Abortion is at a historic low in the United States. Two factors are likely responsible for the drop in abortion rates: restrictions on abortion, and better access to birth control. Birth control deserves more of the credit, as we’ll see, but it’s impossible to totally disentangle the two. What’s more interesting, from a public health perspective, is what other outcomes we get from these two types of policies.
There’s no good evidence that laws prevent abortions, just that they interfere with the ability to get a safe and timely abortion. In fact, barriers to abortion end up pushing abortions later in pregnancy.
More people are using birth control–and more are using better methods. Some of this increase in contraception comes from awareness, but policy also makes a difference. Guttmacher estimates that without Title X, which provides funding for family planning, the rates of both abortions and unplanned birth in 2014 would have both been 33% higher. Also important: the Supreme Court knocking down “targeted (state) regulation of abortion providers” (aka TRAP laws) and, in 2013, the Affordable Care Act’s contraceptive mandate going into effect, requiring insurers to cover most methods of birth control, including the more expensive, and more effective ones such as IUDs.
Preventing abortions this way, by preventing pregnancies, is a public health win. It means people avoid the health risks to parent and child of an unintended pregnancy, while avoiding the often difficult decision of whether to go forward with an abortion. Abortion restrictions, on the other hand, paint a very different picture for reproductive health.
Following the evidence on preventing abortion
If you believe that reducing abortion is a worthwhile goal, as activists and policy makers on both sides of the questions tend to agree, the next question is how best to do that. Evidence supports the idea that, compared to restricting access to abortion, improving access to birth control is more effective and provides for better health of women in the population.
Abortion rates peaked around 1980, less than a decade after Roe v. Wade made the procedure legal throughout the US, at 29.3 abortions per 1,000 women aged 15-44. It’s been steadily falling ever since, and the rate stands at 14.6 abortions per 1,000 in the year with the most recent data, 2014.
Those numbers come from a Jan 16, 2017 Guttmacher Institute study and they agree with the trend in another recent study (Dec 9, 2016) from the Centers for Disease Control and Prevention (CDC), which put the number at 12.3 per 1,000 as of 2013. The two studies use slightly different methodology, and you can read more about the differences here. For example, CDC collects data from each state, but the states each collect and report it differently. Guttmacher actually tracks down abortion providers to survey them, but they can’t guarantee answers from everybody, and they use state data to fill in the blanks. Still, their data is pretty comprehensive, and both studies paint a clear picture of what must be a real decrease.
Better Access to Birth Control ‘Is Critical’
“From a public health standpoint, maintaining and even increasing access to the full range of reproductive health care services and family planning is critical,” Jenna Jerman, research associate at Guttmacher and one of the authors of the January report, says. She didn’t want to state categorically that access to birth control is the only important factor in the decrease, since it’s hard to disentangle from abortion laws and other factors. But it’s clear that contraception plays a very important role.
If women across the country were simply choosing to continue unwanted pregnancies, she pointed out, we would see the birth rate go up at the same time abortions go down. But that’s not what happened. There are fewer abortions (relative to the population of women) and fewer births. That means there just aren’t as many pregnancies in the first place.
Unintended pregnancies make up about half of all pregnancies in the US, but that rate is falling, too. Unintended pregnancies peaked in 2008 for low income women and then dropped sharply, while the rate for all women has been slowly declining. Meanwhile, births to teens are at a historic low as of 2014: just 24 births per 1000 girls aged 15-19. Teens are having less sex than in previous decades, but are also using more contraception.
Besides affecting the abortion rate, access to birth control has huge consequences for women and their families–in other words, just about everyone. The benefits are well established. Here are a few of them:
- Access to the Pill has been linked to greater education and income for women, apparently because it is easier for them to stay in school or the work force. The Pill also may have made it more worthwhile for women to enter careers.
- Unintended pregnancies get less prenatal care, and mothers are less likely to breastfeed. In some studies, the children from unintended pregnancies are more likely to be premature or low birth weight.
- Babies born soon after a sibling (with an inter-pregnancy interval of six months or less) have a greater risk of preterm birth, low birth weight, and being small for gestational age.
Unintended pregnancies are hardest on lower income women: pregnancy is inconvenient and expensive in ways that can make it hard to work–whether from health problems or practical issues like needing to take time off from work for prenatal visits. (Raising a child, of course, is tougher still.) Poorer women are more likely to have an unintended pregnancy than their richer counterparts, even though women across income levels report similar intentions to get pregnant.
More people are using birth control–and more are using better methods, like the IUDs and implants known together as long acting reversible contraception (LARC). The rate of LARC use shot up fivefold between 2011 and 2013, now standing a little over 7%. Meanwhile, in the last few decades, use of the Pill has stayed steady while the number of women reporting that they have used other hormonal methods, condoms, and withdrawal have all increased.
Some of the increase in contraception comes from awareness, but policy also makes a difference. Guttmacher estimates that without Title X, which provides funding for family planning, the rates of both abortions and unplanned birth in 2014 would have both been 33% higher.
Preventing abortions this way, by preventing pregnancies, is a public health win. It means people avoid the downsides of pregnancy–including risks of complications, and the very real economic consequences of the way a pregnancy can mess with your life–while also never having to deal with the hassle and the often difficult decision of deciding whether to go forward with an abortion. Abortion restrictions, on the other hand, paint a very different picture for reproductive health.
Abortion Restrictions Endanger Women
Much policy aimed at reducing abortion targets abortion itself, with varying results. States passed 231 laws restricting abortion between 2010-2014, and only four laws that increased access to abortions.
Those restrictions include the TRAP laws, which put more stringent or even onerous requirements on providers and clinics that provide abortions, than similar providers and clinics that offer other services. Colonoscopies, for example, are riskier than abortions. Only abortion was singled out in laws like Texas’s as needing to be performed in a surgical center by a physician with admitting privileges at a nearby hospital. Meanwhile, midwives faced no such restriction for attending births, even though childbirth is far more dangerous than abortion.
It was only in 2016 that the Supreme Court ruled, in Whole Women’s Health vs. Hellerstedt, that these restrictions are unconstitutional. Part of the logic was that the laws had clearly resulted in the closing of clinics, and thus a hardship on women who had to travel long distances, even out of state, to obtain an abortion. Here’s Justice Kagan in the questioning:
JUSTICE KAGAN: And is it right that in the two week period that the ASC requirement was in effect, that over a dozen facilities shut their doors, and then when that was stayed, when that was lifted, they reopened again immediately; is that right? It’s almost like the perfect controlled experiment as to the effect of the law, isn’t it? It’s like you put the law into effect, 12 clinics closed. You take the law out of effect, they reopen.
The Guttmacher study on abortion rates tried to break down the data state-by-state to compare abortion restrictions with how many abortions occur in each state, but women in restrictive states may cross state lines for an abortion, confusing those numbers.
Poverty and unintended pregnancy
The burden of travel falls heaviest on lower income women and more restrictions make things even harder: fewer clinics mean more travel time, waiting periods mean a person has to make the trip twice or make a multi-day trip. This all requires the ability to take time off from work and to pay for transportation. If a person needs time to save up the money, that could push her abortion into a later stage of pregnancy.
Another new Guttmacher study, published Jan 27, 2017 in PLOS ONE, confirms that barriers to abortion end up pushing abortions later in pregnancy. The authors looked at patients who obtain their abortions either by six weeks of pregnancy, or who obtain them in the second trimester.
People were less likely to get an early abortion if they were aged 20 or younger, if they needed financial assistance to pay for the procedure, and if they lived in a state that required in-person counseling 24 to 72 hours beforehand. Those who got their abortions later were more likely to be Black, have less than a high school degree, need financial assistance, and live more than 25 miles away from the clinic.
Not only is there no good evidence that laws prevent abortions, just that they interfere with the ability to get a safe and timely abortion, the states where people are most likely to google self-induced abortions are also the states that have the strictest abortion laws.
Globally, countries with strict abortion laws have about the same abortion rate as countries with legal abortion. Illegal abortion is more likely to be unsafe, of course, so these laws endanger women with little to no effect on the number of abortions.
A Pivotal Moment
Two things have happened since 2014, the year with the most recent data. First, the Supreme Court ruled against TRAP laws in 2016, and we should expect to see clinics reopening, or at least fewer clinics closing because of these laws. (Unless, of course, a new generation of onerous laws manages to replace them.)
Secondly, in 2013 the Affordable Care Act’s contraceptive mandate went into effect, requiring insurers to cover most methods of birth control, including LARCs. IUDs that cost $1000 without insurance are prohibitively expensive for many people who want them–even though they are extremely effective and are cheaper than many other options once you average out costs over the life of the device.
Colorado’s IUD program caused the teen birth rate and abortion rate to both drop by around 40 percent, but lawmakers declined to fund it because they were worried it would encourage teens to have sex. This is obviously backward if your goals in preventing teen sex include preventing teen births and abortions, but politics is apparently more important.
A similarly misguided policy is now in place globally. The new President reinstated the “global gag rule” that bans any US-funded health care services from even discussing abortions with patients. This rule will harm women worldwide. A previous version of the rule, more limited in scope, actually increased abortion rates in sub-Saharan Africa, and even prevented women from accessing birth control
Future studies will tell us what happens next: whether Texas clinics will reopen, providing more access to abortions in Texas and in other places where clinics had to close under the law; and whether better access to contraception will help the unintended pregnancy rate fall even further.
But the Affordable Care Act and its contraceptive mandate are in jeopardy, and the global gag rule is in effect once again. The current US government is busy proposing and passing bills aimed at restricting abortion further, even though most Americans believe abortion should be legal in at least some cases.
Will the abortion rate continue to drop? We’ll have to wait and see.