day of the last

___________________

1 The terms “medication abortion” and “medical abortion” are used interchangeably in the literature. This report uses “medication abortion” to describe the U.S. Food and Drug Administration (FDA)-approved prescription drug regimen used up to 10 weeks’ gestation.

menstrual period—is the primary factor in deciding what abortion procedure is the most appropriate. Both medication and aspiration abortions are used up to 10 weeks’ gestation. Aspiration procedures may be used up to 14 to 16 weeks’ gestation.

Mifepristone, sold under the brand name Mifeprex, is the only medication specifically approved by the FDA for use in medication abortion. The drug’s distribution has been restricted under the requirements of the FDA Risk Evaluation and Mitigation Strategy program since 2011—it may be dispensed only to patients in clinics, hospitals, or medical offices under the supervision of a certified prescriber. To become a certified prescriber, eligible clinicians must register with the drug’s distributor, Danco Laboratories, and meet certain requirements. Retail pharmacies are prohibited from distributing the drug.

When abortion by aspiration is no longer feasible, D&E and induction methods are used. D&E is the superior method; in comparison, inductions are more painful for women, take significantly more time, and are more costly. However, D&Es are not always available to women. The procedure is illegal in Mississippi 2 and West Virginia 3 (both states allow exceptions in cases of life endangerment or severe physical health risk to the woman). Elsewhere, access to the procedure is limited because many obstetrician/gynecologists (OB/GYNs) and other physicians lack the requisite training to perform D&Es. Physicians’ access to D&E training is very limited or nonexistent in many areas of the country.

Few women are medically ineligible for abortion. There are, however, specific contraindications to using mifepristone for a medication abortion or induction. The drug should not be used for women with confirmed or suspected ectopic pregnancy or undiagnosed adnexal mass; an intrauterine device in place; chronic adrenal failure; concurrent long-term systemic corticosteroid therapy; hemorrhagic disorders or concurrent anticoagulant therapy; allergy to mifepristone, misoprostol, or other prostaglandins; or inherited porphyrias.

Obesity is not a risk factor for women who undergo medication or aspiration abortions (including with the use of moderate intravenous sedation). Research on the association between obesity and complications during a D&E abortion is less certain—particularly for women with Class III obesity (body mass index ≥40) after 14 weeks’ gestation.

A history of a prior cesarean delivery is not a risk factor for women undergoing medication or aspiration abortions, but it may be associated

2 Mississippi Unborn Child Protection from Dismemberment Abortion Act, Mississippi HB 519, Reg. Sess. 2015–2016 (2016).

3 Unborn Child Protection from Dismemberment Abortion Act, West Virginia SB 10, Reg. Sess. 2015–2016 (2016).

with an increased risk of complications during D&E abortions, particularly for women with multiple cesarean deliveries. Because induction abortions are so rare, it is difficult to determine definitively whether a prior cesarean delivery increases the risk of complications. The available research suggests no association.

2. What is the evidence on the physical and mental health risks of these different abortion interventions?

Abortion has been investigated for its potential long-term effects on future childbearing and pregnancy outcomes, risk of breast cancer, mental health disorders, and premature death. The committee found that much of the published literature on these topics does not meet scientific standards for rigorous, unbiased research. Reliable research uses documented records of a prior abortion, analyzes comparable study and control groups, and controls for confounding variables shown to affect the outcome of interest.

Physical health effects The committee identified high-quality research on numerous outcomes of interest and concludes that having an abortion does not increase a woman’s risk of secondary infertility, pregnancy-related hypertensive disorders, abnormal placentation (after a D&E abortion), preterm birth, or breast cancer. Although rare, the risk of very preterm birth (<28 weeks’ gestation) in a woman’s first birth was found to be associated with having two or more prior aspiration abortions compared with first births among women with no abortion history; the risk appears to be associated with the number of prior abortions. Preterm birth is associated with pregnancy spacing after an abortion: it is more likely if the interval between abortion and conception is less than 6 months (this is also true of pregnancy spacing in general). The committee did not find well-designed research on abortion’s association with future ectopic pregnancy, miscarriage or stillbirth, or long-term mortality. Findings on hemorrhage during a subsequent pregnancy are inconclusive.

Mental health effects The committee identified a wide array of research on whether abortion increases women’s risk of depression, anxiety, and/or posttraumatic stress disorder and concludes that having an abortion does not increase a woman’s risk of these mental health disorders.

3. What is the evidence on the safety and quality of medical and surgical abortion care?

Safety The clinical evidence clearly shows that legal abortions in the United States—whether by medication, aspiration, D&E, or induction—are

safe and effective. Serious complications are rare. But the risk of a serious complication increases with weeks’ gestation. As the number of weeks increases, the invasiveness of the required procedure and the need for deeper levels of sedation also increase.

Quality Health care quality is a multidimensional concept. Six attributes of health care quality—safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity—were central to the committee’s review of the quality of abortion care. Table 5-1 details the committee’s conclusions regarding each of these quality attributes. Overall, the committee concludes that the quality of abortion care depends to a great extent on where women live. In many parts of the country, state regulations have created barriers to optimizing each dimension of quality care. The quality of care is optimal when the care is based on current evidence and when trained clinicians are available to provide abortion services.

4. What is the evidence on the minimum characteristics of clinical facilities necessary to effectively and safely provide the different types of abortion interventions?

Most abortions can be provided safely in office-based settings. No special equipment or emergency arrangements are required for medication abortions. For other abortion methods, the minimum facility characteristics depend on the level of sedation that is used. Aspiration abortions are performed safely in office and clinic settings. If moderate sedation is used, the facility should have emergency resuscitation equipment and an emergency transfer plan, as well as equipment to monitor oxygen saturation, heart rate, and blood pressure. For D&Es that involve deep sedation or general anesthesia, the facility should be similarly equipped and also have equipment to provide general anesthesia and monitor ventilation.

Women with severe systemic disease require special measures if they desire or need deep sedation or general anesthesia. These women require further clinical assessment and should have their abortion in an accredited ambulatory surgery center or hospital.

5. What is the evidence on what clinical skills are necessary for health care providers to safely perform the various components of abortion care, including pregnancy determination, counseling, gestational age assessment, medication dispensing, procedure performance, patient monitoring, and follow-up assessment and care?

Required skills All abortion procedures require competent providers skilled in patient preparation (education, counseling, and informed consent);

TABLE 5-1 Does Abortion Care in the United States Meet the Six Attributes of Quality Health Care?

a These attributes of quality health care were first proposed by the Institute of Medicine’s Committee on Quality of Health Care in America in the 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century.

b Elsewhere in this report, effectiveness refers to the successful completion of the abortion without the need for a follow-up aspiration.

clinical assessment (confirming intrauterine pregnancy, determining gestation, taking a relevant medical history, and physical examination); pain management; identification and management of expected side effects and serious complications; and contraceptive counseling and provision. To provide medication abortions, the clinician should be skilled in all these areas. To provide aspiration abortions, the clinician should also be skilled in the technical aspects of an aspiration procedure. To provide D&E abortions, the clinician needs the relevant surgical expertise and sufficient caseload to maintain the requisite surgical skills. To provide induction abortions, the clinician requires the skills needed for managing labor and delivery.

Clinicians that have the necessary competencies Both trained physicians (OB/GYNs, family medicine physicians, and other physicians) and advanced practice clinicians (APCs) (physician assistants, certified nurse-midwives, and nurse practitioners) can provide medication and aspiration abortions safely and effectively. OB/GYNs, family medicine physicians, and other physicians with appropriate training and experience can perform D&E abortions. Induction abortions can be provided by clinicians (OB/GYNs,

family medicine physicians, and certified nurse-midwives) with training in managing labor and delivery.

The extensive body of research documenting the safety of abortion care in the United States reflects the outcomes of abortions provided by thousands of individual clinicians. The use of sedation and anesthesia may require special expertise. If moderate sedation is used, it is essential to have a nurse or other qualified clinical staff—in addition to the person performing the abortion—available to monitor the patient, as is the case for any other medical procedure. Deep sedation and general anesthesia require the expertise of an anesthesiologist or certified registered nurse anesthetist to ensure patient safety.

6. What safeguards are necessary to manage medical emergencies arising from abortion interventions?

The key safeguards—for abortions and all outpatient procedures—are whether the facility has the appropriate equipment, personnel, and emergency transfer plan to address any complications that might occur. No special equipment or emergency arrangements are required for medication abortions; however, clinics should provide a 24-hour clinician-staffed telephone line and have a plan to provide emergency care to patients after hours. If moderate sedation is used during an aspiration abortion, the facility should have emergency resuscitation equipment and an emergency transfer plan, as well as equipment to monitor oxygen saturation, heart rate, and blood pressure. D&Es that involve deep sedation or general anesthesia should be provided in similarly equipped facilities that also have equipment to monitor ventilation.

The committee found no evidence indicating that clinicians that perform abortions require hospital privileges to ensure a safe outcome for the patient. Providers should, however, be able to provide or arrange for patient access or transfer to medical facilities equipped to provide blood transfusions, surgical intervention, and resuscitation, if necessary.

7. What is the evidence on the safe provision of pain management for abortion care?

Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended to reduce the discomfort of pain and cramping during a medication abortion. Some women still report high levels of pain, and researchers are exploring new ways to provide prophylactic pain management for medication abortion. The pharmaceutical options for pain management during aspiration, D&E, and induction abortions range from local anesthesia, to minimal sedation/anxiolysis, to moderate sedation/analgesia, to deep sedation/

analgesia, to general anesthesia. Along this continuum, the physiological effects of sedation have increasing clinical implications and, depending on the depth of sedation, may require special equipment and personnel to ensure the patient’s safety. The greatest risk of using sedative agents is respiratory depression. The vast majority of abortion patients are healthy and medically eligible for all levels of sedation in office-based settings. As noted above (see Questions 4 and 6), if sedation is used, the facility should be appropriately equipped and staffed.

8. What are the research gaps associated with the provision of safe, high-quality care from pre- to postabortion?

The committee’s overarching task was to assess the safety and quality of abortion care in the United States. As noted in the introduction to this chapter, the committee decided that its findings and conclusions fully respond to this charge. The committee concludes that legal abortions are safe and effective. Safety and quality are optimized when the abortion is performed as early in pregnancy as possible. Quality requires that care be respectful of individual patient preferences, needs, and values so that patient values guide all clinical decisions.

The committee did not identify gaps in research that raise concerns about these conclusions and does not offer recommendations for specific actions to be taken by policy makers, health care providers, and others.

The following are the committee’s observations about questions that merit further investigation.

Limitation of Mifepristone distribution As noted above, mifepristone, sold under the brand name Mifeprex, is the only medication approved by the FDA for use in medication abortion. Extensive clinical research has demonstrated its safety and effectiveness using the FDA-recommended regimen. Furthermore, few women have contraindications to medication abortion. Nevertheless, as noted earlier, the FDA REMS restricts the distribution of mifepristone. Research is needed on how the limited distribution of mifepristone under the REMS process impacts dimensions of quality, including timeliness, patient-centeredness, and equity. In addition, little is known about pharmacist and patient perspectives on pharmacy dispensing of mifepristone and the potential for direct-to-patient models through telemedicine.

Pain management There is insufficient evidence to identify the optimal approach to minimizing the pain women experience during an aspiration procedure without sedation. Paracervical blocks are effective in decreasing procedural pain, but the administration of the block itself is painful, and

even with the block, women report experiencing moderate to significant pain. More research is needed to learn how best to reduce the pain women experience during abortion procedures.

Research on prophylactic pain management for women undergoing medication abortions is also needed. Although NSAIDs reduce the pain of cramping, women still report high levels of pain.

Availability of providers APCs can provide medication and aspiration abortions safely and effectively, but the committee did not find research assessing whether APCs can also be trained to perform D&Es.

Addressing the needs of women of lower income Women who have abortions are disproportionately poor and at risk for interpersonal and other types of violence. Yet little is known about the extent to which they receive needed social and psychological supports when seeking abortion care or how best to meet those needs. More research is needed to assess the need for support services and to define best clinical practice for providing those services.

Abortion is a legal medical procedure that has been provided to millions of American women. Since the Institute of Medicine first reviewed the health implications of national legalized abortion in 1975, there has been a plethora of related scientific research, including well-designed randomized clinical trials, systematic reviews, and epidemiological studies examining abortion care. This research has focused on examining the relative safety of abortion methods and the appropriateness of methods for different clinical circumstances. With this growing body of research, earlier abortion methods have been refined, discontinued, and new approaches have been developed.

The Safety and Quality of Abortion Care in the United States offers a comprehensive review of the current state of the science related to the provision of safe, high-quality abortion services in the United States. This report considers 8 research questions and presents conclusions, including gaps in research.

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The abortion debate is headed to the ballot box. Here's where voters will decide

• 2024 elections
• Abortion policy
• election 2024
• abortion access
• abortion ban
• ballot measure
• Abortion rights

South Dakota

• Home Page Top Stories

Since the U.S. Supreme Court overturned the federal right to abortion in 2022, states have had the final say on abortion rights. And now abortion-rights supporters across the United States seek to maneuver around Republican-led legislatures and go straight to voters.

This year, voters in up to 10 states could face abortion-rights amendments. Several states that outlaw most abortions could see those bans reversed if the ballot measures pass: Arkansas, Florida, Missouri, Nebraska and South Dakota.

Voters have already backed abortion rights at the ballot box in at least six states since the reversal of Roe v. Wade, including conservative-leaning Kentucky and Kansas.

Getting amendments on the ballot takes legwork, gathering tens or hundreds of thousands of signatures. Then, there could be court challenges.

The statewide up-or-down votes could motivate more voters to the polls, shaping the race for president, the battle for which party controls Congress and, in Arizona for example, which party runs the legislature.

NPR is tracking the amendment campaigns taking place across the country and will update the developments through November.

Colorado doesn’t restrict abortion at any time during pregnancy. That has led to the state becoming a regional hub for abortion access.

Coloradans did use the ballot to impose one limit in 1984, when they passed a constitutional amendment banning public funding for abortions.

Now, abortion-rights advocates have gotten a proposed amendment on the ballot to guarantee a right to abortion in the state constitution, which would prohibit any laws impeding that right.

The amendment would also remove that current constitutional ban against public funding for abortions — in Medicaid or state employee health plans. The initiative is similar to the state law passed in 2022. It would need 55% of the vote to get into the constitution.

For more, visit Colorado Public Radio .

— Bente Birkeland

Florida is the most populous state where abortion-rights advocates already have enough signatures and the official approval to put a question on the ballot this November. The state will ask voters whether to protect abortion in the state constitution up to the point of fetal viability — usually about 24 weeks of pregnancy — or, in all cases, to protect the life of the pregnant person.

The state’s six-week abortion ban , which has exceptions for rare circumstances, went into effect in May, further energizing voters on both sides of the issue to come out in November. And Florida requires 60% approval to pass the amendment, a level no other state has met since Roe v. Wade ’s reversal in 2022.

For more, visit WFSU .

— Regan McCarthy

Since taking office in 2023, Democratic Gov. Wes Moore has billed Maryland as a “sanctuary state” for reproductive rights. Moore’s administration stockpiled mifepristone — one of two drugs used in medication abortion — when federal court cases threatened the drug’s future, and it has put money into training more health care workers in reproductive care.

In November, Maryland voters will decide on an amendment that would enshrine reproductive rights in the state constitution. The amendment would protect “the ability to make and effectuate decisions to prevent, continue, or end one’s own pregnancy.” The referendum needs a simple majority to pass and is expected to meet that threshold.

Meanwhile, during the legislative session this year, Maryland lawmakers put money aside to help facilities that provide abortions improve security.

For more, visit WYPR .

— Scott Maucione

A group known as Dakotans for Health has submitted 55,000 signatures of voters asking for a question on the ballot that could enshrine abortion protections into the state constitution.

After the Dobbs decision ended the federal right to abortion, an already-in-place South Dakota law went into effect banning all abortions except to save the life of the mother — though critics say that this exception remains undefined.

The proposed amendment would allow abortions in the first trimester, add more restrictions in the second and prohibit abortions in the third trimester, with some exceptions.

Some abortion-rights groups say the amendment is too weak, while an anti-abortion group has called it “extreme.”

For more, visit South Dakota Public Broadcasting .

— Lee Strubinger

Arizona took a confusing turn this spring when a court ruled that a near-total ban on abortions, from a law that had been dormant for decades, could be enforced again. But the Legislature and courts have nullified that law, and the state’s ban on abortions after the 15th week of pregnancy is still in effect.

Now a proposed constitutional amendment would protect abortion rights until the point of fetal viability, or around 24 weeks. The ballot measure would also allow exceptions later in pregnancy when health risks are involved.

Organizers need to gather 383,923 signatures ahead of a July 3 deadline. They say they've already collected more than 500,000.

For more, visit KJZZ .

 — Katherine Davis-Young

Arkansas' ban on abortion is one of the most restrictive in the country, making an exception only to save the life of the mother. One group, Arkansans for Limited Government, is working to legalize abortion, but that’s a tall order in a state with many more registered Republicans than Democrats.

The group needs to collect at least 90,000 signatures by July 5. If the proposed amendment makes it onto the ballot and more than half of voters approve it, it wouldn’t make abortion legal in every case: The amendment raises the cutoff date to the 18th week of pregnancy.

Some abortion-rights groups, like Planned Parenthood, have backed off supporting the effort, saying it doesn’t go far enough to make abortion more accessible.

For more, visit Little Rock Public Radio .

— Josie Lenora

Missouri’s abortion-rights advocates have collected far more than enough signatures to place a constitutional amendment protecting abortion on the 2024 ballot. The measure would undo the state’s law banning all abortions, except to save the life of the pregnant person, and replace it with language making abortion legal up to the point of fetal viability.

The ballot initiative is receiving significant financial support from out-of-state groups, as well as more volunteer support than any other proposed amendment in the state.

To curb the amendment effort, Republican lawmakers tried to get a separate ballot measure to voters that would have made it more difficult to amend the state constitution. However, using the longest filibuster in state history , Democrats overpowered that attempt.

For more, visit St. Louis Public Radio .

— Jason Rosenbaum

The proposed ballot measure in Montana would add language protecting abortion access up until fetal viability — around 24 weeks of pregnancy — to the state constitution during a referendum in November. The initiative’s supporters face a June 21 deadline to collect 60,000 signatures from across the state to qualify for the ballot.

Abortion remains legal and accessible in the state. That’s even though Republican lawmakers have passed several restrictive abortion laws at the request of GOP Gov. Greg Gianforte in recent years. Abortion rights are protected under state judicial precedent.

In 1999, the Montana Supreme Court ruled that the state’s constitutional right to privacy protects access to abortion until the point of viability. The court has reaffirmed the ruling in recent years.

For more, visit Montana Public Radio .

— Shaylee Ragar

In 2023, the Legislature banned abortion after 12 weeks of pregnancy, down from 20 weeks previously. There are exceptions for rape, incest and the life of the pregnant patient. Medicaid and private health insurance plans are banned from covering most abortions.

Now two competing amendment drives are aiming for November. Abortion-rights groups propose asking voters whether they want to guarantee abortion access until fetal viability — usually around 24 weeks of pregnancy — and when needed to “protect the life or health of the pregnant patient.” Meanwhile, another group has started a petition drive to place the state's 12-week ban into the constitution.

They have until July 3 to gather just under 123,000 signatures. If they both make it onto the ballot and pass, whichever initiative gets more supportive votes will go into the constitution.

For more, visit Nebraska Public Media .

— Elizabeth Rembert

Under a state law approved by voters in 1990, abortion is legal in Nevada within the first 24 weeks of pregnancy. Abortion-rights advocates want to put that in the state constitution with an amendment guaranteeing abortion access up until fetal viability, which is usually about 24 weeks.

Supporters need to gather 102,000 signatures by a June deadline. Nevadans for Reproductive Freedom says it has already gathered 200,000. For the amendment to take effect, voters would have to approve the initiative twice, once in 2024 and again in 2026.

Polling has consistently shown that roughly two-thirds of Nevadans believe access to abortion should be legal in “all or most cases.”

Nevada Democrats believe protecting abortion access mobilized voters during the 2022 midterm elections, and they plan to make the issue central to their cause this year, with a U.S. Senate seat and congressional seats at stake.

For more, visit Nevada Public Radio .

— Paul Boger

NPR’s Ryland Barton, Larry Kaplow , Barbara Sprunt and Acacia Squires edited this project. Design and development by Hilary Fung . Copy editing by Preeti Aroon.

Support quality journalism, like the story above, with your gift right now.

Elizabeth Warren warns of efforts to limit abortion in states that have protected access

B OSTON (AP) — U.S. Sen. Elizabeth Warren on Wednesday warned about additional attempts to curb access to abortion — efforts that she said could ultimately target states like Massachusetts that have worked to protect abortion rights.

Warren held a field hearing in Boston along with fellow Democratic Sen. Edward Markey, also of Massachusetts, to highlight some of those concerns following the decision by the U.S. Supreme Court in 2022 to overturn Roe v. Wade.

Even in states that have tried to enshrine abortion rights — in 2022, Massachusetts lawmakers passed a shield law designed to protect abortion providers from out-of-state legal actions when they provide care to people living in states with abortion bans — further restrictions loom, Warren said.

“I’m furious that millions of women have lost fundamental rights. I’m furious that their freedom to make their own decisions has been taken away by a small number of extremists,” Warren said, adding that she's even more concerned about what could happen if Donald Trump wins back the White House.

Markey said he's also concerned about the direction of the nation's high court.

“The Supreme Court has two more cases before it that could imperil abortion care nationwide including here in Massachusetts," he said, “We are in a multi-generational war.”

One of those Supreme Court cases involves a challenge from conservative groups seeking to reverse the federal approval of the drug mifepristone — a medication used in the most common method of abortion in the United States — or roll back policies that have made it easier to obtain.

Massachusetts Attorney General Andrea Campbell is among the critics who say that decision could end up making it harder for people in Massachusetts, where abortion is legal, to get their hands on the drug.

Not everyone in Massachusetts is opposed to increased restrictions on abortion.

Myrna Maloney Flynn, president of Massachusetts Citizens for Life, said elected officials opposed to limiting mail-order abortion medicine fail to consider potential health problems women could face by removing a physician from the equation.

She also faulted political figures like Warren and Markey for their criticism of pregnancy resource centers, which she described as community nonprofits that exist to offer “safe, cost-free, compassionate choices women deserve.”

Critics say the centers can be confusing and are designed to persuade women not to get abortions.

“It might come as a shock to Sens. Warren, Markey and Attorney General Campbell, but not every woman experiencing an unexpected pregnancy wants an abortion,” Flynn said. “Any serious roundtable discussion would consider such women and include ideas for serving them, too.”

Warren also pointed to efforts around the country that would expand legal and constitutional protections for embryos and fetuses, a long-time goal of the anti-abortion movement.

She said some abortion opponents, buoyed by the defeat of Roe v. Wade, are hoping to expand the protections nationally, including into states that have protected abortion rights.

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Guest Essay

Melinda French Gates: The Enemies of Progress Play Offense. I Want to Help Even the Match.

By Melinda French Gates

Ms. French Gates is a philanthropist and the founder of the charitable organization Pivotal.

Many years ago, I received this piece of advice: “Set your own agenda, or someone else will set it for you.” I’ve carried those words with me ever since.

That’s why, next week, I will leave the Bill & Melinda Gates Foundation , of which I was a co-founder almost 25 years ago, to open a new chapter in my philanthropy. To begin, I am announcing $1 billion in new spending over the next two years for people and organizations working on behalf of women and families around the world, including on reproductive rights in the United States.

In nearly 20 years as an advocate for women and girls, I have learned that there will always be people who say it’s not the right time to talk about gender equality. Not if you want to be relevant. Not if you want to be effective with world leaders (most of them men). The second the global agenda gets crowded, women and girls fall off.

It’s frustrating and shortsighted. Decades of research on economics , well-being and governance make it clear that investing in women and girls benefits everyone. We know that economies with women’s full participation have more room to grow. That women’s political participation is associated with decreased corruption. That peace agreements are more durable when women are involved in writing them. That reducing the time women spend in poor health could add as much as $1 trillion to the global economy by 2040.

And yet, around the world, women are seeing a tremendous upsurge in political violence and other threats to their safety, in conflict zones where rape is used as a tool of war, in Afghanistan where the Taliban takeover has erased 20 years of progress for women and girls, in many low-income countries where the number of acutely malnourished pregnant and breastfeeding women is soaring.

In the United States, maternal mortality rates continue to be unconscionable , with Black and Native American mothers at highest risk. Women in 14 states have lost the right to terminate a pregnancy under almost any circumstances. We remain the only advanced economy without any form of national paid family leave. And the number of teenage girls experiencing suicidal thoughts and persistent feelings of sadness and hopelessness is at a decade high.

Despite the pressing need, only about 2 percent of charitable giving in the United States goes to organizations focused on women and girls, and only about half a percentage point goes to organizations focused on women of color specifically.

When we allow this cause to go so chronically underfunded, we all pay the cost. As shocking as it is to contemplate, my 1-year-old granddaughter may grow up with fewer rights than I had.

Over the past few weeks, as part of the $1 billion in new funding I’m committing to these efforts, I have begun directing new grants through my organization, Pivotal, to groups working in the United States to protect the rights of women and advance their power and influence. These include the National Women’s Law Center, the National Domestic Workers Alliance and the Center for Reproductive Rights.

While I have long focused on improving contraceptive access overseas, in the post-Dobbs era, I now feel compelled to support reproductive rights here at home. For too long, a lack of money has forced organizations fighting for women's rights into a defensive posture while the enemies of progress play offense. I want to help even the match.

I’m also experimenting with novel tactics to bring a wider range of perspectives into philanthropy. Recently, I offered 12 people whose work I admire their own $20 million grant-making fund to distribute as he or she sees fit. That group — which includes the former prime minister of New Zealand, Jacinda Ardern, the athlete and maternal-health advocate Allyson Felix, and an Afghan champion of girls’ education, Shabana Basij-Rasikh — represents a wide range of expertise and experience. I’m eager to see the landscape of funding opportunities through their eyes, and the results their approaches unlock.

In the fall, I will introduce a $250 million initiative focused on improving the mental and physical health of women and girls globally. By issuing an open call to grass-roots organizations beyond the reach of major funders, I hope to lift up groups with personal connections to the issues they work on. People on the front lines should get the attention and investment they deserve, including from me.

As a young woman, I could never have imagined that one day I would be part of an effort like this. Because I have been given this extraordinary opportunity, I am determined to do everything I can to seize it and to set an agenda that helps other women and girls set theirs, too.

Melinda French Gates is a philanthropist and the founder of Pivotal, a charitable, investment and advocacy organization.

Source photographs by Bryan Bedder, filipfoto, and Westend61, via Getty Images.

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