Abortion Surveillance — United States, 2020

Description of the Surveillance System

Each year, CDC requests aggregate data from the central health agencies of the 50 states, the District of Columbia, and New York City to document the number and characteristics of women obtaining legal induced abortions in the United States. Not all persons who obtain abortions identify as women; the term “women” has been maintained in this report to be consistent with the collection and reporting of denominator data used to calculate abortion rates and ratios. This report contains data voluntarily reported to CDC as of August 19, 2022. For the purpose of surveillance, legal induced abortion is defined as an intervention performed within the limits of state law by a licensed clinician (e.g., a physician, nurse-midwife, nurse practitioner, or physician assistant) intended to terminate a suspected or known intrauterine pregnancy and that does not result in a live birth. This definition excludes management of intrauterine fetal death, early pregnancy failure/loss, ectopic pregnancy, or retained products of conception. All abortions in this report are considered to be legally induced unless stated otherwise.

In most states and jurisdictions, collection of abortion data are facilitated by a legal requirement for hospitals, facilities, or physicians to report abortions to a central health agency (13); however, reporting is not complete in all areas, including in certain areas with reporting requirements (14). Because the reporting of abortion data to CDC is voluntary, many reporting areas have developed their own data collection forms and might not collect or provide all the information requested by CDC. As a result, the level of detail reported by CDC might vary from year to year and by reporting area. To encourage uniform collection of data, CDC has collaborated with the National Association for Public Health Statistics and Information Systems (NAPHSIS) to develop reporting standards and provide technical guidance for vital statistics personnel who collect and summarize abortion data within the United States.

Variables and Categorization of Data

Each year, CDC sends a suggested template to central health agencies in the United States for compilation of aggregate abortion data among women obtaining legal induced abortions. Aggregate abortion numbers, without individual-level records, are requested for the following variables:

• Age group in years of women obtaining legal induced abortions (<15, 15–19 [age group and by individual year], 20–24, 25–29, 30–34, 35–39, or ≥40)

• Gestational age of pregnancy in completed weeks at the time of abortion (≤6, 7–20 by individual week, or ≥21)

• Race (Black, White, or other [including Asian, Pacific Islander, other races, and multiple races]), ethnicity (Hispanic or non-Hispanic), and race by ethnicity

• Method type (surgical abortion, intrauterine instillation, medical [nonsurgical] abortion, or hysterectomy/hysterotomy)

• Marital status (married [including currently married or separated] or unmarried [including never married, widowed, or divorced])

• Number of previous live births (zero, one, two, three, or four or more)

• Number of previous induced abortions (zero, one, two, or three or more)

• Residence (the state, jurisdiction, territory, or foreign country in which the women obtaining the abortion lived, or, if additional details are unavailable, in-reporting area versus out-of-reporting area)

In addition, the template provided by CDC requests that aggregate abortion numbers for certain variables be cross-tabulated by a second variable. The cross-tabulations presented in this report include weeks of gestation separately by method type, by age group, and by race or ethnicity.

Beginning with 2014 data, instead of reporting the clinician’s estimates of gestational age or estimates of gestational age based on last menstrual period, certain areas have reported “probable postfertilization age,” “clinician’s estimate of gestation based on date of conception,” and “probable gestational age” to CDC. To ensure consistency between data reported as postfertilization age and the data collection practices for gestational age recommended by CDC’s National Center for Health Statistics (15), 2 weeks were added to probable postfertilization age. This method was used to account for time after last menstrual period until ovulation in a standard 28-day cycle because fertilization occurs around the time of ovulation (16). No modifications were made to data reported as clinician’s estimate of gestational age based on date of conception or data reported as probable gestational age.

In this report, medical and surgical abortions are further categorized by gestational age when available in the categories reported to CDC. Early medical abortion is defined as the administration of medications (typically mifepristone followed by misoprostol) to induce an abortion at ≤9 completed weeks’ gestation consistent with U.S. Food and Drug Administration (FDA) labeling for mifepristone that was implemented in 2016 (17). CDC collects information only on the estimated number of weeks (not days) of gestation and acknowledges the conventional use of completed weeks of gestation to describe pregnancy duration; therefore, CDC’s category of ≤9 weeks’ gestation includes abortions through 9 weeks and 6 days. Medications (typically serial prostaglandins, sometimes administered after mifepristone) also might be used to induce an abortion at >9 weeks’ gestation. Surgical abortions, which include uterine aspiration (i.e., dilation and curettage, aspiration curettage, suction curettage, manual vacuum aspiration, menstrual extraction, or sharp curettage) and dilation and evacuation procedures, are categorized as having been performed at ≤13 weeks’ gestation or at >13 weeks’ gestation because of differences in surgical technique at these gestational ages (18). Finally, because intrauterine instillations are unlikely to be performed early in gestation (19), abortions reported to have been performed by intrauterine instillation at ≤12 weeks’ gestation are excluded from calculation of the percentage of abortions by known method type and are grouped with unknown type.

Measures of Abortion

Four measures of abortion are presented in this report: 1) the number of abortions in a given population, 2) the percentage of abortions by selected characteristics, 3) the abortion rate (number of abortions per 1,000 women within a given population), and 4) the abortion ratio (number of abortions per 1,000 live births within a given population). Abortion rates adjust for differences in population size. Abortion ratios measure the relative number of pregnancies in a population that end in abortion compared with live birth.

The U.S. Census Bureau estimates of the resident female population were used as the denominator for calculating abortion rates (20–29). Overall abortion rates were calculated from the population of women aged 15–44 years living in the reporting areas that provided continuously reported data. For adolescents aged <15 years, abortion rates were calculated using the number of adolescents aged 13–14 years as the denominator; for women aged ≥40 years, abortion rates were calculated using the number of women aged 40–44 years as the denominator. For the calculation of abortion ratios, live birth data were obtained from CDC natality files and included births to women of all ages living in the reporting areas that provided abortion data (30,31). For calculation of the total abortion rates and total ratios only, women with unknown data on selected characteristics (e.g., age, race or ethnicity, and marital status) were distributed according to the distribution of abortions among those with known information on the characteristic. For calculation of totals only, abortions for women with an unknown gestational age of pregnancy but known method type were distributed according to the distribution of abortions among those with known information on method type by gestational age to the following categories: surgical, ≤13 weeks’ gestation; surgical, >13 weeks’ gestation; medical, ≤9 weeks’ gestation; and medical, >9 weeks’ gestation.

Data Presentation and Analysis

This report provides aggregate and reporting area–specific abortion numbers, rates, and ratios for the 49 areas that reported to CDC for 2020, which excluded California, Maryland, and New Hampshire. In addition, this report describes characteristics of women who obtained abortions in 2020. The data in this report are presented by the reporting area in which the abortions were performed.

The completeness and quality of data received vary by year, by variable, and by reporting area; this report only describes the characteristics of women obtaining abortions in reporting areas that met CDC reporting standards (i.e., reported at least 20 abortions overall, provided data categorized in accordance with requested variables, and had <15% unknown values for a given characteristic). Cells with a numerical value in the range of 1–4 and cells that would allow for calculation of these values have been suppressed in this report to maintain confidentiality in tables presented by reporting area of occurrence.

The percentage change in abortion measures (number, rate, and ratio of reported abortions) from the most recent past year (2019 to 2020) and during the 10-year period of analysis (2011–2020) were calculated for the 48 areas that reported every year during 2011–2020. The percentage change was also calculated and reported for abortions by age group, weeks of gestation, and early medical abortions (≤9 completed weeks’ gestation) for areas that met reporting standards for these variables every year during 2011–2020. As a result, aggregate measures for 2020 in percentage change analyses might differ from the point estimates reported for 2020. These data describe the percentage changes in abortion measures over time and abortions measures among groups for each characteristic. No statistical testing was performed. Comparisons do not imply statistical significance, and lack of comment regarding the difference between values does not imply that no statistically significant difference exists.

Abortion Mortality

CDC has reported data on abortion-related deaths periodically since information on abortion mortality first was included in the 1972 abortion surveillance report (7,32). An abortion-related death is defined as a death resulting from a direct complication of an abortion (legal or illegal), an indirect complication caused by a chain of events initiated by an abortion, or an aggravation of a pre-existing condition by the physiologic effects of abortion. An abortion is categorized as legal when it is performed by a licensed clinician within the limits of state law.

Since 1987, CDC has monitored abortion-related deaths through PMSS, which includes data from all 50 states, the District of Columbia, and New York City (33). Sources of data to identify abortion-related deaths have included state vital records; media reports, including computerized searches of full-text newspaper and other print media databases; and individual case reports by public health agencies, including maternal mortality review committees, health care providers and provider organizations, private citizens, and citizen groups. For each death that is possibly related to abortion, CDC requests clinical records and autopsy reports. Two medical epidemiologists independently review these reports to determine the cause of death and whether the death was abortion related. Discrepancies are discussed and resolved by consensus. Each death is categorized by abortion type as legal induced, illegal induced, spontaneous, or unknown type.

This report provides PMSS data on induced abortion-related deaths that occurred in 2019, the most recent year for which PMSS data are available. For 1998–2019, abortion surveillance data reported to CDC cannot be used alone to calculate national case-fatality rates for legal induced abortions (number of legal induced abortion-related deaths per 100,000 reported legal induced abortions in the United States) because eight reporting areas did not report abortion data every year during this period (Alaska, 1998–2000; California, 1998–2019; the District of Columbia, 2016; Louisiana, 2005; Maryland, 2007–2019; New Hampshire, 1998–2019; Oklahoma, 1998–1999; and West Virginia, 2003–2004). Thus, denominator data for calculation of national legal induced abortion case-fatality rates were obtained from a published report by the Guttmacher Institute that includes estimated total numbers of abortions in the United States from a national survey of abortion-providing facilities (6,34). The case-fatality rate was calculated using denominator data for 2019. Because rates determined on the basis of a numerator <20 are unstable (35), national case-fatality rates for legal induced abortion were calculated for consecutive 5-year periods during 1973–2012 and then for a consecutive 7-year period during 2013–2019.

Total Abortions Reported to CDC by Occurrence

Among the 49 reporting areas that provided data for 2020, a total of 620,327 abortions were reported. Of these abortions, 615,911 (99.3%) were from 48 reporting areas that provided data every year during 2011–2020. In 2020, these continuously reporting areas had an abortion rate of 11.2 abortions per 1,000 women aged 15–44 years and an abortion ratio of 198 abortions per 1,000 live births (Table 1). From 2019 to 2020, the total number of reported abortions decreased 2% (from 625,346 total abortions), the abortion rate decreased 2% (from 11.4 abortions per 1,000 women aged 15–44 years), and the abortion ratio increased 2% (from 195 abortions per 1,000 live births). From 2011 to 2020, the total number of reported abortions decreased 15% (from 727,554), the abortion rate decreased 18% (from 13.7 abortions per 1,000 women aged 15–44 years), and the abortion ratio decreased 9% (from 217 abortions per 1,000 live births) (Figure).

In 2020, there was a considerable range by reporting area of occurrence in abortion rates (from 0.1 to 23.0 abortions per 1,000 women aged 15–44 years in Missouri and the District of Columbia) and abortion ratios (from two to 498 abortions per 1,000 live births in Missouri and the District of Columbia) (Table 2). The percentage of abortions obtained by out-of-area residents also varied among reporting areas (from 0.5% in Arizona to 70.7% in the District of Columbia).

Age Group, Race or Ethnicity, and Marital Status

Among the 48 areas that reported abortion numbers by women’s age for 2020, women in their 20s accounted for more than half of abortions (57.2%) (Table 3). Women aged 20–24 and 25–29 years accounted for the highest percentages of abortions (27.9% and 29.3%, respectively) and had the highest abortion rates (19.2 and 19.0 abortions per 1,000 women aged 20–24 and 25–29 years, respectively). By contrast, adolescents aged <15 years and women aged ≥40 years accounted for the lowest percentages of abortions (0.2% and 3.7%, respectively) and had the lowest abortion rates (0.4 and 2.6 abortions per 1,000 women aged <15 and ≥40 years, respectively). However, abortion ratios were highest among adolescents (859 and 363 abortions per 1,000 live births among those aged <15 years and 15–19 years, respectively) and lowest among women aged 25–39 years (205, 136, and 144 abortions per 1,000 live births among those aged 25–29, 30–34, and 35–39 years, respectively).

Among the 43 reporting areas that provided data each year by women’s age for 2011–2020, this pattern across age groups was stable, with the highest percentages of abortions and the highest abortion rates occurring among women aged 20–29 years and the lowest percentages of abortions and lowest abortion rates occurring among adolescents aged <15 years and women aged ≥40 years (Table 4). From 2011 to 2020, abortion rates decreased among all age groups, although the decreases for adolescents (56% and 49% for adolescents aged <15 and 15–19 years, respectively) were greater than the decreases for women aged ≥20 years. From 2019 to 2020, abortion rates decreased or did not change for all age groups. During 2011–2020, abortion ratios decreased for all age groups, except among adolescents aged 15–19 years and women aged 25–29 years for whom abortion ratios increased. The decrease in abortion ratio was highest among women aged ≥40 years. From 2019 to 2020, abortion ratios decreased for adolescents aged <15 years and women aged ≥35 years and increased for women aged 15–34 years.

Among the 46 areas that reported age by individual year among adolescents for 2020, adolescents aged 18–19 years accounted for highest percentage (71.1%) of adolescent abortions and had the highest abortion rates (8.3 and 11.9 abortions per 1,000 adolescents aged 18 and 19 years, respectively) (Table 5). Adolescents aged <15 years accounted for the lowest percentage of adolescent abortions (2.7%) and had the lowest abortion rate (0.4 abortions per 1,000 adolescents aged 13–14 years). The abortion ratio for adolescents was highest among adolescents aged <15 years (828 abortions per 1,000 live births) and was lowest among adolescents aged 17–19 years (343, 371, and 313 abortions per 1,000 live births among adolescents aged 17, 18, and 19 years, respectively).

Among the 30 areas that reported race by ethnicity data for 2020, non-Hispanic White women (White) and non-Hispanic Black women (Black) accounted for the highest percentages of all abortions (32.7% and 39.2%, respectively), and Hispanic women and non-Hispanic women in the other race category accounted for lower percentages (21.1% and 7.0%, respectively) (Table 6). White women had the lowest abortion rate (6.2 abortions per 1,000 women aged 15–44 years) and ratio (118 abortions per 1,000 live births), and Black women had the highest abortion rate (24.4 abortions per 1,000 women aged 15–44 years) and ratio (426 abortions per 1,000 live births).

Among the 40 areas that reported by marital status for 2020, 13.7% of women who obtained an abortion were married, and 86.3% were unmarried (Table 7). The abortion ratio was 46 abortions per 1,000 live births for married women and 412 abortions per 1,000 live births for unmarried women.

Previous Live Births and Previous Induced Abortions

Among the 43 areas that reported the number of previous live births for 2020, 39.1%, 24.5%, 20.3%, 9.7%, and 6.4% of abortions reported were among women who had zero, one, two, three, or four or more previous live births, respectively (Table 8). Among the 42 areas that reported the number of previous induced abortions for 2020, 57.7%, 24.1%, 10.5%, and 7.8% of abortions reported were among women who had had zero, one, two, or three or more previous induced abortions, respectively (Table 9).

Weeks of Gestation and Method Type

Among the 41 areas that reported gestational age at the time of abortion for 2020, 80.9% of abortions were performed at ≤9 weeks’ gestation, and nearly all (93.1%) were performed at ≤13 weeks’ gestation (Table 10). Fewer abortions were performed at 14–20 weeks’ gestation (5.8%) or at ≥21 weeks’ gestation (0.9%). Among the 33 reporting areas that provided data every year on gestational age for 2011–2020, the percentage of abortions performed at ≤13 weeks’ gestation changed from 91.3% to 92.5% (Table 11). However, within this gestational age range, a shift occurred toward earlier gestational ages, with the percentage of abortions performed at ≤6 weeks’ gestation increasing 17% and the percentage of abortions performed at 7–9 weeks’ and 10–13 weeks’ gestation decreasing 2% and 21%, respectively.

Among the 46 areas that reported by method type for 2020 and included medical abortion on their reporting form, 51.0% were early medical abortions (a nonsurgical abortion at ≤9 weeks’ gestation), 40.0% of abortions were surgical abortions at ≤13 weeks’ gestation, 6.7% were surgical abortions at >13 weeks’ gestation, and 2.4% were medical abortions at >9 weeks’ gestation; other methods, including intrauterine instillation and hysterectomy/hysterotomy, were rare (<0.1%) (Table 12). During 2011−2020, a total of 37 reporting areas (excludes Alabama, California, the District of Columbia, Florida, Hawaii, Illinois, Louisiana, Maine, Maryland, New Hampshire, New Mexico, Tennessee, Vermont, Wisconsin, and Wyoming) provided continuous data and included medical abortion on their reporting form. Among these 37 areas, use of early medical abortion increased 22% from 2019 to 2020 (from 41.1% to 50.0% of abortions) and 154% from 2011 to 2020 (from 19.7% to 50.0% of abortions).