Between 2011 and 2017, the U.S. abortion mural changed significantly. As documented past the Guttmacher Plant's periodic abortion provider census, all the main measures of ballgame declined, including the number of abortions, the abortion charge per unit and the abortion ratio.1,2 The declines are office of trends that become dorsum decades.

  • The number of abortions fell past 196,000—a 19% refuse from 1,058,000 abortions in 2011 to 862,000 abortions in 2017.i,2
  • The ballgame rate (the number of abortions per 1,000 women aged 15–44) vicious by 20%, from 16.9 in 2011 to 13.5 in 2017.
  • The ballgame ratio (the number of abortions per 100 pregnancies catastrophe in either abortion or alive nascence) savage 13%, from 21.ii in 2011 to 18.4 in 2017.

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

Even so, declines in abortion do not serve patients if the reason backside the turn down is interference with individuals' decision making about their reproductive options. Reducing ballgame by shuttering clinics and erecting logistical barriers for patients is in directly disharmonize with sound public health policy, and the debate should not be framed based on the false premise that any reduction in abortion is a proficient consequence. Rather, it is critical to remember that timely and affordable access to abortion should be available to anyone who wants and needs information technology. And it is equally of import to recognize that obstructing or denying care in the name of reducing abortion is a violation of individuals' dignity, bodily autonomy and reproductive freedom.

With the available bear witness, it is impossible to pinpoint exactly which factors drove recent declines, and to what degree. However, previous Guttmacher analyses have documented that abortion restrictions, while incredibly harmful at an private level, were not the main driver of national declines in the abortion rate in the 2008–2011v or 2011–20146 time periods. Much the same appears to hold truthful for the 2011–2017 timeframe, as detailed below. Rather, the refuse in abortions appears to be part of a broader pass up in pregnancies, as evidenced by fewer births over the same period.

Abortion Restrictions

Abortion restrictions target either individuals' ability to access the procedure (such as by imposing coercive waiting periods and counseling requirements) or providers' ability to offering it (such equally through unnecessary and intentionally crushing regulations). Any 1 of these restrictions could result in some people being forced to continue pregnancies they were seeking to end; this could, in theory, lower the abortion charge per unit.

Restrictions and Clinic Closures

Because 95% of all abortions reported in 2017 were provided at clinics—either those specializing in ballgame or those where ballgame is role of a broader gear up of medical services—changes in the number of clinics is a good proxy for changes in abortion admission overall.1 Between 2011 and 2017, the number of clinics providing ballgame in the The states declined past less than 4%, from 839 to 808.1,2

However, this seemingly minor change masks meaning differences by region of the country: Between 2011 and 2017, the South had a cyberspace decline of 50 clinics, with 25 in Texas solitary, and the Midwest had a cyberspace decline of 33 clinics, including ix each in Iowa, Michigan and Ohio.1,two The West lost a net of seven clinics. Past contrast, the Northeast added a net 59 clinics, by and large 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 2 regions. It seems clear that these like geographic patterns are not a coincidence (meet figure 1).ane,ii In detail, when researchers look at the impact of abortion restrictions on clinic numbers, i type of restriction stands out: TRAP (targeted regulation of ballgame providers) laws and administrative regulations did reduce the number of clinics providing ballgame between 2011 and 2014.6,vii And although few clinic regulations were enacted between 2014 and 2017, enforcement of existing regulations played a role in the closure of some clinics during that period.eight

Betwixt 2011 and 2017, TRAP regulations resulted in the closure of roughly half of all clinics that provided abortion in four states—Arizona, Kentucky, Ohio and Texas—and the closure of five clinics in Virginia, including ii of the state's largest providers.1,ii The clinic regulations in Texas were struck down past the U.S. Supreme Courtroom in 2016 (thereby prohibiting some of the nigh egregious TRAP laws nationwide) and the Virginia regulations were more often than not repealed in 2017.9,ten However, clinic numbers in the afflicted states did not increase significantly even with these restrictions eliminated, underscoring that one time a dispensary is forced to shut, information technology can exist challenging if not outright incommunicable for it to reopen.

Smaller changes in clinic numbers are also important, peculiarly in states where access to abortion services is already extremely limited. Missouri, West Virginia and Wisconsin each lost i clinic in the 2011–2017 timeframe out of an already small number in each state.1,2 In cases like this, the remaining clinics typically cannot absorb all the patients seeking ballgame care and patients must face greater and sometimes insurmountable obstacles to obtaining an abortion, such as longer travel distances and increased fiscal costs.11,12

Restrictions and Abortion Rates

While at that place appears to be a clear link in many states betwixt abortion restrictions—and TRAP laws in particular—and dispensary closures, there is no clear blueprint linking abortion restrictions to changes in the abortion rate. While 32 states enacted 394 restrictions between 2011 and 2017,3,4 virtually every state had a lower abortion rate in 2017 than in 2011, regardless of whether it had restricted ballgame access (see figure 2).one,4 Several states with new restrictions really had abortion rate increases.1,four

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 any new ballgame restrictions.13 Some of these states, such equally California, fifty-fifty took steps to increase access.fourteen And even in states that enacted new restrictions and saw declines in abortion numbers, information technology is uncertain what part these restrictions, as opposed to other factors, played in the declines.

Similarly, there is no clear link, even indirectly, from new abortion restrictions to clinic closures to decreases in abortion rates. Amid the 26 states and the District of Columbia that had a turn down in clinics between 2011 and 2017, 24 states saw declines in their ballgame rate (see Figure 3).1,2 However, 13 of the 15 states that added clinics also saw declines in their ballgame rates, equally did eight of the nine states where the number of clinics stayed the same.

The just exception here may once over again be TRAP laws. 4 of the states hitting hardest by the consequences of TRAP laws over this time period in terms of clinic closures besides saw declines in the abortion rate that were larger than the national average of xx%: Arizona (27%), Ohio (27%), Texas (thirty%) and Virginia (42%).13 Kentucky, which lost one of its two clinics because of the implementation of TRAP regulations, had an abortion rate decline that was slightly lower than the national boilerplate (18%).

While in that location is no clear blueprint linking restrictions and abortion declines, restrictions often exact a heavy toll on individuals seeking an abortion. In fact, restrictions are usually enacted with the explicit and fell intent of creating hardship. Nigh egregiously, restrictions practice keep some people from getting the abortions they want to obtain. And fifty-fifty for those who are able to overcome various barriers, restrictions can crusade serious financial and emotional consequences, including by causing delays in obtaining care.15 Yet people take long shown that they will endure these hardships, including by diverting coin meant for rent, groceries or utilities to pay for their procedure.

Explaining the Declines

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

Attitudes and Choices

Antiabortion activists often argue that more people are turning confronting ballgame rights and that this shift in attitudes can explicate broad-based declines in the number of abortions beyond the land, including in states that did not enact new restrictions. Under this theory, changes in public opinion compel 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 Enquiry Center found that abortion attitudes in 2018 were substantially the same equally in the mid-1990s, with Gallup and an ABC News/Washington Mail service poll showing very like trends.16–18 More to the betoken, these major polls do not evidence a decline in support for abortion rights betwixt 2011 and 2017. Moreover, if antiabortion activists were truly winning "hearts and minds," they would not need to rely on ever more farthermost and coercive ballgame restrictions, including an unprecedented wave of ballgame bans passed in a number of states in the starting time six months of 2019.19

A closely related argument focuses on the abortion ratio (the number of abortions per 100 pregnancies ending in either abortion or live birth), which fell 13% between 2011 and 2017.1,ii Abortion opponents often attribute this decline to more pregnant individuals deciding or being forced to conduct a pregnancy to term. If this were the case, then there would take been a corresponding increase in births over that fourth dimension, which did not happen. Rather, both the number of U.S. abortions and the number of U.Due south. births declined from 2011 to 2017, with births dropping by 98,000 and abortions by 196,000.i,ii,20

Fewer Pregnancies

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

Ane possible contributing cistron is contraceptive access and use. Since 2011, contraception has become more attainable, as nigh private wellness insurance plans are now required past the Affordable Care Act (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 15–44 nationwide who were uninsured dropped more than 40% between 2013 and 2017.21 At that place is bear witness that employ of long-acting reversible contraceptive methods—specifically IUDs and implants—increased through at least 2014, specially amidst women in their early 20s, a population that accounts for a significant proportion of all abortions.22 Some other 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 get more expensive to access in the future.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 factor might be a decline in sexual activity. Findings from one national survey suggest a long-term increment in the number of people in the United States—mostly younger men—reporting not having sexual practice in the by year.26,27 Merely in addition to a small sample size, it is unclear how well this survey captures data on sexual behavior. Other data testify that the proportion of high school students who have ever had sexual intercourse declined betwixt 2011 and 2017, with most of the turn down happening in the 2013–2015 menstruum.28 Nonetheless, this is unlikely to have had a major touch on on the U.Southward. abortion charge per unit, every bit minors account for only iv% of abortions overall.29 In sum, the bachelor information exercise non betoken significant decreases in sexual action among women in their 20s and 30s, the groups that together account for 85% of all abortions nationally.

Nonetheless some other possibility is that infertility is increasing in the United States, thereby reducing the chances of getting meaning and later seeking to obtain an abortion. However, it is highly unlikely that there would accept been a big enough spike in infertility to meaningfully touch on pregnancy and abortion rates in the 2011–2017 timeframe.

More than generally, in that location are a host of other potential factors that could be driving declines in pregnancy rates, from individuals' evolving desires almost whether and when to become parents to people's irresolute economic and social circumstances.

Cocky-Managed Abortion

Finally, it is possible that the 2011–2017 decline in abortion was not as large as it appears from the Guttmacher Establish'southward abortion provider census: In that location could have been an increase in cocky-managed abortions happening outside of medical facilities, which the census would exist unable to capture. The Guttmacher ballgame demography providing data for 2017 found that xviii% of nonhospital facilities reported having seen at to the lowest degree one patient who had attempted to end a pregnancy on her own, an increase from 12% in 2014 (the first year that question was included in the survey).1,7 The drugs used in a medication abortion (misoprostol and mifepristone) are condign increasingly available online, as are resources about how to safely and effectively cocky-manage an ballgame outside of a clinical setting (see "Cocky-Managed Medication Abortion: Expanding the Available Options for U.S. Abortion Care," 2018). More testify is necessary to better understand these emerging trends and how to serve the needs of patients equally engineering science and new options for cocky-managing an abortion are changing access to and availability of abortion.

Centering the Needs of Individuals

We know that abortion restrictions were not the main driver of abortion declines between 2011 and 2017, nor were shifts in public opinion about ballgame. Nonetheless, in many means, that is all beside the point. The reality is that a pass up in the abortion rate should not be an cease in and of itself.

Rather, declines in abortion rates and the number of clinics are strong reminders that nosotros need to continue to back up those seeking abortion, so that they receive timely, accessible, affordable and supportive care. Because despite nearly 40 years of declines in abortion numbers, ane in 4 women of reproductive age nationally will accept an abortion in her lifetime.30 Moreover, the legal, logistical and financial barriers to abortion are growing, and these burdens are largely borne by low-income individuals, people of color and young people.

Rather than trying to coerce pregnant individuals into giving birth as their only option, and stigmatizing and targeting ballgame patients and providers in the name of reducing abortion, we must heart individuals' needs in their detail circumstances. That means policies must exist grounded in medical ideals, including the principles of informed and voluntary consent, which back up information on, referral for and access to all pregnancy options. Centering each person's needs likewise ways providing affordable, high-quality contraceptive and prenatal care, making resources available to raise children with dignity, and improving admission to safety, affordable and timely abortion care.