Teenage abortion and pregnancy statistics by state, 1996.

CONTEXT: State-level teenage pregnancy rates, birthrates and abortion rates are needed for state-specific programs and policies. Accurate and complete state-level data were last published in 1992. METHODS: Teenage abortion rates according to state of residence, race and ethnicity were calculated from the results of The Alan Guttmacher Institute's survey of abortion providers and from information compiled by state health statistics agencies and the Centers for Disease Control and Prevention. Natality data were obtained from the National Center for Health Statistics, and population denominators from the Census Bureau. RESULTS: In 1996, some 97 pregnancies, 54 births and 29 abortions occurred per 1,000 U.S. women aged 15-19. At the national level and in virtually all states, these rates have fallen since 1992, yet they remain higher than rates in most other developed countries. The decline in the teenage abortion rate (from 36 per 1,000 in 1992) has been proportionately greater than the drop in the birthrate (from 61 per 1,000), indicating that an increasing proportion of pregnant teenagers are continuing their pregnancies. Pregnancy rates, birthrates and abortion rates vary enormously among the states for reasons that are largely unexplained. Pregnancy rates and birthrates tend to be highest in the South and Southwest, while abortion rates are highest in the most urban states. CONCLUSIONS: Teenage pregnancy is declining in all parts of the country. Although rates have fallen, further progress is possible, as is indicated by the low rates in certain states and in other developed countries. More research is needed to identify the factors influencing the reproductive behavior of adolescents.

The incidence of abortion worldwide.

CONTEXT: Accurate measurement of induced abortion levels has proven difficult in many parts of the world. Health care workers and policymakers need information on the incidence of both legal and illegal induced abortion to provide the needed services and to reduce the negative impact of unsafe abortion on women's health. METHODS: Numbers and rates of induced abortions were estimated from four sources: official statistics or other national data on legal abortions in 57 countries; estimates based on population surveys for two countries without official statistics; special studies for 10 countries where abortion is highly restricted; and worldwide and regional estimates of unsafe abortion from the World Health Organization. RESULTS: Approximately 26 million legal and 20 million illegal abortions were performed worldwide in 1995, resulting in a worldwide abortion rate of 35 per 1,000 women aged 15-44. Among the subregions of the world, Eastern Europe had the highest abortion rate (90 per 1,000) and Western Europe to the lowest rate (11 per 1,000). Among countries where abortion is legal without restriction as to reason, the highest abortion rate, 83 per 1,000, was reported for Vietnam and the lowest, seven per 1,000, for Belgium and the Netherlands. Abortion rates are no lower overall in areas where abortion is generally restricted by law (and where many abortions are performed under unsafe conditions) than in areas where abortion is legally permitted. CONCLUSIONS: Both developed and developing countries can have low abortion rates. Most countries, however, have moderate to high abortion rates, reflecting lower prevalence and effectiveness of contraceptive use. Stringent legal restrictions do not guarantee a low abortion rate.

Abortion incidence and services in the United States, 1995-1996.

CONTEXT: In the 1980s, the number of abortion providers in the United States began to decline, and more recently, so has the number of abortions performed. Whether the decline in service providers, which was last documented in 1992, is continuing and whether this influences the availability and number of abortions is of public interest. METHODS: In 1997, the Alan Guttmacher Institute conducted its 12th survey of all known abortion providers in the United States. The number and location of abortion providers and abortions were tabulated for 1995 and 1996, and trends were calculated by comparing these data with those from earlier surveys. Limited data were also gathered on types of abortion procedures. RESULTS: Between 1992 and 1996, the number of abortions fell from 1,529,000 to 1,366,000, and the abortion rate decreased from 26 to 23 per 1,000 women aged 15-44. The number of providers fell 14%, to 2,042, with the greatest decline among hospitals and physicians' offices rather than clinics. Eighty-six percent of counties had no known abortion provider, and 32% of women aged 15-44 lived in these counties. Of the country's 320 metropolitan areas, 89 had no known abortion provider, and for an additional 12, fewer than 50 abortions each were reported. Seventy percent of abortions were performed in specialized clinics and only 7% in hospitals. In the first half of 1997, early medical abortions were being offered in about 160 facilities, virtually all of which were also providers of surgical abortions. CONCLUSIONS: While abortion services in some areas of the country have declined since 1992 and many women continue to have limited access to providers, other factors have probably had more influence on the level of abortions performed. Early medical abortion methods are too new to be a measurable factor in abortion access.

PIP: The aim of this research was to update information on the number and geographic distribution of abortion providers and rates in 1996 in the US. Data were derived from a national abortion survey by the Alan Guttmacher Institute (AGI). The AGI abortion survey included 1279 provider responses to questionnaires mailed to 3032 providers. Fear of reprisals hampered full reporting. Abortions amounted to 1,363,690 in 1995 and 1,365,730 in 1996. The abortion rate declined from 25.9 to 22.9/1000 women 15-44 years old. During 1995-96, the abortion ratio was 26 abortions/100 live births, which is a decline from 28/100 in 1990. California, New York, Florida, and Texas had the most abortions. Under 2000 abortions were performed in Wyoming, Idaho, and North and South Dakota. The highest abortion rates were in Nevada (45/1000 women age 15-44), New York (41/1000), and New Jersey (36/1000). Abortion rates were below 8/1000 in Idaho, Mississippi, South Dakota, West Virginia, and Wyoming. 86% did not have an abortion provider. 92% had no providers performing at least 400 abortions annually. 32% of women lived in counties without a provider. 41% lived in counties without a large provider. 95% of nonmetropolitan counties had no providers. About 50% of metropolitan counties were under served. The rate of decline of abortion services accelerated by 1996.

Measuring the extent of abortion underreporting in the 1995 National Survey of Family Growth.

CONTEXT: Induced abortions are often severely underreported in national surveys, hampering the estimation and analysis of unintended pregnancies. To improve the level of abortion reporting, the 1995 National Survey of Family Growth (NSFG) incorporated new interview and self-report procedures, as well as a monetary incentive to respondents. METHODS: The weighted numbers of abortions reported in the main interview of the 1995 NSFG (Cycle 5), in the self-report and in the two procedures combined are compared with abortion estimates from The Alan Guttmacher Institute. The Cycle 5 estimates are also compared with estimates from previous cycles of the NSFG. RESULTS: The self-report produces better reporting than the main interview, but combining data from the two procedures yields the highest count of abortions. For the period 1991-1994, the level of reporting is 45% in the main interview, 52% in the self-report and 59% when the two methods are combined. The level of abortion reporting in the combined data ranges from 40% for women with an income less than the federal poverty level to more than 75% among women who were older than 35, those who were married at the time of their abortion and those with an income above 200% of the poverty level. The completeness of abortion reporting in the main interview of Cycle 5, though indicating a remarkable improvement over reporting in Cycle 4, is comparable to the levels in Cycles 2 and 3. CONCLUSIONS: The usefulness of the NSFG remains extremely limited for analyses involving unintended pregnancy and abortion.

PIP: This study assessed the extent of full reporting of induced abortion in the 1995 National Survey of Family Growth (NSFG). NSFG has new interview and self-report procedures for correcting undercounts. NSFG Cycles 2-4 were found to record under 50% of abortions that actually occurred in the US. This study compared the level of abortions reported under each of two NSFG survey procedures (the main interview and the self-report). These 2 sources were used to derive the best abortion estimates available from Cycle 5. Estimates from Cycle 5 were compared to earlier cycles for general reporting and for reporting on subgroups of women. Self-reported abortion data appeared to be somewhat less consistent than main interviews and lacked valid dates. The computer entries could increase the potential for input errors. Analysis includes the comparison between: 1) the number of abortions that were reported in the main interview with those that actually occurred in the US; 2) self-reported abortions with external estimates; and 3) both sources of abortions with external estimates. In general, women reported abortions more completely in self-reports during 1976-90. A more complete count occurred with the combined sources. Even with the new procedures in Cycle 5, abortions were undercounted. The combined sources yielded 64% of the actual abortion events. Abortion reporting in the main interview and combined sources varied widely across subgroups. However, for some subgroups, self-reports improved reporting by 33%. Higher level of education was associated with a low accuracy of reporting.

Unintended pregnancy in the United States.

CONTEXT: Current debates on how to reduce the high U.S. abortion rate often fail to take into account the role of unintended pregnancy, an important determinant of abortion. METHODS: Data from the 1982, 1988 and 1995 cycles of the National Survey of Family Growth, supplemented by data from other sources, are used to estimate 1994 rates and percentages of unintended birth and pregnancy and the proportion of women who have experienced an unintended birth, an abortion or both. In addition, estimates are made of the proportion of women who will have had an abortion by age 45. RESULTS: Excluding miscarriages, 49% of the pregnancies concluding in 1994 were unintended; 54% of these ended in abortion. Forty-eight percent of women aged 15-44 in 1994 had had at least one unplanned pregnancy sometime in their lives; 28% had had one or more unplanned births, 30% had had one or more abortions and 11% had had both. At 1994 rates, women can expect to have 1.42 unintended pregnancies by the time they are 45, and at 1992 rates, 43% of women will have had an abortion. Between 1987 and 1994, the unintended pregnancy rate declined by 16%, from 54 to 45 per 1,000 women of reproductive age. The proportion of unplanned pregnancies that ended in abortion increased among women aged 20 and older, but decreased among teenagers, who are now more likely than older women to continue their unplanned pregnancies. The unintended pregnancy rate was highest among women who were aged 18-24, unmarried, low-income, black or Hispanic. CONCLUSION: Rates of unintended pregnancy have declined, probably as a result of higher contraceptive prevalence and use of more effective methods. Efforts to achieve further decreases should focus on reducing risky behavior, promoting the use of effective contraceptive methods and improving the effectiveness with which all methods are used.

PIP: Data from the 1982, 1988, and 1995 cycles of the National Survey of Family Growth, together with data from other sources, were used to estimate 1994 rates and percentages of unintended birth and pregnancy and the proportion of women who have experienced an unintended birth, abortion, or both. Excluding miscarriages, 49% of the pregnancies occurring in 1994 were unintended, 54% of which ended in abortion. 48% of women aged 15-44 in 1994 had had at least one unplanned pregnancy at some point in their lives, 28% had had one or more unplanned births, 30% had had one or more abortions, and 11% had had both. At 1994 rates, women can expect to have 1.42 unintended pregnancies by the time they are 45 years old, and at 1992 rates, 43% will have had an abortion. However, between 1987 and 1994, the unintended pregnancy rate fell by 16%, from 54 to 45 per 1000 women of reproductive age. The proportion of unplanned pregnancies which ended in abortion increased among women aged 20 years and older, but decreased among teenagers. The unintended pregnancy rate was highest among women who were aged 18-24 years, unmarried, of low-income, and Black or Hispanic. The rates of unintended pregnancy have declined probably due to higher contraceptive prevalence and the use of more effective methods.

A global review of laws on induced abortion, 1985-1997.

CONTEXT: The legal status of induced abortion helps determine the availability of safe, affordable abortion services in a country, which in turn influences rates of maternal mortality and morbidity. It is important, therefore, for health professionals to know both the current status of abortion laws worldwide and the extent to which those laws are changing. METHODS: Abortion-related laws in 152 nations and dependent territories with populations of one million or more were reviewed, and changes in these laws since 1985 were documented. RESULTS: Currently 61% of the world's people live in countries where induced abortion is permitted either for a wide range of reasons or without restriction as to reason; in contrast, 25% reside in nations where abortion is generally prohibited. However, even in countries with highly restrictive laws, induced abortion is usually permitted when the woman's life is endangered; in contrast, even in nations with very liberal laws, access may be limited by gestational age restrictions, requirements that third parties authorize an abortion or limitations on the types of facilities that perform induced abortions. Since 1985, 19 nations have significantly liberalized their abortion laws; only one country has substantially curtailed legal access to abortion. CONCLUSIONS: A global trend toward liberalization of abortion laws observed before 1985 appears to have continued in more recent years. Nevertheless, women's ability to obtain abortion services is affected not just by the laws in force in a particular country, but also by how these laws are interpreted, how they are enforced and what the attitude of the medical community is toward abortion.

The impact of Mississippi's mandatory delay law on abortions and births.

CONTEXT: Beginning August 8, 1992, a woman in the state of Mississippi had to wait 24 hours after in-person receipt of state-mandated information regarding abortion and birth complications, fetal development, and alternatives to abortion before an abortion could be performed. OBJECTIVE: To analyze the effect of the law on the abortion and birth rates of Mississippi residents. DESIGN: A retrospective analysis of abortion and birth rates before and after the law in Mississippi as contrasted with abortion and birth rates in 2 comparison states, Georgia and South Carolina. Neither Georgia nor South Carolina enforced a mandatory delay law, but both states began enforcement of parental notification statutes during the study period. PATIENTS: Female residents of reproductive age in Mississippi, Georgia, and South Carolina between 1989 and 1994. MAIN OUTCOME MEASURES: We compared birth rates, abortion rates, the percentage of late abortions, and the percentage of abortions performed outside the state of residence for all women and then by age and race before and after August 1992 among women of Mississippi, Georgia, and South Carolina. RESULTS: We found that rate ratios (RRs) of resident abortion rates (rate after law implementation/rate before law implementation) declined 12% more in Mississippi than in South Carolina (95% confidence interval [CI], 8%-15%) and 14% more in Mississippi than in Georgia (95% CI, 10%-17%) in the 12 months after the law went into effect. Rate ratios for white adults declined 22% more in Mississippi than in South Carolina (95% CI, 17%-27%) and 20% more in Mississippi than in Georgia (95% CI, 15%-25%). Changes among nonwhite adults and white teens were more modest but also statistically significant (P<.05). For all women, RRs of the percentage of abortions performed after 12 weeks' gestation increased 39% more in Mississippi than in either South Carolina or Georgia (P<.05); the increase in the percentage of abortions after 12 weeks' gestation was observed for white and non-white adults (P<.05). We also show that the percentage of abortions performed out of state increased 42% more among women in Mississippi relative to women in South Carolina after the law (95% CI, 34%-50%). CONCLUSION: The timing of the decline in abortion rates in Mississippi, the lack of similar declines in comparison states, the rise in percentage of late abortions and abortions performed out of state and the apparent completeness of abortion reports suggest that Mississippi's mandatory delay statute was responsible for a decline in abortion rates and an increase in abortions performed later in pregnancy among residents of Mississippi. The effect of delay laws in other states will likely depend on whether statutes require 2 separate visits to the abortion provider (ie, clinics, hospitals, or physicians' offices where abortions are performed) and the availability of abortion services.

Teenage abortion and pregnancy statistics by state, 1992.

In 1992, 112 pregnancies occurred per 1,000 U.S. women aged 15-19; of these, 61 ended in births, 36 in abortions and 15 in miscarriages. Black teenagers' rates of pregnancies, births and abortions were 2-3 times those of whites; Hispanic teenagers had rates of births and abortions between those of blacks and whites. While similar proportions of pregnant black and non-Hispanic white teenagers had abortions (40% and 38%, respectively), the proportion was lower among Hispanics (29%). Among all women 15-19, the birthrate rose 12 points between 1987 and 1991; one-third of the rise (four points) may be attributable to a fall in the abortion rate. Between 1991 and 1995, the birth rate of black teenagers fell from 116 to 96 per 1,000, a level well below that of Hispanics (106 per 1,000). Among the states, pregnancy rates per 1,000 teenagers in 1992 ranged from 159 (in California) to 59 (in North Dakota), birth rates per 1,000 varied from 84 (Mississippi) to 31 (New Hampshire) and abortion rates per 1,000 ranged from 67 (Hawaii) to nine (Utah). The pregnancy rates of white and black teenagers are negatively correlated.

PIP: An analysis of data collected by the US National Center for Health Statistics, the Centers for Disease Control and Prevention, and the Alan Guttmacher Institute enabled the identification of trends in teenage abortion and pregnancy by geographic region and race. In 1992, there were 112 pregnancies per 1000 US women 15-19 years old; of these, 61 ended in births, 36 in abortion, and 14 in spontaneous abortion. Black teenagers' rates of pregnancy, birth, and abortion were 2-3 times those of Whites, while Hispanic teens occupied an intermediate position. Abortions were sought by 40% of pregnant White teens, 38% of Black teens, and only 29% of Hispanics. Between 1987 and 1991, the birth rate among US teens 15-19 years old rose 12 points, presumably reflecting reduced availability of abortion services and greater acceptance of childbearing outside of marriage. During 1991-95, the birth rate of Black teenagers fell most dramatically, from 116 to 96/1000, and their condom use increased substantially. The state-level analysis indicated a range in pregnancy rates per 1000 teenagers in 1992 from 59 in North Dakota to 159 in California; birth rates per 1000 ranged from 31 in New Hampshire to 84 in Mississippi, while abortion rates per 1000 ranged from 9 in Utah to 67 in Hawaii. An unexpected finding was a negative correlation between the pregnancy rates of White and Black teenagers. Overall, these findings suggest that state policies and other state characteristics either have little influence on teenage pregnancy rates or exert different influences on Black and White teenagers.

Repeat abortions in Canada, 1975-1993.

In Canada, 20% of women who obtained an abortion between 1975 and 1993 had had at least one previous abortion. An analysis of data on 1.2 million abortions shows that the proportion of abortion patients undergoing repeat procedures increased from 9% to 29% over the 19-year period. The proportion was above average (22-28% for all years combined) among women who were in common-law marriages, those aged 25-39 and those who had previously had children. In 1993, 27 women per 1,000 who had ever had an abortion underwent another one, while 13 women per 1,000 who had never had an abortion obtained their first one; among teenagers, the repeat rate was four times the rate of first abortions (81 per 1,000 vs. 19 per 1,000). During the study period, the repeat rate rose sharply among women younger than 25 but fell among those aged 30 and older. In 1993, fewer than 2% of abortions were obtained by women who had had three or more previous procedures, suggesting that abortion is not widely used as a primary method of birth control.

Abortion patients in 1994-1995: characteristics and contraceptive use.

Results of a 1994-1995 national survey of 9,985 abortion patients reveal that women who live with a partner outside marriage or have no religious identification are 3.5-4.0 times as likely as women in the general population to have an abortion. Nonwhites, women aged 18-24, Hispanics, separated and never-married women, and those who have an annual income of less than +15,000 or who are enrolled in Medicaid are 1.6-2.2 times as likely to do so; residents of metropolitan counties have a slightly elevated likelihood of abortion. When age is controlled, women who have had a live birth are more likely to have an abortion than are those who have never had children. Catholics are as likely as women in the general population to have an abortion, while Protestants are only 69% as likely and Evangelical or born-again Christians are only 39% as likely. Since 1987, the proportion of abortions obtained by Hispanic women and the abortion rate among Hispanics relative to that for other ethnic groups have increased. The proportion of abortion patients who had been using a contraceptive during the month they became pregnant rose from 51% in 1987 to 58%. Nonuse is most common among women with low education and income, blacks, Hispanics, unemployed women and those who want more children. The proportion of abortion patients whose pregnancy is attributable to condom failure has increased from 15% to 32%, while the proportions reporting the failure of other barrier methods and spermicides have decreased.

PIP: This article reports data collected in a 1994-95 Alan Guttmacher Institute survey of 9985 abortion patients on a broad range of characteristics, including socioeconomic status, religious affiliation, residence, childbearing intention, and contraceptive use prior to pregnancy. The survey found that women who live with a partner outside marriage or have no religious identification are 3.5-4.0 times as likely as women in the general population to have an abortion. Non-Whites, women aged 18-24 years, Hispanics, separated and never-married women, and those who have an annual income of less than $15,000 or who are enrolled in Medicaid are 1.6-2.2 times as likely to have an abortion; residents of metropolitan countries have a slightly elevated likelihood of abortion. When age is controlled, women who have had a live birth are more likely to have an abortion than are those who have never had children. Catholics are as likely as women in the general population to have an abortion, while Protestants are only 69% as likely and Evangelical or born-again Christians are only 39% as likely. The survey further found that since 1987, the proportion of abortions obtained by Hispanic women and the abortion rate among Hispanics relative to that for other ethnic groups have increased. The proportion of abortion patients who had been using a contraceptive during the month they became pregnant increased from 51% in 1987 to 58%. Nonuse of contraception is most common among women with low education and income, Blacks, Hispanics, unemployed women, and those who want more children. The proportion of abortion patients whose pregnancy is attributable to condom failure increased from 15% to 32%, while the proportions reporting the failure of other barrier methods and spermicides have decreased.

The impact of requirements for parental consent on minors' abortions in Mississippi.

Mississippi data for 1993 indicate that the state's new parental consent requirement had little effect on the abortion rate among minors. In a comparison of Mississippi residents who had abortions during the five months before and the six months after the law went into effect, the ratio of minors to adults who sought abortions in the state declined by 13%, a decrease offset by a 32% increase in the ratio of minors to adults who obtained abortions out of state. There was also a 28% drop in the ratio of minors to adults from other states who had abortions in Mississippi. The parental consent requirement increased by 19% the ratio of minors to adults who obtained their procedure after 12 weeks of gestation.

PIP: Mississippi data for 1993 indicate that the state's new parental consent requirement had little effect on the abortion rate among minors. Although the law was passed in 1986, its constitutionality was challenged in federal court, and enforcement was delayed until June 16, 1993. No other abortion restrictions took effect during 1993, so a relatively clear comparison can be made of the situation before and after the law took effect. The impact of the law was assessed by comparing abortion data for January through May 1993 with data for July through December 1993. The ratio of the number of abortions obtained by minors (younger than age 18) to the number obtained by women 18 or older was calculated. For the period January-May 1993, minors' abortions amounted to 0.1163 of the abortions obtained by older women, while during July-December 1993, that proportion was 0.1188 (p 0.010). During the first 5 months of 1993 the number of abortions performed in Mississippi for minors equalled 0.126 of the number obtained by older women. In July through December, after the parental consent law took effect, the ratio was 0.106, 16% lower than the earlier ratio of 0.126. In a comparison of Mississippi residents who had abortions (n = 4484) during the 5 months before and the 6 months after the law went into effect, the ratio of minors to adults who sought abortions in the state declined by 13%, from 0.127 to 0.111. This decrease was offset by a 32% increase in the ratio of minors to adults (n = 1462) who obtained abortions out of state, from 0.120 to 0.158. There was also a 28% drop in the ratio of minors to adults from other states who had abortions in Mississippi (n = 1066) from 0.120 to 0.087. The results suggest that minors, on average, were delayed by about 3 days. This delay is marginally statistically significant (p = 0.10). The parental consent requirement raised by 19% the ratio of minors to adults who obtained their procedure after 12 weeks of gestation.

Factors hindering access to abortion services.

Although abortion services are readily available in large urban areas to those able to pay, a 1993 survey of U.S. abortion providers shows that access to service is still problematic for many women because of barriers related to distance, gestation limits, costs and harassment. Among women who have nonhospital abortions, an estimated 24% travel at least 50 miles from their home to the abortion facility. Although 98% of providers will perform abortions at eight weeks after the last menstrual period, only 48% will perform abortions at 13 weeks and 13% at 21 weeks. Half of nonhospital abortion providers estimate that more than four days elapse on average between their patients' first telephone contact and the date of the procedure; one in seven say that more than one week elapses. Most women are able to obtain abortion services in one visit to a clinic. The average woman having a first-trimester nonhospital abortion with local anesthesia paid $296 for the procedure in 1993, up from $251 in 1989. On average, nonhospital facilities charged $604 at 16 weeks of gestation and $1,067 at 20 weeks. Eighty-six percent of nonhospital facilities providing 400 or more abortions in 1992 were the targets of antiabortion harassment. Picketing at facilities and the homes of staff members, vandalism and chemical attacks increased significantly between 1988 and 1992, but the incidence of bomb threats decreased.

PIP: In 1988, 1.6 million US women had abortions, and 1.7 carried unintended pregnancies to term. Little is known about why unintended pregnancies are carried to term, but financial, physical, psychological, social, or other obstacles to abortion are undoubtedly important as well as lack of knowledge about the availability of services. This fact is borne out by the wide discrepancy in the abortion rates in various states (ranging from 9/1000 women aged 15-44 years in South Dakota to 45.8 in California in 1988). Data from the Alan Guttmacher Institute's 1993 Abortion Provider Survey reveal that 24% of women travel at least 50 miles to obtain abortion services; that 98% of providers will perform abortions at 8 weeks since last menstrual period, 48% at 13 weeks, and 13% at 21 weeks; that most women receive an abortion 4-7 days from their initial inquiry in a single visit to a clinic (this time reflects an increase in recent years and may grow worse due to the provider shortage); and that providers charge $296 for an average first-trimester nonhospital abortion with local anesthesia, $604 at 16 weeks gestation, and $1067 at 20 weeks. The exclusion of abortion from Medicaid coverage in most states results in a severe legislative restriction for poor women. In addition, the data show that 86% of the clinics which provided 400 or more abortions in 1992 were the targets of anti-abortion harassment. Between 1988 and 1992, the picketing of abortion facilities and the homes of staff members increased, as did attacks with butyric acid. Although the incidence of bomb threats decreased, the recent murders of providers, escorts, and staff indicate gradually increasing violence. If abortions were integrated with other health care services for women, most of the difficulties in obtaining and providing access would disappear. This change is unlikely, however, as long as vocal opposition to abortion remains. An alternative is the use of RU-486, which has the potential to change the types of abortion providers and to reduce some of the barriers in some cases. Medical abortion, however, can be used only in early pregnancy and requires 2 visits to a clinic as well as surgical backup.

Abortion services in the United States, 1991 and 1992.

According to a survey by The Alan Guttmacher Institute, 1,529,000 abortions were performed in 1992, the lowest number of abortions since 1979. The abortion rate has gradually declined, from a high of 29 per 1,000 women of reproductive age in 1981 to 26 per 1,000 in 1992. The number of hospitals, clinics and physicians' offices that provide abortions--2,380 in 1992--has been declining at a rate of about 65 a year. Most of the decline has occurred among hospitals; the number providing abortions decreased by 18% between 1988 and 1992. Most U.S. counties (84%) have no known abortion provider, and in nonmetropolitan areas, 94% of counties have no provider. Among metropolitan areas, 33% have either no abortion provider or none that serves at least 50 women per year. Among states, North Dakota and South Dakota have only one provider each. Most abortions (69%) are performed in abortion clinics, and only 7% are performed in hospitals. Fewer than 1% of women who have an abortion are hospitalized for the procedure.

PIP: The most recent Alan Guttmacher Institute survey, which collected data on abortions provided in the US in 1991 and 1992, documented continued declines in the abortion rate and the number of abortion providers. The number of abortions performed per year remained relatively stable from 1980-90, at about 1,600,000, but declined to l,557,000 in 1991 and to l,529,000 in 1992. This represents a decline in the abortion rate from a high of 29/1000 women of reproductive age in 1981 to 26/1000 in 1992. 49% of all abortions in 1992 occurred in New York, California, Texas, Florida, and Illinois. At present, two states--North and South Dakota--have only one abortion provider each. The number of abortions performed in nonmetropolitan counties has dropped from 67,000 in 1979 to 23,000 in 1992, and 94% of these counties currently have no abortion provider. Even in metropolitan counties, 51% have no abortion service. In 1992, there were 2380 facilities providing abortion--a decline of 202 since 1988. Only 7% of abortions are performed at hospitals--the sector that has been eliminating abortion services at the fastest rate. Only one-sixth of the decline in abortion procedures since 1988 can be explained by the changing age structure of women in the reproductive years. Other contributing factors may include fewer unintended pregnancies, greater acceptance of single motherhood, erosions in acceptance of the right to abortion, and the lack of accessibility of abortion services in nonmetropolitan areas.

Family planning agencies: services, policies and funding.

Approximately 2,614 agencies are providing family planning services in at least 5,460 clinics throughout the nation, a slight increase over the 2,462 agencies and 5,174 clinics that were estimated to be providing such services in 1983. Health departments operate an estimated 52% of clinic sites; Planned Parenthood affiliates, 15%; hospital, 6%; and other agencies, 27%. Although many agencies also offer noncontraceptive services, the large majority provide family planning services in separate clinic sessions devoted to that purpose. According to a 1992-1993 survey of a random sample of family planning agencies, Planned Parenthood affiliates provide contraceptive services for an average of 2,041 clients per clinic site, compared with 761 per health department clinic. The agencies report offering an average of 7.2 contraceptive methods at their clinics, with Planned Parenthood affiliates and hospitals offering the highest mean number, 9.2. The clinics provide an average of 8.3 tests and examinations for their medical contraceptive clients, with at least 98% providing a pelvic examination, blood pressure measurement, breast examination and Pap smear; 90% screen for anemia, and 70% screen for gonorrhea. While almost all of the agencies get some income from Medicaid (83%), only 15% receive more than 20% of their budget for contraceptive services from that source. The federal Title X program provides more than 20% of the budgets of 53% of agencies; state and local governments fund 40% of family planning agencies at that level; and client fees do the same for 32% of agencies. Some 92% of clinics with Title X funding provide the initial visit and a three-month supply of the pill without charge to clients with an income below the federal poverty level, compared with about 50% of clinics without Title X funding.

Abortion services under national health insurance: the examples of England and France.

PIP: The US can anticipate possible problems and benefits of different financing mechanisms as it moves to providing national health insurance coverage. England, Wales, and France have a national health service with a policy mandating abortion services. Examination of these systems shows that bureaucratic health care structures do not assure that all women have access to abortion services, however. Ideological, budgetary, and bureaucratic resistance operates at many public hospitals and public sector services. Abortion services always are a target for spending cuts when there is limited health care funding. In the US, the strong anti-abortion faction is likely to pressure health maintenance organizations and other managed care systems to limit access to abortion services. In the UK and France, independent, private health facilities fill the gaps in the public system and thus provide women universal access to abortion services. These facilities are at least as necessary in the US as they are in the UK and France. UK's National Health Service process of abortion referral delays abortions. In the UK and France, women tend to view public facilities as lacking confidentiality, so they automatically go to private providers. Other problems with obtaining a referral by a primary care provider include an extra health care visit, that the provider may not make or may delay the referral, and the woman's desire not to discuss the pregnancy with the regular provider. Bureaucratic and legal barriers in France force many women to seek and physicians to perform illegal abortions. Barriers in France are a one-week waiting period, required counseling by a social worker, and a required overnight stay in the hospital. These barriers must be avoided in the US to prevent illegal abortions.^ieng

Recent trends in the legal status of induced abortion.

During the middle and later years of the twentieth century, a movement to liberalize laws governing induced abortion swept the industrialized world and some of the major developing countries. The changes have generated an increasingly visible reaction among groups that seek to block further liberalization and re-institute restrictions on abortion. An examination of all changes in laws and regulations governing induced abortion that took effect between January, 1988 and February, 1993 found that the overall movement is still in the direction of liberalization of abortion laws, although restrictions have been increased in a few countries. During the time period studied, five countries made major liberalizing changes in their laws, while only one imposed major restrictions.

PIP: The desire for fertility control, changes in the role of women, the secularization of society, and more open attitudes about sexuality are some of the factors which led to the liberalization of abortion laws and services in countries around the world. The author hypothesized that since these underlying factors are stable or increasing in importance, the worldwide trend toward liberalization should be continuing. He therefore examined all changes which took effect from January 1988 - February 1993 in the abortion laws and regulations of countries with populations of one million or more. Data were gathered from all available sources, including newspapers, newsletters, and published articles. Satisfying the hypothesis, results show the overall movement to be still in the direction of liberalization, although restrictions have been increased in a few countries; five countries made major liberalizing changes in their laws, while only one imposed major restrictions.

Teenage abortion, birth and pregnancy statistics by state, 1988.

PIP: The report provided updated estimates of teenage abortion by state in the United States for 1988 as well as pregnancy and birth rates. Teenagers were grouped at the age of pregnancy outcome. The findings revealed 400,000 women pregnant under the age of 18 years and 600,000 pregnant women aged 18-19 years. About 66% of the 1,034,000 teenagers were White. The national rate of teenage pregnancy in 1988 was 111/1000 women aged 15-19 years (53 births, 43 abortions, and 15 miscarriages), 113/1000 for all races, and 103/1000 for Whites, and 96/1000 without miscarriages. The highest rates were in California (154/1000) and the lowest in North Dakota (57/1000). Nevada (142/1000), Hawaii (134/1000), Florida (133/1000), and Maryland (129/1000) also had high rates. Low rates of 69/1000 were found in Utah, Minnesota, South Dakota, and Iowa. The rates among 15-17 year olds were 74/1000, and rates among those 18-19 years were 164/1000. About 50% of pregnancies had a birth outcome, and birth outcomes were higher among those aged 18-19 years. Abortion and birth rates did not follow the same pattern as pregnancy rates. For example, in Mississippi there was a 106/1000 pregnancy rate, a 73/1000 birth rate, and a 16/1000 abortion rate. Other states with a high birth rate and a low abortion rate were New Mexico, Arkansas, Arizona, Georgia, and Texas. Low birth rates were found in Minnesota, North Dakota, Massachusetts, Iowa, New Hampshire, and Vermont. The highest abortion rates were in California (76/1000), Hawaii (68/1000), New York (61/1000), Maryland (61/1000), and New Jersey (60/1000). Low abortion rates were in Utah (15/1000), Mississippi (16/1000), Idaho (17/1000), and West Virginia (17/1000). Birth and abortion rates by state followed similar patterns regardless of age, except among women 15-17 years compared to those 18-19 years in Missouri and Rhode Island, which have parental consent laws. Race data on abortion among teenagers was available for only 29 states. In general, pregnancy, birth, and abortion rates were 2-3 times higher among non-Whites. The highest White pregnancy rates were in Arizona, New Mexico, and Texas with large Hispanic populations. States with low pregnancy, birth, and abortion rates for Whites did not always have low rates for Blacks.^ieng

Providing controversial health care: abortion services since 1973.

PIP: Half of the 6.4 million pregnancies annually in the US are unintended and half of these result in 1.6 million abortions/year. When abortion was legalized in 1973, it was assumed that hospitals would provide the service. In fact, only 1040 of the nation's 5401 non-Catholic hospitals currently offer abortions (a decline from 1687 in 1976). By 1988, 64% of abortions occurred in specialized clinics, with another 22% taking place in clinics which offer other services. Among the 2600 providers, 20% perform over 1000 abortions/year (80% of the total). 40% of the clinics offer middle and late second-trimester abortions, with 60% of late abortions ( 20 weeks since the last menstrual period [LMP]) occurring in clinics or doctor's offices. The overall safety record for all abortion services has been excellent (0.6 deaths/100,000 procedures from 1980-87). However, many women face a problem of access to the service; 31% of women of reproductive age live in counties with no provider. In 1988, 6% of abortion-seekers traveled outside of their home state, 33% traveled to another county, 9% of women traveled more than 100 miles, and 18% traveled 50-100 miles. This shortage of providers has increased, and, in some clinics, physicians are flown in from out-of-state. A cause of continuing concern is that 11% of abortions occur in the second trimester, with 4% after 15 weeks since the LMP. A survey of these women revealed that almost 50% were delayed by the difficulty in making arrangements for the procedure (transportation, finding a provider, funding). The largest proportion, 71%, were late in recognizing their pregnancy. Since 42% of obstetrician-gynecologists in private practice surveyed in 1983 stated that they do not provide abortions (41% for moral or religious reasons), the scarcity of providers is not surprising. This situation is made worse by the harassment of anti-abortion activists. In 1988, 81% of clinics performing at least 400 abortions/year had been picketed; for 46% the picketing involved physical contact, for 38% the demonstrations resulted in arrests, 36% had bomb threats, 34% vandalism, and 17% picketing of the homes of staff members. In addition to these problems, the renumeration for abortions is very low. An abortion which cost $165 in 1976 should cost $474 today but, in fact, costs $251. Physicians still receive the same amount per abortion (about $50). These fees, which are too low to provide a financial incentive for physicians, nevertheless provide a barrier for poor women, especially since the fees for second trimester abortions are much higher (over $900 at 20 weeks since the LMP). This means that lack of Medicaid coverage for abortion is the most serious abortion access issue. The problem of funding will also have to be faced by any universal health insurance plan so that the need for referral, approval, or screening is minimized. A further access problem is the increasing number of restrictions placed on abortion-seekers which may be difficult and expensive for smaller clinics to comply with. This will likely continue the trend toward fewer, larger clinics.^ieng