Abortion Incidence and Service Availability
In the United States, 2014
CONTEXT: National and state-level information about abortion incidence can help inform policies and programs
intended to reduce levels of unintended pregnancy.
METHODS: In 2015–2016, all U.S. facilities known or expected to have provided abortion services in 2013 or 2014 were
surveyed. Data on the number of abortions were combined with population data to estimate national and state-level
abortion rates. The number of abortion-providing facilities and changes since a similar 2011 survey were also assessed.
The number and type of new abortion restrictions were examined in the states that had experienced the largest proportionate changes in clinics providing abortion services.
RESULTS: In 2014, an estimated 926,200 abortions were performed in the United States, 12% fewer than in 2011; the
2014 abortion rate was 14.6 abortions per 1,000 women aged 15–44, representing a 14% decline over this period. The
number of clinics providing abortions declined 6% between 2011 and 2014, and declines were steepest in the Midwest
(22%) and the South (13%). Early medication abortions accounted for 31% of nonhospital abortions, up from 24% in
2011. Most states that experienced the largest proportionate declines in the number of clinics providing abortions had
enacted one or more new restrictions during the study period, but reductions were not always associated with declines
in abortion incidence.
CONCLUSIONS: The relationship between abortion access, as measured by the number of clinics, and abortion rates is
not straightforward. Further research is needed to understand the decline in abortion incidence.
Perspectives on Sexual and Reproductive Health, 2017, 49(1):TK, doi: 10.1363/psrh.12015

Information about abortion incidence in the United States
is necessary to estimate accurate pregnancy rates and to
determine rates of unintended pregnancy.1 In 2011, there
were 1.06 million abortions, and 21% of pregnancies
were terminated.2 These figures reveal that abortion is not
uncommon. Abortion incidence in 2011 was remarkable
for several reasons. Between 1990 and 2008, the abortion rate declined an average of 2% per year,3 but between
2008 and 2011, it dropped 13%.2 Fewer women had abortions in 2011 than in 2008 because fewer women became
pregnant when they did not want to: Over this period, the
proportion of pregnancies that were unintended declined
from 51% to 45%, and the rate of unintended pregnancy
dropped 18%, from 54 to 45 per 1,000 women.1
Research suggests that a rise in contraceptive use was
responsible for at least some of the decline in unintended
pregnancy between 2008 and 2011, and that increased use
may have continued into more recent years. Reliance on
long-acting reversible contraceptive (LARC) methods—the
IUD and the implant—increased 130% between 2007 and
2009,4 and this trend continued, albeit at a slightly slower
pace, through 2012.5 The proportion of clients obtaining
LARC methods at Title X–supported family planning clinics rose from 7% in 2011 to 11% in 2014.6 Clients at Title
X–supported facilities are disproportionately young and
low-income,7 and these populations account for the majority of unintended pregnancies.1 Thus, even relatively small

Volume 49, Number 1, March 2017

increases in LARC use among this population could reduce
the incidence of unintended pregnancy and abortion.
Abortion incidence can also decline if women who want
abortions are unable to obtain them; abortion restrictions
have the potential to reduce abortion incidence by impeding access to services. Between 2008 and 2011, some 24
states enacted 106 abortion restrictions.2 However, no
strong evidence exists that these restrictions were the main
factor behind the decline in abortion. While some hospitals
and physicians’ offices provided abortions, the overwhelming majority of procedures—95%—were accounted for by
clinics.2 Between 2008 and 2011, the number of clinics
providing abortions declined by only 1%, and decreases
in abortion incidence occurred in almost all states, including states that enacted multiple restrictions and states that
enacted none.2 Some of the laws implemented in 2008–
2011 would not be expected to have a measurable impact
on abortion incidence—for example, regulations requiring that new information be added to existing counseling
materials. Additionally, 62 of the 106 abortion restrictions
were enacted in 2011, and many were not implemented or
enforced until late in the year. Thus, their impact might not
have been evidenced until 2012 (or later).
State efforts to restrict abortion have maintained their
momentum, and states have enacted hundreds of new
restrictions pertaining to abortion since 2011.8 Most
restrictions, such as mandated ultrasounds and in-person

By Rachel K. Jones
and Jenna Jerman
Rachel K. Jones is
principal research
scientist, and Jenna
Jerman is research
associate, both at the
Guttmacher Institute,
New York.

Additional supporting information
may be found in
the online version
of this article at the
publisher’s website.

© 2017 The Authors.
Perspectives
on Sexual and
Reproductive Health
published by
Wiley Periodicals,
Inc., on behalf of
the Guttmacher
Institute.
This is an open
access article under
the terms of the
Creative Commons
AttributionNonCommercialNoDerivs License,
which permits use
and distribution
in any medium,
provided the
original work
is properly
cited, the use is
noncommercial
and no modifications or adaptations
are made.

 Abortion Incidence and Service Availability in the United States, 2014

counseling requirements, are intended to discourage
women from having abortions, thereby reducing demand
for services.9 However, legislators have increased efforts to
restrict the provision of abortion, typically through targeted
regulation of abortion providers, or TRAP, laws.9,10 These
laws place burdensome regulations on abortion providers
and the facilities in which they work. Perhaps the most
high-profile case was Texas, which, in 2013, implemented
TRAP laws requiring that physicians who provided abortions have admitting privileges at nearby hospitals and that
clinics providing abortions meet the standards of ambulatory surgical centers. Following the implementation of
these laws, more than half of the 46 clinics in the state
closed, and the abortion rate had declined 13% by April
2014.11 In June 2016, the Supreme Court overturned both
provisions of this law,12 and in the succeeding four months,
the decision was cited three times to block enforcement of
abortion restrictions in Alabama,13 Florida14 and Indiana.15
Moreover, the Supreme Court has denied judicial review
to pending cases in Mississippi and Wisconsin,16 and more
TRAP laws are likely to be challenged. However, as of
August 1, 2016, some 24 states had implemented TRAP
laws, and these regulations may have affected access to
abortion in 2013 and 2014.17
When unable to access abortion services in the face of
restrictive laws, some women may turn to self-induced
abortion.18 One study estimated that as many as 100,000
women aged 18–49 residing in Texas had ever attempted
to end a pregnancy on their own,18 and a media analysis
found that interest in self-induced abortion—as measured
via Google searches—was higher in states with restrictive
abortion laws than in states without them.19 If substantial
numbers of women were able to have abortions outside of
a health care setting, the estimated incidence of abortions
occurring in clinical settings would be too low.
This study summarizes findings from the Guttmacher
Institute’s most recent Abortion Provider Census, reflecting
abortion incidence and the number of facilities providing
abortion in 2013 and 2014. Because of the important role
of clinics, we examine the abortion policy context in states
that experienced the greatest proportionate changes in the
number of these types of facilities.
METHODS

Survey Content and Fielding
Data for this study come from the Guttmacher Institute’s
2014 Abortion Provider Census, which surveyed the
known universe of abortion-providing facilities in the
United States.2 Questionnaires were similar to the instrument used in 2011; some modifications were made for
clarity, and several new items were added. Nonhospital
facilities (clinics and physicians’ offices) received a longer
questionnaire than hospitals because of differences in service provision. Regardless of facility type, all respondents
were asked the number of induced abortions that were
provided at their location in 2013 and 2014; hence, the
state in which a patient obtained an abortion was not nec-

essarily her state of residence. Past iterations of this survey
used a simple “yes/no” item to determine whether hospitals had provided terminations, and this was intended to
capture terminations for any reason. However, to ensure
that we were capturing all abortions, and not only elective
ones, the item was expanded to include specific reasons
for providing an abortion: for health indications (such as
fetal anomaly or health of the mother), because a patient
requested one and for other reasons. This strategy was also
adopted during nonresponse follow-up, when hospital
facilities were contacted by telephone.
In addition to the foregoing items, nonhospital facilities
were asked about the proportion of services accounted for
by abortion and the number of early medication abortions
provided. The survey instrument defined early medication
abortions as procedures performed up to nine weeks’ gestation; to ensure that we captured all such abortions (and
not just those done with mifepristone), we asked providers to identify the type of medication used, distinguishing
among mifepristone (with misoprostol), methotrexate and
misoprostol alone. The 2014 survey included two new
items for nonhospital facilities. We asked respondents to
estimate the total number of days on which the facility was
unable to provide abortion services in 2014 because of
efforts to come into compliance with local or state laws or
regulations. This item was intended to capture the potential impact of TRAP and other types of laws on abortion
services. In addition, we asked if the facility had treated any
patients for missed or failed abortion as a result of women’s
attempts to end a pregnancy on their own and, if yes, to
estimate the total number of patients seen for this reason.
This item was intended to serve as a crude measure of the
prevalence of self-induced abortion.
The survey universe comprised all facilities known to
have provided abortions in 2011, as well as possible new
abortion-providing facilities, as identified via Internet
searches, telephone directories, media articles and membership directories of organizations that work with abortion service providers. We mailed the first questionnaire to
all facilities in the universe in March 2015, and we followed
with two mailings at four-week intervals to nonrespondents. Intensive follow-up of nonrespondents was conducted via telephone, fax and e-mail between June 2015
and April 2016 to obtain completed questionnaires; these
efforts prioritized obtaining the total number of abortions
over other survey items. During this phase of data collection, more than 11,800 contacts were made with approximately 1,800 facilities, including administrators at facilities
that had closed.
We also requested abortion data from health department
agencies in the District of Columbia and the 45 states in
which they were available. Reliability and type of information available varied across states. Where possible, we
collected the number of abortions by facility, but most
commonly, we obtained information by county of occurrence or facility type; in some states, we were able to obtain
only the total number of abortions. This information was
Perspectives on Sexual and Reproductive Health

 used to supplement and validate information obtained
from abortion-providing facilities and was sometimes used
to generate estimates for nonresponding facilities.
Of the 2,313 facilities in the universe of potential
abortion-providing facilities, we collected data from 868
(38%) via the questionnaire and from 463 (20%) during
telephone follow-up. Health department data were used
to determine caseloads for 460 facilities (20%). We estimated abortion figures for 390 facilities (17%). For 265
of these, we based our estimates on abortion numbers
from previous census results and service patterns of other
abortion-providing facilities in the community; for another
125, we used information from key informants (e.g., grassroots organizations and individuals who were knowledgeable about reproductive health services in a community)
and the facilities’ websites. The majority of nonresponding facilities for which we made estimates (291 of the 390)
were hospitals and physicians’ offices, and both types of
facilities typically have small caseloads;2 75 of the 390 facilities were estimated to have provided no abortions during
the survey period. The remaining 132 facilities (6%)* in
the overall universe were found to be closed or to have
stopped providing abortion services.
Of the abortions counted in 2014, some 68% were
reported via questionnaire, and an additional 20% during nonresponse follow-up. Five percent of abortions were
reported by health departments, and 7% were estimated
using historical data and information from key informants
and facilities’ websites.† Notably, the extent to which
data had to be estimated was not uniform across states.
The highest proportions of missing data were seen in the
District of Columbia (12%), Florida (21%), Georgia (11%),
Hawaii (19%), Michigan (15%), New Jersey (16%), New
Mexico (21%) and Oklahoma (18%).
Undoubtedly, some facilities that provide abortion care,
especially those with small caseloads, are not known to us
and are excluded from our census. To address this issue,
we used the American Medical Association’s master list to
obtain a random sample of 2,000 physicians who identified their specialty as obstetrics and gynecology,‡ and
who provided a phone number; the latter was necessary
so that we could conduct phone follow-up. Notably, 49%
of all obstetrician-gynecologists on the master list did not
provide a phone number, and our strategy assumed that
these physicians did not differ from those who did with
regard to abortion provision. We mailed a survey to each
of the sample’s physicians asking, among other things,
whether they had provided abortions in 2014 and, if so,
how many. If a physician did not respond to any of three
mailings, we made up to three attempts to contact the
individual by phone. During fielding, we determined that
74 physicians in the sample were already known to us
to provide abortion services, and 432 physicians were
deceased, retired or unreachable because of incorrect
contact information; 551 did not respond to mailings or
telephone follow-up. The information we obtained from
the responding 943 physicians was used to estimate the
Volume 49, Number 1, March 2017

potential number of physicians’ offices and abortions
missed by our survey.
We obtained approval for this study through expedited
review by the Guttmacher Institute’s federally registered
institutional review board.

Analysis
Census Bureau data on the population of women aged
15–44 on July 1, 2013, and July 1, 2014, were used
as denominators for calculating abortion rates for the
entire United States and for each state and the District of
Columbia.20 We estimated the national abortion ratio as
the proportion of pregnancies (excluding those ending in
miscarriages) that ended in abortion. To do this, we combined our abortion counts with National Center for Health
Statistics data on the number of U.S. births in the one-year
periods beginning on July 1 of 2013 and 2014 (to match
conception times for births with those for abortions).21–23
We distinguished among four types of abortion-providing
facilities: abortion clinics, nonspecialized clinics, hospitals
and physicians’ offices. Abortion clinics are defined as nonhospital facilities in which half or more of patient visits are
for abortion services, regardless of annual abortion caseload. Nonspecialized clinics are nonhospital sites in which
fewer than half of patient visits are for abortion services.
Physicians’ offices are defined as facilities that provide
fewer than 400 abortions per year and have names suggesting that they are private practices. Physicians’ offices that
provide 400 or more abortions per year were categorized as
nonspecialized clinics; because of their relatively large caseload, we assume that their service provision more closely
mirrors that of a nonspecialized clinic.
Eighty percent of nonhospital facilities provided information on early medication abortion, 60% provided information on self-induced abortion and 63% answered items
about lost service days. Response rates to these measures
varied by facility type and caseload, and we constructed
weights to account for these differences.
Our analysis takes a particularly close look at states
that experienced the largest changes in clinics of both
types between 2011 and 2014. Specifically, we examined the 10 states that experienced the proportionately
largest declines in clinics and the 10 that exhibited the
largest increases, and compared three measures: the percentage change in abortion rate between 2011 and 2014,
the number of abortion restrictions enacted between
2012 and 2014, and whether the state had a TRAP law.
Information on state laws came from the Guttmacher
Institute.24–27 Appendix Table 1 (Supporting Information)
provides a list of laws and the states in which they were
implemented.
*Percentages add up to more than 100% because of rounding.
†Similarly, in 2011, some 86% of abortions were reported by facilities, 4%
were reported by health departments and 10% were estimated.
‡We excluded obstetrician-gynecologists who, because of their subspecialty, were highly unlikely to provide abortion care.

 Abortion Incidence and Service Availability in the United States, 2014

RESULTS

Abortion Incidence
The number of abortions and the abortion rate declined
steadily between 2011 and 2014, by 3–6% per year (Table 1).
In 2014, there were 926,200 abortions, and the abortion
rate was 14.6 abortions per 1,000 women aged 15–44.
This is the lowest rate since abortion was legalized nationally in 1973.3 Nineteen percent of pregnancies (excluding
miscarriages) ended in abortion in 2014, a decrease of 11%
from the 2011 figure of 21%.
Overall, the abortion rate declined 14% between 2011
and 2014, while the number of abortions dropped by 12%
(Table 2). The rate declined in almost all states. Increases
were generally small (1–4% in Arkansas, Kansas, Michigan,
Mississippi, North Carolina and Vermont), but the District of
Columbia had an increase of 15%. Three states experienced a
decline in the abortion rate that was at least twice the national
decline (Delaware, 41%; Hawaii, 33%; and Texas, 28%).
Abortion rates dropped in all four regions of the country,
but declines were steeper in the West and the South (16%
each) than in the Midwest (9%) and the Northeast (11%).
Following previous patterns, the Northeast maintained the
highest abortion rate, followed by the West, the South and the
Midwest. The five highest abortion rates were in the District
of Columbia, New York, New Jersey, Maryland and Florida;
rate declines in the four states ranged from 5% to 18%.

Facility Type and Numbers
In 2014, a total of 1,671 facilities provided at least one
abortion (Table 3). Abortion clinics accounted for 16% of
all facilities but for 59% of all abortions (Figure 1), largely
because a majority of these facilities had caseloads of 1,000
or more per year. Nonspecialized clinics represented 31%
of all known abortion-providing facilities and accounted
for 36% of abortions. While many of these clinics primarily serve contraceptive and family planning clients, about
half provided 400 or more abortions per year. Thirty-eight
percent of facilities were hospitals; however, most of these
provided fewer than 30 abortions per year, and these types
of facilities accounted for 4% of all abortions. Finally, private physicians’ offices made up 15% of abortion facilities
and provided 1% of procedures.
The total number of abortion facilities declined 3%
between 2011 and 2014, but the drop was particularly
marked among abortion clinics (17%), especially those
with caseloads of 1,000–4,999 per year (26%). The number of nonspecialized clinics that provided abortions
remained stable. The 7% increase in the number of hospitals providing abortions was likely due to the fact that
the 2014 survey did a better job of capturing abortions
provided for reasons of fetal or maternal indications. The
number of physicians’ offices providing abortions declined
by 14% between 2011 and 2014.
*In prior analyses, Wyoming was classified as not having any clinics that
provided abortion care.2 However, we have since determined that a facility previously classified as a physician’s office is a health clinic.

Six percent fewer clinics were providing abortions
in 2014 than in 2011 (Table 4). The number of clinics
decreased in 25 states, remained stable in 14 states and the
District of Columbia, and increased in 11 states. In 2014,
five states—Mississippi, Missouri, North Dakota, South
Dakota and Wyoming*—had only one clinic that provided
abortion services.
The Northeast was the only region that had more clinics
providing abortion services in 2014 than in 2011; the number increased by 14%, largely because of an increase from
24 to 41 in New Jersey. Most of the New Jersey facilities
were nonspecialized clinics that started offering early medication abortion (not shown). The Midwest experienced the
largest decline in clinics—22%, or 27 clinics. Most of this
decrease was accounted for by Michigan (which lost 10
clinics), Ohio (six) and Iowa (five). The South also experienced a substantial decline in clinics (13%); more than half
of this was accounted for by the loss of 18 clinics in Texas.
In the West, the number of clinics fell by 7%.
In 2014, some 90% of U.S. counties had no clinics that
provided abortion care, and 39% of women aged 15–44 lived
in those counties; these numbers were essentially unchanged
from the 2011 figures of 89% and 38%, respectively.2 Access
to abortion services appeared to be best in California,
Connecticut, the District of Columbia, Hawaii and Nevada,
where fewer than 10% of women lived in a county without
a clinic. More than 90% of women residing in Mississippi,
Missouri or Wyoming lived in a county without a clinic.
Of the 943 physicians from whom we obtained information, 58, or 6%, reported providing an average of

TABLE 1. Number of reported abortions, abortion rate
and abortion ratio, United States, 1995–2014
Year

No. (in 000s)

Rate*

Ratio†

1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014

1,359.4
1,360.2
[1,335.0]
[1,319.0]
1,314.8
1,313.0
[1,291.0]
[1,269.0]
[1,250.0]
1,222.1
1,206.2
[1,242.2]
1,209.6
1,212.4
[1,151.6]
1,102.7
1,058.5
[1,011.0]
958.7
926.2

22.5
22.4
[21.9]
[21.5]
21.4
21.3
[20.9]
[20.5]
[20.2]
19.7
19.4
[19.9]
19.4
19.4
[18.5]
17.7
16.9
[16.1]
15.2
14.6

25.9
25.9
[25.5]
[25.1]
24.6
24.5
[24.4]
[23.8]
[23.3]
22.9
22.4
[22.9]
21.9
22.5
[22.2]
21.7
21.2
[20.4]
19.4
18.8

*Abortions per 1,000 women aged 15–44 as of July 1 of each year. †Abortions
per 100 pregnancies ending in abortion or live birth; for each year, the ratio is
based on births occurring during the 12-month period starting in July of that
year. Note: Figures in brackets were estimated by interpolation of numbers of
abortions and adjustments made to state health department reports. Sources:
Number of abortions, population data and birth data, 1995–2011—references
2 and 3. Number of abortions, 2012—2010–2011 Guttmacher Abortion Provider Census and interpolations. Population data, 2012–2014—reference 20.
Birth data, 2012–2015—references 21–23.

Perspectives on Sexual and Reproductive Health

 TABLE 2. Number of reported abortions and abortion rate, selected years; and percentage change in rate, 2011–2014—all
by region and state in which the abortions occurred
Region and state

Number

Rate*

2011

2013

2014

2011

2013

2014

% change,
2011–2014

1,058,490

958,700

926,190

16.9

15.2

14.6

–14

Northeast
Connecticut
Maine
Massachusetts
New Hampshire
New Jersey
New York
Pennsylvania
Rhode Island
Vermont

272,020
14,640
2,360
24,030
3,200
46,990
138,370
36,870
4,210
1,370

195,330
13,320
2,190
20,890
2,320
43,670
119,170
32,370
3,550
1,490

240,320
13,140
2,220
21,020
2,540
44,460
119,940
32,030
3,580
1,400

24.6
21.3
9.9
17.8
12.9
27.1
34.2
15.1
19.8
11.7

17.7
19.4
9.3
15.3
9.5
25.3
29.4
13.4
16.9
12.8

21.8
19.2
9.5
15.3
10.4
25.8
29.6
13.3
17.0
12.1

–11
–10
–4
–14
–19
–5
–13
–12
–14
3

Midwest
Illinois
Indiana
Iowa
Kansas
Michigan
Minnesota
Missouri
Nebraska
North Dakota
Ohio
South Dakota
Wisconsin

153,380
44,580
9,430
5,640
6,940
29,190
11,140
5,820
2,570
1,250
28,590
600
7,640

143,650
43,400
8,600
4,900
7,470
28,800
10,030
5,470
2,230
1,180
24,560
600
6,410

138,940
42,270
8,180
4,380
7,240
29,120
9,760
5,130
2,280
1,260
22,730
550
6,050

11.7
17.0
7.3
9.7
12.5
15.3
10.7
5.0
7.2
9.5
12.9
3.9
7.0

10.9
16.6
6.7
8.4
13.4
15.2
9.5
4.7
6.2
8.4
11.1
3.8
5.9

10.6
16.3
6.3
7.5
12.9
15.4
9.3
4.4
6.3
8.7
10.3
3.5
5.6

–9
–4
–14
–23
4
1
–13
–12
–13
–8
–20
–11
–21

South
Alabama
Arkansas
Delaware
District of Columbia
Florida
Georgia
Kentucky
Louisiana
Maryland
Mississippi
North Carolina
Oklahoma
South Carolina
Tennessee
Texas
Virginia
West Virginia

356,790
9,550
4,370
5,090
4,750
84,990
34,910
3,970
12,210
34,260
2,220
28,600
5,860
6,620
16,720
73,200
27,110
2,390

330,790
8,420
4,470
3,190
5,650
77,020
33,550
3,700
9,890
29,360
2,210
30,550
5,770
6,350
15,180
67,530
25,890
2,070

308,060
8,020
4,590
3,010
5,820
75,990
33,000
3,530
10,150
28,140
2,290
29,960
5,330
6,040
13,880
55,230
21,080
2,020

15.2
10.0
7.6
28.4
28.5
23.7
16.8
4.6
13.1
28.6
3.7
14.6
7.9
7.1
13.1
13.5
16.3
7.0

13.9
8.8
7.8
17.8
32.2
21.1
16.0
4.3
10.5
24.5
3.7
15.5
7.6
6.8
11.8
12.1
15.4
6.1

12.9
8.3
8.0
16.7
32.7
20.6
15.7
4.1
10.8
23.4
3.8
15.1
7.0
6.4
10.7
9.8
12.5
6.0

–16
–16
4
–41
15
–13
–7
–11
–18
–18
3
3
–12
–10
–18
–28
–23
–14

West
Alaska
Arizona
California
Colorado
Hawaii
Idaho
Montana
Nevada
New Mexico
Oregon
Utah
Washington
Wyoming

276,300
1,820
16,100
181,730
14,710
5,580
1,680
2,220
11,290
5,180
10,690
3,290
21,880
120

245,290
1,570
13,580
164,190
12,870
4,250
1,350
1,840
9,810
4,200
9,130
3,170
19,190
140

238,860
1,470
12,870
157,350
13,160
3,760
1,320
1,690
10,970
4,650
9,330
2,960
19,230
120

18.5
12.4
12.7
23.0
14.2
21.1
5.4
12.3
20.6
13.0
14.1
5.4
16.0
1.1

16.2
10.7
10.5
20.5
12.0
15.9
4.3
10.0
17.5
10.5
11.9
5.0
13.8
1.3

15.6
10.0
9.8
19.5
12.1
14.0
4.2
9.1
19.4
11.7
12.0
4.6
13.7
1.1

–16
–20
–22
–15
–14
–33
–23
–26
–6
–10
–15
–14
–14
–4

U.S. total

*Abortions per 1,000 women aged 15–44. Note: Numbers of abortions are rounded to the nearest 10. Sources: See Table 1.

25 abortions per year. Assuming the respondents were
representative of the universe of 33,379 practicing
obstetrician-gynecologists in the United States,28 our main
survey missed 2,069 physicians, who collectively provided
51,725 abortions in 2014. If this estimate is correct, our
study undercounted the total number of abortions by 5%.
Volume 49, Number 1, March 2017

Early Medication Abortion
In 2014, an estimated 272,400 early medication abortions were provided in nonhospital facilities, representing
a 14% increase since 2011 (Table 5). Early medication
abortions accounted for 31% of all nonhospital abortions, compared with 24% in 2011. Half or more of all

 Abortion Incidence and Service Availability in the United States, 2014

TABLE 3. Number of abortion-providing facilities, by type
of facility and caseload, 2011 and 2014; and percentage
change between these years
Facility type
and caseload

2011

2014

% change

Total
1–29
30–399
400–999
1,000–4,999
>
_ 5,000

1,720
610
534
227
329
20

1,671
659
477
247
269
19

–3
8
–11
9
–18
–5

Abortion clinics
1–29
30–399
400–999
1,000–4,999
>
_ 5,000

329
0
20
50
244
15

272
1
23
51
180
17

–17
na
15
2
–26
13

Nonspecialized clinics
1–29
30–399
400–999
1,000–4,999
>
_ 5,000

510
50
216
158
81
5

516
52
198
178
86
2

1
4
–8
13
6
–60

Hospitals
1–29
30–399
400–999
1,000–4,999
>
_ 5,000

595
400
172
19
4
0

638
463
154
18
3
0

7
16
–10
–5
–25
na

Physicians’ offices*
1–29
30–399
400–999
1,000–4,999
>
_ 5,000

286
160
126
na
na
na

245
143
102
na
na
na

–14
–11
–19
na
na
na

*Offices that reported 400 or more abortions a year were classified as nonspecialized clinics. Note: na=not applicable. Source: 2011 data—reference 2.

FIGURE 1. Percentage of abortion-providing facilities accounted for by each facility
type, and percentage of abortions that are performed in each type of facility, 2014

%

100
90
80
70
60
50
40
30
20
10
0

Abortion clinics

Nonspecialized clinics
Facilities

Hospitals

Physicians offices

Abortions

abortions (50–68%) provided by facilities with annual
caseloads of fewer than 400 procedures were early medication abortions.
We assumed that the majority of facilities provided medication abortion up to nine weeks’ gestation; this was the
gestational limit defined on the survey. Using gestational
data from the Centers for Disease Control and Prevention,
we estimated that 45% of abortions up to nine weeks’

gestation in 2014 were early medication procedures (not
shown), up from approximately 36% in 2011.* While
other drugs can be administered in early medication abortion, the overwhelming majority—97%—were done with
mifepristone; the remaining procedures used methotrexate
or misoprostol alone.
The use of early medication abortion increased across
all facility types and sizes between 2011 and 2014. While
abortion clinics saw only a 2% increase, nonspecialized
clinics and physicians’ offices reported increases of 26%
and 20%, respectively. Though nonspecialized clinics
accounted for 36% of all abortions, they provided 51% of
all early medication abortions.
For 2014, we estimated that 900 nonhospital
facilities—87% of all nonhospital provider sites—
provided early medication abortion (not shown). The
overwhelming majority of both abortion clinics (99.8%)
and nonspecialized clinics (88%) offered this service. At
least 23% of all nonhospital facilities offered only early
medication abortions; most of these facilities were nonspecialized clinics, and 38% of such clinics offered only
early medication abortion. Most facilities that provided
only early medication abortions were located in areas
that were also served by facilities offering surgical abortion, though 11 were the sole abortion-providing facility
in the metropolitan statistical area in which they were
located.

State Abortion Policy Context
Abortion restrictions were associated with a decrease
in the number of abortion and nonspecialized clinics,
but fluctuations in clinic numbers—whether decreases
or increases—were not clearly associated with abortion
rates. Eight of the 10 states that experienced the largest
proportionate declines in the number of clinics over the
period 2011–2014 implemented at least one new abortion restriction between 2012 and 2014, and six enacted
three or four (Table 6). Four states—Arizona, Michigan,
Ohio and Texas—implemented TRAP regulations during this period, and four had TRAP laws in place prior
to 2012.29 Hawaii and Iowa experienced substantial
declines in the number of clinics providing abortions,
but enacted no new abortion restrictions and, along with
Montana, had no TRAP laws.
Seven of the states that experienced the largest proportionate declines in clinics also experienced a larger than
average decline in the abortion rate. However, the states
with the two largest proportionate declines in clinic
numbers—Missouri and Utah—experienced declines in
the abortion rate that were comparable to the national
average. And while Michigan had 33% fewer clinics in

*If, in 2014, all nonhospital facilities were already adhering to the
evidence-based regimen that the U.S. Food and Drug Administration
approved in May 2016, and early medication abortion was allowed up to
70 days’ gestation, these procedures would have accounted for 39% of
eligible procedures.

Perspectives on Sexual and Reproductive Health

 TABLE 4. Number of abortion-providing facilities and number of clinics, 2011 and 2014, and percentage change between these years; number of counties and percentage with no clinic, 2014; and percentage of women aged 15–44 living in counties with no clinic, 2014—all by region and state
Region and state

All facilities

Clinics

2011

2014

2011

2014

1,720

1,671

–3

839

788

Northeast
Connecticut
Maine
Massachusetts
New Hampshire
New Jersey
New York
Pennsylvania
Rhode Island
Vermont

453
41
11
40
13
64
225
47
4
8

476
59
9
43
12
79
218
42
5
9

5
44
–18
8
–8
23
–3
–11
25
13

186
21
5
12
5
24
94
20
2
3

Midwest
Illinois
Indiana
Iowa
Kansas
Michigan
Minnesota
Missouri
Nebraska
North Dakota
Ohio
South Dakota
Wisconsin

173
37
12
18
3
41
15
5
5
1
26
2
8

142
40
11
13
4
29
11
2
5
1
17
2
7

–18
8
–8
–28
33
–29
–27
–60
0
0
–35
0
–13

South
Alabama
Arkansas
Delaware
District of Columbia
Florida
Georgia
Kentucky
Louisiana
Maryland
Mississippi
North Carolina
Oklahoma
South Carolina
Tennessee
Texas
Virginia
West Virginia

357
8
5
8
9
88
28
3
7
34
2
36
5
9
14
62
35
4

336
9
4
6
9
86
28
3
5
41
2
37
5
7
11
44
34
5

West
Alaska
Arizona
California
Colorado
Hawaii
Idaho
Montana
Nevada
New Mexico
Oregon
Utah
Washington
Wyoming

737
9
17
512
42
33
4
8
14
12
29
9
45
3

717
8
12
512
36
29
5
5
13
11
27
6
50
3

U.S. total

% change

Counties, 2014
% change

% of women in counties
with no clinic, 2014*

No.

% with no clinic

–6

3,142

90

39

212
25
4
14
4
41
95
20
3
6

14
19
–20
17
–20
71
1
0
50
100

217
8
16
14
10
21
62
67
5
14

60
13
81
43
60
33
44
85
80
64

23
5
55
14
30
23
10
48
36
38

124
26
10
17
3
30
7
4
3
1
18
1
4

97
24
9
12
4
20
6
1
3
1
12
1
4

–22
–8
–10
–29
33
–33
–14
–75
0
0
–33
0
0

1,055
102
92
99
105
83
87
115
93
53
88
66
72

95
92
95
89
97
89
95
99
97
98
93
98
96

55
40
66
42
56
40
59
94
41
73
56
77
67

–6
13
–20
–25
0
–2
0
0
–29
21
0
3
0
–22
–21
–29
–3
25

245
6
3
4
5
72
19
2
7
21
1
21
3
3
9
46
21
2

214
5
3
3
5
71
17
2
5
25
1
16
3
3
7
28
18
2

–13
–17
0
–25
0
–1
–11
0
–29
19
0
–24
0
0
–22
–39
–14
0

1,422
67
75
3
1
67
159
120
64
24
82
100
77
46
95
254
133
55

93
93
97
33
0
70
96
98
92
67
99
90
96
93
96
96
92
98

51
59
77
18
0
20
58
74
63
24
91
53
54
71
63
43
78
90

–3
–11
–29
0
–14
–12
25
–38
–7
–8
–7
–33
11
0

284
4
15
160
24
6
2
7
8
7
15
4
32
1

265
3
9
152
21
4
3
5
8
9
15
2
33
1

–7
–25
–40
–5
–13
–33
50
–29
0
29
0
–50
3
0

448
29
15
58
64
5
44
56
17
33
36
29
39
23

80
90
80
43
78
40
95
93
88
91
78
97
64
96

17
37
19
5
27
5
68
55
9
48
30
62
15
96

*Population counts are for July 1, 2014.20 Source: 2011 data—reference 2.

2014 than in 2011, the state’s abortion rate increased
slightly.
Patterns among the 10 states with the largest
proportionate increases in the number of clinics further
demonstrated that changes in clinic numbers and abortion
rates were not clearly related. The abortion rate declined in
Volume 49, Number 1, March 2017

eight of these states and increased slightly (3–4%) in two.
Only one of these 10 states enacted new abortion restrictions between 2012 and 2014; Kansas enacted four new
provisions, even as one new facility opened. Two states—
Rhode Island and Connecticut—had implemented TRAP
laws prior to 2012.

 Abortion Incidence and Service Availability in the United States, 2014

TABLE 5. Number of early medication abortions provided at nonhospital facilities,
2011 and 2014, and percentage change between these years; and these abortions as
a percentage of all nonhospital abortions—all by facility type and by caseload
Facility type
and caseload

Number

% of all nonhospital
abortions

2011

2014

% change

2011

2014

239,400

272,400

14

24*

31

Facility
Abortion clinics
Nonspecialized clinics
Hospitals
Physicians’ offices

123,400
111,100
u
4,900

126,300
140,200
u
5,900

2
26
u
20

18
33
u
35

23
42
u
46

Caseload
1–29
30–399
400–999
1,000–4,999
>
_ 5,000

1,000
31,700
41,700
142,500
22,600

1,100
37,000
66,000
144,100
24,200

10
17
58
1
7

43*
54*
30*
21
17

50
68
44
26
19

Total

*Previously published figure was incorrect and has been adjusted to exclude abortions performed in hospitals. Notes: Early medication abortions are those performed with mifepristone, methotrexate or misoprostol
alone. Numbers of abortions are rounded to the nearest 100. u=unavailable. Source: 2011 data—reference 2.

Other Potential Impacts of Restrictions
Overall, 4% of nonhospital facilities (located in 15 states)
reported being unable to provide care on one or more days
in order to be in compliance with local or state regulations (not shown). These closures presumably occurred in
response to state inspections, as well as TRAP and other
types of laws. Facilities in the South were the most likely to
report lost days (15%),* followed by those in the Midwest
(5%). Only 1% of nonhospital facilities in the Northeast
and the West reported lost service days.
Twelve percent of nonhospital facilities reported treating at least one patient who had attempted to end her
pregnancy on her own in 2014 (not shown). This figure
included facilities in 30 states, but there were regional variations: The proportion of facilities that had treated such
patients was higher in the South and the Midwest (21%
and 16%, respectively) than in the West (10%) and the
Northeast (8%). More than two-thirds of facilities were able
to quantify this caseload, and three-quarters reported having treated 10 or fewer of these patients in 2014.
DISCUSSION
The long-term decline in abortion continued through
2014; in that year, the abortion rate and ratio were both
lower than those documented in 1973, the year abortion
was legalized nationwide. The drop in abortion was found
in all but six states and the District of Columbia, though
there was substantial variation across states. It is beyond
the scope of this descriptive study to explore the larger
dynamics responsible for these patterns, but we suggest
several potential factors that may have contributed to some
of the observed patterns.
*Facilities that reported lost days in the South were located in nine states;
one-third were in Texas.

Abortion incidence can be affected by service availability. The overwhelming majority of abortions—95%—are
provided by abortion clinics and nonspecialized clinics, and
6% fewer clinics provided abortions in 2014 than in 2011.
Declines in the numbers of clinics were most pronounced
in the Midwest (22%) and the South (13%), regions of
the country where the majority of new abortion restrictions were enacted during the study period.26,27 However,
regional patterns in clinic numbers did not always correspond with changes in abortion rates, as rate declines were
steepest in the West and the South (both 16%) and lowest
in the Midwest (9%). And while the Northeast had more
clinics providing abortion care in 2014 than in 2011, that
region’s abortion rate declined 11%. These patterns demonstrate that the relationship between abortion access, as
measured by numbers of clinics, and abortion rates is not
straightforward. These trends may obscure more nuanced
relationships between clinics with the largest caseloads
and abortion rates. For example, abortion clinics provided
the majority of abortions in 2014 (59%), but the number of such clinics with annual caseloads of 1,000–4,999
declined by 26%.
Six of the 10 states that experienced the greatest proportionate declines in the number of clinics enacted three or
four new abortion restrictions between 2012 and 2014,
and four of these states implemented new TRAP laws. At
the same time, however, two of the 10 states did not enact
new restrictions during this period, and three had no TRAP
laws. Thus, restrictions alone do not account for declines
in clinic numbers. Michigan and Ohio both experienced
a 33% decline in the number of clinics providing abortion services, and both implemented multiple restrictions,
including TRAP laws, between 2012 and 2014. However,
some Michigan facilities located near the Ohio border were
able to both meet the TRAP requirement and expand services to meet increased demand from women in the neighboring state.30 This may have been one reason why the
abortion rate in Michigan increased slightly.
Hawaii and Iowa experienced larger than average
declines in both numbers of clinics and abortion rates, and
neither had TRAP laws or enacted new abortion restrictions. The decline in abortion incidence in Iowa may have
been due to reduced levels of unintended pregnancy. In
2006, Iowa expanded access to family planning for lowincome women, and between 2007 and 2013, a privately
funded initiative sought to increase access to LARC methods among the same population.31 Areas of the state with
the most exposure to these programs experienced larger
declines in abortion than did those with less exposure.31
We are not aware of similar programs or initiatives in
Hawaii, and it is unclear what accounted for the changes
there. The loss of two abortion-providing clinics may
have reduced access to the procedure. However, only 5%
of women in Hawaii lived in a county without a clinic in
2014, so this seems unlikely. Alternately, because 19% of
abortions in Hawaii were estimated using information from
sources other than the facilities where the abortions were
Perspectives on Sexual and Reproductive Health

 TABLE 6. Number of clinics providing abortions in 2011 and 2014, and percentage change between these years; percentage
change in abortion rates, 2011–2014; number of new abortion restrictions enacted in 2012–2014; and status of TRAP laws—
all among states with the largest proportionate changes in numbers of clinics
State

No. of clinics

% change in
abortion rate,
2011–2014

No. of restrictions TRAP laws
enacted in
Existed prior
2012–2014
to 2012

Enacted in
2012–2014
9

2011

2014

839

788

–6

–14

84

46

States with largest declines
Missouri
Utah
Arizona
Texas
Hawaii
Michigan
Ohio
Iowa
Louisiana
Montana

4
4
15
46
6
30
18
17
7
7

1
2
9
28
4
20
12
12
5
5

–75
–50
–40
–39
–33
–33
–33
–29
–29
–29

–12
–14
–22
–28
–33
1
–20
–23
–18
–26

3
1
4
3
0
3
3
0
4
1

X
X

States with largest increases
Vermont
New Jersey
Idaho
Rhode Island
Kansas
New Mexico
Connecticut
Maryland
Massachusetts
Washington

3
24
2
2
3
7
21
21
12
32

6
41
3
3
4
9
25
25
14
33

100
71
50
50
33
29
19
19
17
3

3
–5
–23
–14
4
–10
–10
–18
–14
–14

0
0
0
0
4
0
0
0
0
0

Total

% change

X

X
X
X
X

X

X

X

Note: TRAP=targeted regulation of abortion providers.

performed, we may have underestimated the number of
procedures that occurred, and the actual change in abortion incidence may be smaller (or larger).
At least some of the decline in abortion across the United
States likely is due to declines in unintended pregnancy. Use
of LARC methods increased 36% among all women using
contraceptives between 2009 and 2012,5 and 48% among
clients at Title X–supported family planning facilities.6
Clients at the latter facilities are disproportionately young
adults and lower income women, two groups who are at the
highest risk for unintended pregnancy.1 Additionally, reliance on LARC methods has been increasing since 2002,4
and this may have had a cumulative effect. For example,
the most commonly used IUD is effective for five (or more)
years, and the implant for three; if a majority of women
who received LARC methods in 2011 were still using them
in 2014, they would have been protected from unintended
pregnancy during the entire study period.

Limitations
We are aware of several shortcomings of our study. We
obtained responses from only 58% of facilities that we
believed provided abortions in 2014. Health department
data, which can be of variable quality, were used to determine caseloads for 20% of facilities, and we estimated
caseloads for 17%. Moreover, some states required more
estimation than others. The overwhelming majority of the
abortions that we counted—88%—were based on information given to us by providers, but the fact that 12% were
Volume 49, Number 1, March 2017

estimated using other sources may introduce inaccuracy
into the data.
Undoubtedly, some abortion-providing facilities were not
counted because we were unable to identify them. Our survey of a random sample of obstetrician-gynecologists suggests that some 2,000 physicians who provide abortions in
their private practice were not captured in our study; hence
our estimate of abortions may be 5% lower than it would
have been if these providers had been included.
While we are confident that our study captured most, if
not all, clinics that provide abortion services, we are aware
that some of the information in this study is already out
of date. The media have closely monitored clinic closures
(and reopenings) in Texas; as of June 2016, some 18–21
clinics were providing abortion services there,32 whereas we
counted 28. In part, this difference is due to our inclusion
of facilities that provided at least one abortion in 2014; a
number of clinics closed at some point in that year, many in
response to the TRAP laws,11,33 and more facilities closed in
2015.34,35 Substantial numbers of clinics may have closed in
other states as well, while other facilities may have opened
(or reopened).
Some evidence suggests that women who live in states
that have restrictive abortion laws are turning to selfinduced abortion,18,19 but our study did not capture abortions that occurred outside of medical settings.36 Overall,
12% of nonhospital facilities had seen at least one patient
who had attempted to end her pregnancy on her own in
2014, and reports of self-induction were greater in the

 Abortion Incidence and Service Availability in the United States, 2014

South and the Midwest, regions that had higher numbers
of abortion restrictions.26,27 If reliance on self-induced abortion was higher in 2014 than in 2011, the observed decline
in abortion would not be as large as our findings suggest.
Our abortion counts and rates are tabulated by state of
occurrence. The five states with the lowest abortion rates
were Wyoming, South Dakota, Mississippi, Kentucky and
Idaho. Data from the Centers for Disease Control and
Prevention suggest that in 2012, some 14% of abortion
patients who lived in South Dakota went out of state for
services, as did more than 90% of abortion patients who
lived in Wyoming.37 Thus, the abortion numbers and
rates in this study do not always reflect abortion incidence
among women who reside in a given state.

Conclusions
Abortion is an important indicator of unintended pregnancy, but it is unclear whether the most recent decline in
abortion is due to fewer women’s having unintended pregnancies, more women’s being unable to access abortion services or some combination of these dynamics. That there
were fewer clinics providing abortions in 2014 than in
2011 could be attributed to several factors. In some states,
increased abortion restrictions likely contributed to the
decline in abortions, but in others, the decline may have
been driven by a drop in demand. For example, increased
reliance on LARC methods likely contributed to the decline
in unintended pregnancy that occurred between 2008 and
2011.1 If women continued to experience fewer unintended pregnancies in 2014, there may have been less need
for abortion services and, in turn, decreased need for providers. Future research should aim to elucidate patterns
in abortion incidence and numbers of abortion-providing
facilities and identify reasons for change. In addition,
because state legislatures continued to pass new abortion
restrictions in 2015 and 2016, subsequent research will
need to monitor the accessibility of abortion services.
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Acknowledgments
The authors thank Alexandra Arpaia, Silvia Beltran, Kristen Burke,
Kate Castle, Meghan Ingerick, Rachel Schwab, Raina Suski and
Elizabeth Witwer for research assistance; Elizabeth Nash for assistance with state policy documentation; and Rachel Benson Gold,
Lawrence Finer, Kathryn Kost and Elizabeth Nash for reviewing
early versions of this article.

Author contact: rjones@guttmacher.org