Betwixt 2011 and 2017, the U.Southward. abortion landscape inverse significantly. Equally documented by the Guttmacher Institute's periodic abortion provider census, all the main measures of abortion declined, including the number of abortions, the abortion rate and the abortion ratio.i,2 The declines are part of trends that go back decades.

  • The number of abortions fell by 196,000—a 19% decline from 1,058,000 abortions in 2011 to 862,000 abortions in 2017.1,2
  • The abortion rate (the number of abortions per 1,000 women aged fifteen–44) barbarous by xx%, from xvi.9 in 2011 to xiii.5 in 2017.
  • The abortion ratio (the number of abortions per 100 pregnancies ending in either ballgame or live birth) fell 13%, from 21.two in 2011 to 18.4 in 2017.

The question of what is behind these trends has important policy implications, and the 2011–2017 period warrants particular attention because it coincided with an unprecedented wave of new abortion restrictions. During that timeframe, 32 states enacted a total of 394 new restrictions,3,four with the vast majority of these measures having taken effect (that is, they were not struck down by a court).

Even so, declines in abortion practice non serve patients if the reason behind the decline is interference with individuals' conclusion making about their reproductive options. Reducing abortion by shuttering clinics and erecting logistical barriers for patients is in directly conflict with sound public health policy, and the debate should not exist framed based on the false premise that any reduction in abortion is a good outcome. Rather, it is critical to remember that timely and affordable access to abortion should exist available to anyone who wants and needs information technology. And it is equally important to recognize that obstructing or denying care in the name of reducing ballgame is a violation of individuals' dignity, bodily autonomy and reproductive freedom.

With the available evidence, information technology is impossible to pinpoint exactly which factors drove contempo declines, and to what degree. However, previous Guttmacher analyses take documented that ballgame restrictions, while incredibly harmful at an individual level, were not the master driver of national declines in the abortion rate in the 2008–20115 or 2011–20146 fourth dimension periods. Much the same appears to hold true for the 2011–2017 timeframe, as detailed below. Rather, the refuse in abortions appears to be role of a broader decline in pregnancies, as evidenced by fewer births over the aforementioned catamenia.

Ballgame Restrictions

Abortion restrictions target either individuals' power to admission the process (such as by imposing coercive waiting periods and counseling requirements) or providers' power to offer information technology (such as through unnecessary and intentionally burdensome regulations). Any ane of these restrictions could event in some people being forced to continue pregnancies they were seeking to end; this could, in theory, lower the abortion rate.

Restrictions and Clinic Closures

Because 95% of all abortions reported in 2017 were provided at clinics—either those specializing in abortion or those where abortion is part of a broader set of medical services—changes in the number of clinics is a practiced proxy for changes in abortion admission overall.1 Between 2011 and 2017, the number of clinics providing abortion in the United states of america declined by less than 4%, from 839 to 808.ane,2

However, this seemingly modest change masks pregnant differences by region of the country: Between 2011 and 2017, the South had a net turn down of fifty clinics, with 25 in Texas solitary, and the Midwest had a net refuse of 33 clinics, including ix each in Iowa, Michigan and Ohio.ane,two The W lost a net of seven clinics. By contrast, the Northeast added a internet 59 clinics, generally in New Jersey and New York.

The S and the Midwest also had the largest share of new abortion restrictions during that period, with nearly 86% of total restrictions nationwide enacted in those ii regions. It seems clear that these like geographic patterns are not a coincidence (run across figure 1).1,two In particular, when researchers wait at the impact of abortion restrictions on clinic numbers, one blazon of restriction stands out: TRAP (targeted regulation of abortion providers) laws and administrative regulations did reduce the number of clinics providing abortion between 2011 and 2014.6,7 And although few clinic regulations were enacted betwixt 2014 and 2017, enforcement of existing regulations played a role in the closure of some clinics during that menstruation.viii

Between 2011 and 2017, TRAP regulations resulted in the closure of roughly half of all clinics that provided abortion in 4 states—Arizona, Kentucky, Ohio and Texas—and the closure of five clinics in Virginia, including two of the land's largest providers.i,2 The clinic regulations in Texas were struck down past the U.S. Supreme Court in 2016 (thereby prohibiting some of the well-nigh egregious TRAP laws nationwide) and the Virginia regulations were by and large repealed in 2017.ix,ten Yet, clinic numbers in the afflicted states did non increase significantly even with these restrictions eliminated, underscoring that one time a clinic is forced to close, it tin can exist challenging if non outright impossible for information technology to reopen.

Smaller changes in clinic numbers are also important, especially in states where access to abortion services is already extremely limited. Missouri, Due west Virginia and Wisconsin each lost 1 dispensary in the 2011–2017 timeframe out of an already modest number in each state.1,two In cases like this, the remaining clinics typically cannot absorb all the patients seeking abortion care and patients must face greater and sometimes insurmountable obstacles to obtaining an abortion, such as longer travel distances and increased financial costs.11,12

Restrictions and Abortion Rates

While there appears to be a clear link in many states between ballgame restrictions—and TRAP laws in particular—and clinic closures, there is no clear pattern linking abortion restrictions to changes in the abortion charge per unit. While 32 states enacted 394 restrictions betwixt 2011 and 2017,three,4 nearly every country had a lower abortion charge per unit in 2017 than in 2011, regardless of whether it had restricted abortion access (see effigy 2).ane,4 Several states with new restrictions really had ballgame rate increases.1,4

Notably, 57% of the 2011–2017 decline in the number of abortions nationwide happened in the 18 states and the District Columbia that did non adopt whatever new ballgame restrictions.thirteen Some of these states, such equally California, even took steps to increase access.fourteen And even in states that enacted new restrictions and saw declines in abortion numbers, it is uncertain what role these restrictions, as opposed to other factors, played in the declines.

Similarly, at that place is no clear link, even indirectly, from new abortion restrictions to clinic closures to decreases in abortion rates. Among the 26 states and the Commune of Columbia that had a turn down in clinics between 2011 and 2017, 24 states saw declines in their ballgame rate (run into Figure three).1,2 However, 13 of the xv states that added clinics also saw declines in their abortion rates, equally did viii of the nine states where the number of clinics stayed the same.

The only exception here may once again exist TRAP laws. Iv of the states hitting hardest past the consequences of TRAP laws over this time period in terms of clinic closures as well saw declines in the abortion rate that were larger than the national average of twenty%: Arizona (27%), Ohio (27%), Texas (30%) and Virginia (42%).13 Kentucky, which lost i of its two clinics because of the implementation of TRAP regulations, had an abortion rate decline that was slightly lower than the national average (18%).

While at that place is no clear pattern linking restrictions and abortion declines, restrictions often verbal a heavy price on individuals seeking an abortion. In fact, restrictions are ordinarily enacted with the explicit and cruel intent of creating hardship. Most egregiously, restrictions do keep some people from getting the abortions they want to obtain. And even for those who are able to overcome various barriers, restrictions can cause serious fiscal and emotional consequences, including by causing delays in obtaining care.15 Yet people accept long shown that they will endure these hardships, including by diverting money meant for rent, groceries or utilities to pay for their procedure.

Explaining the Declines

If ballgame restrictions are not the main driver of the 2011–2017 abortion turn down, what can explain this trend? A number of possible explanations exist, some of them more than plausible than others, including changes around abortion attitudes and stigma, contraceptive use, sexual activity, infertility and self-managed abortion.

Attitudes and Choices

Antiabortion activists oftentimes argue that more than people are turning confronting abortion rights and that this shift in attitudes can explain wide-based declines in the number of abortions beyond the state, including in states that did non enact new restrictions. Under this theory, changes in public opinion hogtie more pregnant individuals to choose to give birth rather than obtain an abortion. This theory is flawed on several levels.

Public stance on ballgame, while fluctuating at times, has remained remarkably stable over the long term. The Pew Research Heart found that abortion attitudes in 2018 were essentially the same as in the mid-1990s, with Gallup and an ABC News/Washington Post poll showing very similar trends.16–18 More to the indicate, these major polls do not show a decline in back up for abortion rights betwixt 2011 and 2017. Moreover, if antiabortion activists were truly winning "hearts and minds," they would non demand to rely on always more extreme and coercive ballgame restrictions, including an unprecedented wave of abortion bans passed in a number of states in the beginning half dozen months of 2019.19

A closely related statement focuses on the ballgame ratio (the number of abortions per 100 pregnancies ending in either ballgame or live nativity), which fell 13% between 2011 and 2017.1,two Ballgame opponents often aspect this pass up to more pregnant individuals deciding or being forced to bear a pregnancy to term. If this were the case, and then there would have been a corresponding increment in births over that time, which did non happen. Rather, both the number of U.S. abortions and the number of U.S. births declined from 2011 to 2017, with births dropping past 98,000 and abortions by 196,000.ane,two,20

Fewer Pregnancies

Because both abortions and births declined, it is clear that there were fewer pregnancies overall in the United States in 2017 than in 2011. The big question is why.

Ane possible contributing factor is contraceptive admission and use. Since 2011, contraception has become more accessible, as nearly private health insurance plans are at present required past the Affordable Intendance Human action (ACA) to cover contraceptives without out-of-pocket costs. In addition, thanks to expansions in Medicaid and individual insurance coverage under the ACA, the proportion of women aged xv–44 nationwide who were uninsured dropped more than than 40% betwixt 2013 and 2017.21 There is show that use of long-acting reversible contraceptive methods—specifically IUDs and implants—increased through at least 2014, especially among women in their early 20s, a population that accounts for a pregnant proportion of all abortions.22 Another study suggests that the use of IUDs might have increased in the wake of the 2016 presidential election, spurred by fears that such methods could become more expensive to access in the time to come.23 Notably, contraceptive use has driven the long-term decline in adolescent pregnancies and births, which continued through the 2011–2017 period.24,25

Another possible contributing cistron might be a decline in sexual activity. Findings from one national survey advise a long-term increment in the number of people in the United States—by and large younger men—reporting non having sexual activity in the past year.26,27 But in addition to a small-scale sample size, it is unclear how well this survey captures data on sexual behavior. Other data show that the proportion of high school students who have always had sexual intercourse declined between 2011 and 2017, with virtually of the turn down happening in the 2013–2015 menstruum.28 However, this is unlikely to have had a major touch on on the U.S. abortion rate, as minors account for only 4% of abortions overall.29 In sum, the available data practice not indicate pregnant decreases in sexual activity amidst women in their 20s and 30s, the groups that together account for 85% of all abortions nationally.

Yet some other possibility is that infertility is increasing in the United states, thereby reducing the chances of getting pregnant and later on seeking to obtain an abortion. However, it is highly unlikely that there would have been a big plenty spike in infertility to meaningfully impact pregnancy and abortion rates in the 2011–2017 timeframe.

More mostly, there are a host of other potential factors that could exist driving declines in pregnancy rates, from individuals' evolving desires about whether and when to get parents to people's changing economic and social circumstances.

Self-Managed Abortion

Finally, information technology is possible that the 2011–2017 decline in ballgame was not as big as information technology appears from the Guttmacher Institute'south abortion provider demography: In that location could have been an increase in self-managed abortions happening outside of medical facilities, which the census would be unable to capture. The Guttmacher ballgame census providing information for 2017 plant that eighteen% of nonhospital facilities reported having seen at least ane patient who had attempted to stop a pregnancy on her ain, an increment from 12% in 2014 (the first year that question was included in the survey).one,7 The drugs used in a medication abortion (misoprostol and mifepristone) are becoming increasingly available online, as are resources nearly how to safely and finer cocky-manage an ballgame exterior of a clinical setting (run across "Self-Managed Medication Abortion: Expanding the Available Options for U.S. Abortion Care," 2018). More evidence is necessary to amend empathize these emerging trends and how to serve the needs of patients as technology and new options for self-managing an abortion are changing access to and availability of abortion.

Centering the Needs of Individuals

Nosotros know that abortion restrictions were not the master driver of abortion declines between 2011 and 2017, nor were shifts in public stance nearly abortion. Yet, in many means, that is all beside the point. The reality is that a decline in the ballgame charge per unit should non be an stop in and of itself.

Rather, declines in ballgame rates and the number of clinics are potent reminders that nosotros need to continue to support those seeking abortion, and then that they receive timely, attainable, affordable and supportive intendance. Because despite nearly xl years of declines in ballgame numbers, i in four women of reproductive age nationally will have an abortion in her lifetime.30 Moreover, the legal, logistical and financial barriers to abortion are growing, and these burdens are largely borne by depression-income individuals, people of color and young people.

Rather than trying to coerce pregnant individuals into giving birth as their just option, and stigmatizing and targeting abortion patients and providers in the name of reducing abortion, we must center individuals' needs in their particular circumstances. That ways policies must exist grounded in medical ideals, including the principles of informed and voluntary consent, which support data on, referral for and access to all pregnancy options. Centering each person'due south needs also means providing affordable, high-quality contraceptive and prenatal intendance, making resources available to raise children with nobility, and improving access to safe, affordable and timely abortion intendance.