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Determinants and effects of abortion accessibility in the United States

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Senior Theses and Projects

Abortion in america after roe: an examination of the impact of dobbs v. jackson women’s health organization on women’s reproductive health access.

Natalie Maria Caffrey Follow

Date of Award

Spring 5-12-2023

Degree Name

Bachelor of Arts

Public Policy and Law

First Advisor

Professor Adrienne Fulco

Second Advisor

Professor Glenn Falk

This thesis will examine the limitations in access to abortion and other necessary reproductive healthcare in states that are hostile to abortion rights, as well as discuss the ongoing litigation within those states between pro-choice and pro-life advocates. After analyzing the legal landscape and the different abortion laws within these states, this thesis will focus on the practical consequences of Dobbs on women’s lives, with particular attention to its impact on women of color and poor women in states with the most restrictive laws. The effect of these restrictive laws on poor women will be felt disproportionately due to their lack of ability to travel to obtain care from other states that might offer abortion services. And even if these women find a way to obtain access to abortions, there is now the real possibility of criminal prosecution for those who seek or assist women who obtain abortions post- Dobbs . To compound the problem, the Court made clear in Dobbs that its decision to revisit the privacy rights issue signals the possibility of new limitations on protections previously taken for granted in the areas of In vitro fertilization, birth control, emergency contraception, and other civil rights such as gay marriage. Finally, this thesis will examine the political and legal efforts of liberal states, private companies, and grassroots organizations attempting to mitigate Dobbs ’s effects. These pro-choice actors have, to some extent, joined forces to protect access for women in the United States through protective legislation and expanding access in all facets of reproductive healthcare, particularly for minority women who will be disproportionately affected by abortion bans in conservative states. The current efforts to mitigate the legal and medical implications of Dobbs will determine the future of women’s rights in America, not only regarding abortion but more broadly in terms of adequate reproductive care access.

Senior thesis completed at Trinity College, Hartford CT for the degree of Bachelor of Arts in Public Policy & Law.

Recommended Citation

Caffrey, Natalie Maria, "Abortion in America After Roe: An Examination of the Impact of Dobbs v. Jackson Women’s Health Organization on Women’s Reproductive Health Access". Senior Theses, Trinity College, Hartford, CT 2023. Trinity College Digital Repository, https://digitalrepository.trincoll.edu/theses/1033

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Key facts about the abortion debate in america.

The U.S. Supreme Court’s June 2022 ruling to overturn Roe v. Wade – the decision that had guaranteed a constitutional right to an abortion for nearly 50 years – has shifted the legal battle over abortion to the states, with some prohibiting the procedure and others moving to safeguard it.

As the nation’s post-Roe chapter begins, here are key facts about Americans’ views on abortion, based on two Pew Research Center polls: one conducted from June 25-July 4 , just after this year’s high court ruling, and one conducted in March , before an earlier leaked draft of the opinion became public.

This analysis primarily draws from two Pew Research Center surveys, one surveying 10,441 U.S. adults conducted March 7-13, 2022, and another surveying 6,174 U.S. adults conducted June 27-July 4, 2022. Here are the questions used for the March survey , along with responses, and the questions used for the survey from June and July , along with responses.

Everyone who took part in these surveys is a member of the Center’s American Trends Panel (ATP), an online survey panel that is recruited through national, random sampling of residential addresses. This way nearly all U.S. adults have a chance of selection. The survey is weighted to be representative of the U.S. adult population by gender, race, ethnicity, partisan affiliation, education and other categories.  Read more about the ATP’s methodology .

A majority of the U.S. public disapproves of the Supreme Court’s decision to overturn Roe. About six-in-ten adults (57%) disapprove of the court’s decision that the U.S. Constitution does not guarantee a right to abortion and that abortion laws can be set by states, including 43% who strongly disapprove, according to the summer survey. About four-in-ten (41%) approve, including 25% who strongly approve.

About eight-in-ten Democrats and Democratic-leaning independents (82%) disapprove of the court’s decision, including nearly two-thirds (66%) who strongly disapprove. Most Republicans and GOP leaners (70%) approve , including 48% who strongly approve.

Most women (62%) disapprove of the decision to end the federal right to an abortion. More than twice as many women strongly disapprove of the court’s decision (47%) as strongly approve of it (21%). Opinion among men is more divided: 52% disapprove (37% strongly), while 47% approve (28% strongly).

About six-in-ten Americans (62%) say abortion should be legal in all or most cases, according to the summer survey – little changed since the March survey conducted just before the ruling. That includes 29% of Americans who say it should be legal in all cases and 33% who say it should be legal in most cases. About a third of U.S. adults (36%) say abortion should be illegal in all (8%) or most (28%) cases.

Generally, Americans’ views of whether abortion should be legal remained relatively unchanged in the past few years , though support fluctuated somewhat in previous decades.

Relatively few Americans take an absolutist view on the legality of abortion – either supporting or opposing it at all times, regardless of circumstances. The March survey found that support or opposition to abortion varies substantially depending on such circumstances as when an abortion takes place during a pregnancy, whether the pregnancy is life-threatening or whether a baby would have severe health problems.

While Republicans’ and Democrats’ views on the legality of abortion have long differed, the 46 percentage point partisan gap today is considerably larger than it was in the recent past, according to the survey conducted after the court’s ruling. The wider gap has been largely driven by Democrats: Today, 84% of Democrats say abortion should be legal in all or most cases, up from 72% in 2016 and 63% in 2007. Republicans’ views have shown far less change over time: Currently, 38% of Republicans say abortion should be legal in all or most cases, nearly identical to the 39% who said this in 2007.

However, the partisan divisions over whether abortion should generally be legal tell only part of the story. According to the March survey, sizable shares of Democrats favor restrictions on abortion under certain circumstances, while majorities of Republicans favor abortion being legal in some situations , such as in cases of rape or when the pregnancy is life-threatening.

There are wide religious divides in views of whether abortion should be legal , the summer survey found. An overwhelming share of religiously unaffiliated adults (83%) say abortion should be legal in all or most cases, as do six-in-ten Catholics. Protestants are divided in their views: 48% say it should be legal in all or most cases, while 50% say it should be illegal in all or most cases. Majorities of Black Protestants (71%) and White non-evangelical Protestants (61%) take the position that abortion should be legal in all or most cases, while about three-quarters of White evangelicals (73%) say it should be illegal in all (20%) or most cases (53%).

In the March survey, 72% of White evangelicals said that the statement “human life begins at conception, so a fetus is a person with rights” reflected their views extremely or very well . That’s much greater than the share of White non-evangelical Protestants (32%), Black Protestants (38%) and Catholics (44%) who said the same. Overall, 38% of Americans said that statement matched their views extremely or very well.

Catholics, meanwhile, are divided along religious and political lines in their attitudes about abortion, according to the same survey. Catholics who attend Mass regularly are among the country’s strongest opponents of abortion being legal, and they are also more likely than those who attend less frequently to believe that life begins at conception and that a fetus has rights. Catholic Republicans, meanwhile, are far more conservative on a range of abortion questions than are Catholic Democrats.

Women (66%) are more likely than men (57%) to say abortion should be legal in most or all cases, according to the survey conducted after the court’s ruling.

More than half of U.S. adults – including 60% of women and 51% of men – said in March that women should have a greater say than men in setting abortion policy . Just 3% of U.S. adults said men should have more influence over abortion policy than women, with the remainder (39%) saying women and men should have equal say.

The March survey also found that by some measures, women report being closer to the abortion issue than men . For example, women were more likely than men to say they had given “a lot” of thought to issues around abortion prior to taking the survey (40% vs. 30%). They were also considerably more likely than men to say they personally knew someone (such as a close friend, family member or themselves) who had had an abortion (66% vs. 51%) – a gender gap that was evident across age groups, political parties and religious groups.

Relatively few Americans view the morality of abortion in stark terms , the March survey found. Overall, just 7% of all U.S. adults say having an abortion is morally acceptable in all cases, and 13% say it is morally wrong in all cases. A third say that having an abortion is morally wrong in most cases, while about a quarter (24%) say it is morally acceptable in most cases. An additional 21% do not consider having an abortion a moral issue.

Among Republicans, most (68%) say that having an abortion is morally wrong either in most (48%) or all cases (20%). Only about three-in-ten Democrats (29%) hold a similar view. Instead, about four-in-ten Democrats say having an abortion is morally  acceptable  in most (32%) or all (11%) cases, while an additional 28% say it is not a moral issue. 

White evangelical Protestants overwhelmingly say having an abortion is morally wrong in most (51%) or all cases (30%). A slim majority of Catholics (53%) also view having an abortion as morally wrong, but many also say it is morally acceptable in most (24%) or all cases (4%), or that it is not a moral issue (17%). Among religiously unaffiliated Americans, about three-quarters see having an abortion as morally acceptable (45%) or not a moral issue (32%).

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Public Opinion on Abortion

Majority in u.s. say abortion should be legal in some cases, illegal in others, three-in-ten or more democrats and republicans don’t agree with their party on abortion, partisanship a bigger factor than geography in views of abortion access locally, most popular.

About Pew Research Center Pew Research Center is a nonpartisan fact tank that informs the public about the issues, attitudes and trends shaping the world. It conducts public opinion polling, demographic research, media content analysis and other empirical social science research. Pew Research Center does not take policy positions. It is a subsidiary of The Pew Charitable Trusts .

The Safety and Quality of Abortion Care in the United States (2018)

Chapter: 1 introduction, 1 introduction.

When the Institute of Medicine (IOM) 1 issued its 1975 report on the public health impact of legalized abortion, the scientific evidence on the safety and health effects of legal abortion services was limited ( IOM, 1975 ). It had been only 2 years since the landmark Roe v. Wade decision had legalized abortion throughout the United States and nationwide data collection was just under way ( Cates et al., 2000 ; Kahn et al., 1971 ). Today, the available scientific evidence on abortion’s health effects is quite robust.

In 2016, six private foundations came together to ask the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine to conduct a comprehensive review of the state of the science on the safety and quality of legal abortion services in the United States. The sponsors—The David and Lucile Packard Foundation, The Grove Foundation, The JPB Foundation, The Susan Thompson Buffett Foundation, Tara Health Foundation, and William and Flora Hewlett Foundation—asked that the review focus on the eight research questions listed in Box 1-1 .

The Committee on Reproductive Health Services: Assessing the Safety and Quality of Abortion Care in the U.S. was appointed in December 2016 to conduct the study and prepare this report. The committee included 13 individuals 2 with research or clinical experience in anesthesiology,

___________________

1 In March 2016, the IOM, the division of the National Academies of Sciences, Engineering, and Medicine focused on health and medicine, was renamed the Health and Medicine Division.

2 A 14th committee member participated for just the first 4 months of the study.

obstetrics and gynecology, nursing and midwifery, primary care, epidemiology of reproductive health, mental health, health care disparities, health care delivery and management, health law, health professional education and training, public health, quality assurance and assessment,

statistics and research methods, and women’s health policy. Brief biographies of committee members are provided in Appendix A .

This chapter describes the context for the study and the scope of the inquiry. It also presents the committee’s conceptual framework for conducting its review.

ABORTION CARE TODAY

Since the IOM first reviewed the health implications of national legalized abortion in 1975, there has been a plethora of related scientific research, including well-designed randomized controlled trials (RCTs), systematic reviews, and epidemiological studies examining abortion care. This research has focused on examining the relative safety of abortion methods and the appropriateness of methods for different clinical circumstances ( Ashok et al., 2004 ; Autry et al., 2002 ; Bartlett et al., 2004 ; Borgatta, 2011 ; Borkowski et al., 2015 ; Bryant et al., 2011 ; Cates et al., 1982 ; Chen and Creinin, 2015 ; Cleland et al., 2013 ; Frick et al., 2010 ; Gary and Harrison, 2006 ; Grimes et al., 2004 ; Grossman et al., 2008 , 2011 ; Ireland et al., 2015 ; Kelly et al., 2010 ; Kulier et al., 2011 ; Lohr et al., 2008 ; Low et al., 2012 ; Mauelshagen et al., 2009 ; Ngoc et al., 2011 ; Ohannessian et al., 2016 ; Peterson et al., 1983 ; Raymond et al., 2013 ; Roblin, 2014 ; Sonalkar et al., 2017 ; Upadhyay et al., 2015 ; White et al., 2015 ; Wildschut et al., 2011 ; Woodcock, 2016 ; Zane et al., 2015 ). With this growing body of research, earlier abortion methods have been refined, discontinued, and new approaches have been developed ( Chen and Creinin, 2015 ; Jatlaoui et al., 2016 ; Lichtenberg and Paul, 2013 ). For example, the use of dilation and sharp curettage is now considered obsolete in most cases because safer alternatives, such as aspiration methods, have been developed ( Edelman et al, 1974 ; Lean et al, 1976 ; RCOG, 2015 ). The use of abortion medications in the United States began in 2000 with the approval by the U.S. Food and Drug Administration (FDA) of the drug mifepristone. In 2016, the FDA, citing extensive clinical research, updated the indications for mifepristone for medication abortion 3 up to 10 weeks’ (70 days’) gestation ( FDA, 2016 ; Woodcock, 2016 ).

Box 1-2 describes the abortion methods currently recommended by U.S. and international medical, nursing, and other health organizations that set professional standards for reproductive health care, including the American College of Obstetricians and Gynecologists (ACOG), the Society of Family Planning, the American College of Nurse-Midwifes, the National Abortion Federation (NAF), the Royal College of Obstetricians and Gynaecologists (RCOG) (in the United Kingdom), and the World

3 The terms “medication abortion” and “medical abortion” are used interchangeably in the literature.

Health Organization ( ACNM, 2011 , 2016 ; ACOG, 2013 , 2014 ; Costescu et al., 2016 ; Lichtenberg and Paul, 2013 ; NAF, 2017 ; RCOG, 2011 ; WHO, 2014 ).

A Continuum of Care

The committee views abortion care as a continuum of services, as illustrated in Figure 1-1 . For purposes of this study, it begins when a woman, who has decided to terminate a pregnancy, contacts or visits a provider seeking an abortion. The first, preabortion phase of care includes an initial clinical assessment of the woman’s overall health (e.g., physical examination, pregnancy determination, weeks of gestation, and laboratory and other testing as needed); communication of information on the risks and benefits of alternative abortion procedures and pain management options; discussion of the patient’s preferences based on desired anesthesia and weeks of gestation; discussion of postabortion contraceptive options if desired; counseling

and referral to services (if needed); and final decision making and informed consent. The next phases in the continuum are the abortion procedure itself and postabortion care, including appropriate follow-up care and provision of contraceptives (for women who opt for them).

A Note on Terminology

Important clinical terms that describe pregnancy and abortion lack consistent definition. The committee tried to be as precise as possible to avoid misinterpreting or miscommunicating the research evidence, clinical practice guidelines, and other relevant sources of information with potentially significant clinical implications. Note that this report follows Grimes and Stuart’s (2010) recommendation that weeks’ gestation be quantified using cardinal numbers (1, 2, 3...) rather than ordinal numbers (1st, 2nd, 3rd...). It is important to note, however, that these two numbering conventions are sometimes used interchangeably in the research literature despite having different meanings. For example, a woman who is 6 weeks pregnant has completed 6 weeks of pregnancy: she is in her 7th (not 6th) week of pregnancy.

This report also avoids using the term “trimester” where possible because completed weeks’ or days’ gestation is a more precise designation, and the clinical appropriateness of abortion methods does not align with specific trimesters.

Although the literature typically classifies the method of abortion as either “medical” or “surgical” abortion, the committee decided to specify methods more precisely by using the terminology defined in Box 1-2 . The term “surgical abortion” is often used by others as a catchall category that includes a variety of procedures, ranging from an aspiration to a dilation and evacuation (D&E) procedure involving sharp surgical and other instrumentation as well as deeper levels of sedation. This report avoids describing abortion procedures as “surgical” so as to characterize a method more accurately as either an aspiration or D&E. As noted in Box 1-2 , the term “induction abortion” is used to distinguish later abortions that use a

medication regimen from medication abortions performed before 10 weeks’ gestation.

See Appendix B for a glossary of the technical terms used in this report.

Regulation of Abortion Services

Abortion is among the most regulated medical procedures in the nation ( Jones et al., 2010 ; Nash et al., 2017 ). While a comprehensive legal analysis of abortion regulation is beyond the scope of this report, the committee agreed that it should consider how abortion’s unique regulatory environment relates to the safety and quality of abortion care.

In addition to the federal, state, and local rules and policies governing all medical services, numerous abortion-specific federal 4 and state laws and regulations affect the delivery of abortion services. Table 1-1 lists the abortion-specific regulations by state. The regulations range from prescribing information to be provided to women when they are counseled and setting mandatory waiting periods between counseling and the abortion procedure to those that define the clinical qualifications of abortion providers, the types of procedures they are permitted to perform, and detailed facility standards for abortion services. In addition, many states place limitations on the circumstances under which private health insurance and Medicaid can be used to pay for abortions, limiting coverage to pregnancies resulting from rape or incest or posing a medical threat to the pregnant woman’s life. Other policies prevent facilities that receive state funds from providing abortion services 5 or place restrictions on the availability of services based on the gestation of the fetus that are narrower than those established under federal law ( Guttmacher Institute, 2017h ).

Trends and Demographics

National- and state-level abortion statistics come from two primary sources: the Centers for Disease Control and Prevention’s (CDC’s) Abortion

4 Hyde Amendment (P.L. 94-439, 1976); Department of Defense Appropriations Act (P.L. 95-457, 1978); Peace Corps Provision and Foreign Assistance and Related Programs Appropriations Act (P.L. 95-481, 1978); Pregnancy Discrimination Act (P.L. 95-555, 1977); Department of the Treasury and Postal Service Appropriations Act (P.L. 98-151, 1983); FY1987 Continuing Resolution (P.L. 99-591, 1986); Dornan Amendment (P.L. 100-462, 1988); Partial-Birth Abortion Ban (P.L. 108-105, 2003); Weldon Amendment (P.L. 108-199, 2004); Patient Protection and Affordable Care Act (P.L. 111-148 as amended by P.L. 111-152, 2010).

5 Personal communication, O. Cappello, Guttmacher Institute, August 4, 2017: AZ § 15-1630, GA § 20-2-773; KS § 65-6733 and § 76-3308; KY § 311.800; LA RS § 40:1299 and RS § 4 0.1061; MO § 188.210 and § 188.215; MS § 41-41-91; ND § 14-02.3-04; OH § 5101.57; OK 63 § 1-741.1; PA 18 § 3215; TX § 285.202.

TABLE 1-1 Overview of State Abortion-Specific Regulations That May Impact Safety and Quality, as of September 1, 2017

a Excludes laws or regulations permanently or temporarily enjoined pending a court decision.

b States have abortion-specific requirements generally following the established principles of informed consent.

c The content of informed consent materials is specified in state law or developed by the state department of health.

d In-person counseling is not required for women who live more than 100 miles from an abortion provider.

e Counseling requirement is waived if the pregnancy is the result of rape or incest or the patient is younger than 15.

f Maximum distance requirement does not apply to medication abortions.

g Some states also exempt women whose physical health is at severe risk and/or in cases of fetal impairment.

h Some states have exceptions for pregnancies resulting from rape or incest, pregnancies that severely threaten women’s physical health or endanger their life, and/or in cases of fetal impairment.

SOURCES: Guttmacher Institute, 2017b , c , d , e , f , g , h , i , 2018b .

Surveillance System and the Guttmacher Institute’s Abortion Provider Census ( Jatlaoui et al., 2016 ; Jerman et al., 2016 ; Jones and Kavanaugh, 2011 ; Pazol et al., 2015 ). Both of these sources provide estimates of the number and rate of abortions, the use of different abortion methods, the characteristics of women who have abortions, and other related statistics. However, both sources have limitations.

The CDC system is a voluntary, state-reported system; 6 , 7 three states (California, Maryland, and New Hampshire) do not provide information ( CDC, 2017 ). The Guttmacher census, also voluntary, solicits information from all known abortion providers throughout the United States, including in the states that do not submit information to the CDC surveillance system. For 2014, the latest year reported by Guttmacher, 8 information was obtained directly from 58 percent of abortion providers, and data for nonrespondents were imputed ( Jones and Jerman, 2017a ). The CDC’s latest report, for abortions in 2013, includes approximately 70 percent of the abortions reported by the Guttmacher Institute for that year ( Jatlaoui et al., 2016 ).

Both data collection systems report descriptive statistics on women who have abortions and the types of abortion provided, although they define demographic variables and procedure types differently. Nevertheless, in the aggregate, the trends in abortion utilization reported by the CDC and Guttmacher closely mirror each other—indicating decreasing rates of abortion, an increasing proportion of medication abortions, and the vast majority of abortions (90 percent) occurring by 13 weeks’ gestation (see Figures 1-2 and 1-3 ) ( Jatlaoui et al., 2016 ; Jones and Jerman, 2017a ). 9 Both data sources are used in this chapter’s brief review of trends in abortions and throughout the report.

Trends in the Number and Rate of Abortions

The number and rate of abortions have changed considerably during the decades following national legalization in 1973. In the immediate years after

6 In most states, hospitals, facilities, and physicians are required by law to report abortion data to a central health agency. These agencies submit the aggregate utilization data to the CDC ( Guttmacher Institute, 2018a ).

7 New York City and the District of Columbia also report data to the CDC.

8 Guttmacher researchers estimate that the census undercounts the number of abortions performed in the United States by about 5 percent (i.e., 51,725 abortions provided by 2,069 obstetrician/gynecologist [OB/GYN] physicians). The estimate is based on a survey of a random sample of OB/GYN physicians. The survey did not include other physician specialties and other types of clinicians.

9 A full-term pregnancy is 40 weeks.

national legalization, both the number and rate 10 of legal abortions steadily increased ( Bracken et al., 1982 ; Guttmacher Institute, 2017a ; Pazol et al., 2015 ; Strauss et al., 2007 ) (see Figure 1-2 ). The abortion rate peaked in the

10 Reported abortion rates are for females aged 15 to 44.

1980s, and the trend then reversed, a decline that has continued for more than three decades ( Guttmacher Institute, 2017a ; Jones and Kavanaugh, 2011 ; Pazol et al., 2015 ; Strauss et al., 2007 ). Between 1980 and 2014, the abortion rate among U.S. women fell by more than half, from 29.3 to 14.6 per 1,000 women ( Finer and Henshaw, 2003 ; Guttmacher Institute, 2017a ; Jones and Jerman, 2017a ) (see Figure 1-2 ). In 2014, the most recent year for which data are available, the aggregate number of abortions reached a low of 926,190 after peaking at nearly 1.6 million in 1990 ( Finer and Henshaw, 2003 ; Jones and Jerman, 2017a ). The reason for the decline is not fully understood but has been attributed to several factors, including the increasing use of contraceptives, especially long-acting methods (e.g., intrauterine devices and implants); historic declines in the rate of unintended pregnancy; and increasing numbers of state regulations resulting in limited access to abortion services ( Finer and Zolna, 2016 ; Jerman et al., 2017 ; Jones and Jerman, 2017a ; Kost, 2015 ; Strauss et al., 2007 ).

Weeks’ Gestation

Length of gestation—measured as the amount of time since the first day of the last menstrual period—is the primary factor in deciding what abortion procedure is most appropriate ( ACOG, 2014 ). Since national legalization, most abortions in the United States have been performed in early pregnancy (≤13 weeks) ( Cates et al., 2000 ; CDC, 1983 ; Elam-Evans et al., 2003 ; Jatlaoui et al., 2016 ; Jones and Jerman, 2017a ; Koonin and Smith, 1993 ; Lawson et al., 1989 ; Pazol et al., 2015 ; Strauss et al., 2007 ). CDC surveillance reports indicate that since at least 1992 (when detailed data on early abortions were first collected), the vast majority of abortions in the United States were early-gestation procedures ( Jatlaoui et al., 2016 ; Strauss et al., 2007 ); this was the case for approximately 92 percent of all abortions in 2013 ( Jatlaoui et al., 2016 ). With such technological advances as highly sensitive pregnancy tests and medication abortion, procedures are being performed at increasingly earlier gestational stages. According to the CDC, the percentage of early abortions performed ≤6 weeks’ gestation increased by 16 percent from 2004 to 2013 ( Jatlaoui et al., 2016 ); in 2013, 38 percent of early abortions occurred ≤6 weeks ( Jatlaoui et al., 2016 ). The proportion of early-gestation abortions occurring ≤6 weeks is expected to increase even further as the use of medication abortions becomes more widespread ( Jones and Boonstra, 2016 ; Pazol et al., 2012 ).

Figure 1-3 shows the proportion of abortions in nonhospital settings by weeks’ gestation in 2014 ( Jones and Jerman, 2017a ).

Abortion Methods

Aspiration is the abortion method most commonly used in the United States, accounting for almost 68 percent of all abortions performed in 2013 ( Jatlaoui et al., 2016 ). 11 Its use, however, is likely to decline as the use of medication abortion increases. The percentage of abortions performed by the medication method rose an estimated 110 percent between 2004 and 2013, from 10.6 to 22.3 percent ( Jatlaoui et al., 2016 ). In 2014, approximately 45 percent of abortions performed up to 9 weeks’ gestation were medication abortions, up from 36 percent in 2011 ( Jones and Jerman, 2017a ).

Fewer than 9 percent of abortions are performed after 13 weeks’ gestation; most of these are D&E procedures ( Jatlaoui et al., 2016 ). Induction abortion is the most infrequently used of all abortion methods, accounting for approximately 2 percent of all abortions at 14 weeks’ gestation or later in 2013 ( Jatlaoui et al., 2016 ).

Characteristics of Women Who Have Abortions

The most detailed sociodemographic statistics on women who have had an abortion in the United States are provided by the Guttmacher Institute’s Abortion Patient Survey. Respondents to the 2014/2015 survey included more than 8,000 women who had had an abortion in 1 of 87 outpatient (nonhospital) facilities across the United States in 2014 ( Jerman et al., 2016 ; Jones and Jerman, 2017b ). 12 Table 1-2 provides selected findings from this survey. Although women who had an abortion in a hospital setting are excluded from these statistics, the data represent an estimated 95 percent of all abortions provided (see Figure 1-3 ).

The Guttmacher survey found that most women who had had an abortion were under age 30 (72 percent) and were unmarried (86 percent) ( Jones and Jerman, 2017b ). Women seeking an abortion were far more likely to be poor or low-income: the household income of 49 percent was below the federal poverty level (FPL), and that of 26 percent was 100 to 199 percent of the FPL ( Jerman et al., 2016 ). In comparison, the

11 CDC surveillance reports use the catchall category of “curettage” to refer to nonmedical abortion methods. The committee assumed that the CDC’s curettage estimates before 13 weeks’ gestation refer to aspiration procedures and that its curettage estimates after 13 weeks’ gestation referred to D&E procedures.

12 Participating facilities were randomly selected and excluded hospitals. All other types of facilities were included if they had provided at least 30 abortions in 2011 ( Jerman et al., 2016 ). Jerman and colleagues report that logistical challenges precluded including hospital patients in the survey. The researchers believe that the exclusion of hospitals did not bias the survey sample, noting that hospitals accounted for only 4 percent of all abortions in 2011.

TABLE 1-2 Characteristics of Women Who Had an Abortion in an Outpatient Setting in 2014, by Percent

NOTE: Percentages may not sum to 100 because of rounding.

SOURCES: (a) Jones and Jerman, 2017b (n = 8,098); (b) Jerman et al., 2016 (n = 8,380).

corresponding percentages among all women aged 15 to 49 are 16 and 18 percent. 13 Women who had had an abortion were also more likely to be women of color 14 (61.0 percent); overall, half of women who had had an abortion were either black (24.8 percent) or Hispanic (24.5 percent) ( Jones and Jerman, 2017b ). This distribution is similar to the racial and ethnic distribution of women with household income below 200 percent of the FPL, 49 percent of whom are either black (20 percent) or Hispanic (29 percent). 15 Poor women and women of color are also more likely than others to experience an unintended pregnancy ( Finer and Henshaw, 2006 ; Finer et al., 2006 ; Jones and Kavanaugh, 2011 ).

Many women who have an abortion have previously experienced pregnancy or childbirth. Among respondents to the Guttmacher survey, 59.3 percent had given birth at least once, and 44.8 percent had had a prior abortion ( Jerman et al., 2016 ; Jones and Jerman, 2017b ).

While precise estimates of health insurance coverage of abortion are not available, numerous regulations limit coverage. As noted in Table 1-1 , 33 states prohibit public payers from paying for abortions and other states have laws that either prohibit health insurance exchange plans (25 states) or private insurance plans (11 states) sold in the state from covering or paying for abortions, with few exceptions. 16 In the Guttmacher survey, only 14 percent of respondents had paid for the procedure using private insurance coverage, and despite the disproportionately high rate of poverty and low income among those who had had an abortion, only 22 percent reported that Medicaid was the method of payment for their abortion. In 2015, 39 percent of the 25 million women lived in households that earned less than 200 percent of the FPL in the United States were enrolled in Medicaid, and 36 percent had private insurance ( Ranji et al., 2017 ).

Number of Clinics Providing Abortion Care

As noted earlier, the vast majority of abortions are performed in nonhospital settings—either an abortion clinic (59 percent) or a clinic offering a variety of medical services (36 percent) ( Jones and Jerman, 2017a ) (see Figure 1-4 ). Although hospitals account for almost 40 percent of facilities offering abortion care, they provide less than 5 percent of abortions overall.

13 Calculation by the committee based on estimates from Annual Social and Economic Supplement (ASEC) to the Current Population Survey (CPS) .

14 Includes all nonwhite race and ethnicity categories in Table 1-2 . Data were collected via self-administered questionnaire ( Jones and Jerman, 2017b ).

15 Calculation by the committee based on estimates from Annual Social and Economic Supplement (ASEC) to the Current Population Survey (CPS) .

16 Some states have exceptions for pregnancies resulting from rape or incest, pregnancies that endanger the woman’s life or severely threaten her health, and in cases of fetal impairment.

The overall number of nonhospital facilities providing abortions—especially specialty abortion clinics—is declining. The greatest proportional decline is in states that have enacted abortion-specific regulations ( Jones and Jerman, 2017a ). In 2014, there were 272 abortion clinics in the United States, 17 percent fewer than in 2011. The greatest decline (26 percent) was among large clinics with annual caseloads of 1,000–4,999 patients and clinics in the Midwest (22 percent) and the South (13 percent). In 2014, approximately 39 percent of U.S. women aged 15 to 44 resided in a U.S. county without an abortion provider (90 percent of counties overall) ( Jones and Jerman, 2017a ). Twenty-five states have five or fewer abortion clinics; five states have one abortion clinic ( Jones and Jerman, 2017a ). A recent analysis 17 by Guttmacher evaluated geographic disparities in access to abortion by calculating the distance between women of reproductive age (15 to 44) and the nearest abortion-providing facility in 2014 ( Bearak et al., 2017 ). Figure 1-5 highlights the median distance to the nearest facility by county.

17 The analysis was limited to facilities that provided at least 400 abortions per year and those affiliated with Planned Parenthood that performed at least 1 abortion during the period of analysis.

The majority of facilities offer early medication and aspiration abortions. In 2014, 87 percent of nonhospital facilities provided early medication abortions; 23 percent of all nonhospital facilities offered this type of abortion ( Jones and Jerman, 2017a ). Fewer facilities offer later-gestation procedures, and availability decreases as gestation increases. In 2012, 95 percent of all abortion facilities offered abortions at 8 weeks’ gestation, 72 percent at 12 weeks’ gestation, 34 percent at 20 weeks’ gestation, and 16 percent at 24 weeks’ gestation ( Jerman and Jones, 2014 ).

STUDY APPROACH

Conceptual framework.

The committee’s approach to this study built on two foundational developments in the understanding and evaluation of the quality of health

care services: Donabedian’s (1980) structure-process-outcome framework and the IOM’s (2001) six dimensions of quality health care. Figure 1-6 illustrates the committee’s adaptation of these concepts for this study’s assessment of abortion care in the United States.

Structure-Process-Outcome Framework

In seminal work published almost 40 years ago, Donabedian (1980) proposed that the quality of health care be assessed by examining its structure, process, and outcomes ( Donabedian, 1980 ):

• Structure refers to organizational factors that may create the potential for good quality. In abortion care, such structural factors as the availability of trained staff and the characteristics of the clinical setting may ensure—or inhibit—the capacity for quality.
• Process refers to what is done to and for the patient. Its assessment assumes that the services patients receive should be evidence based and correlated with patients’ desired outcomes—for example, an early and complete abortion for women who wish to terminate an unintended pregnancy.
• Outcomes are the end results of care—the effects of the intervention on the health and well-being of the patient. Does the procedure achieve its objective? Does it lead to serious health risks in the short or long term?

Six Dimensions of Health Care Quality

The landmark IOM report Crossing the Quality Chasm: A New Health System for the 21st Century ( IOM, 2001 ) identifies six dimensions of health care quality—safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. The articulation of these six dimensions has guided public and private efforts to improve U.S. health care delivery at the local, state, and national levels since that report was published ( AHRQ, 2016 ).

In addition, as with other health care services, women should expect that the abortion care they receive meets well-established standards for objectivity, transparency, and scientific rigor ( IOM, 2011a , b ).

Two of the IOM’s six dimensions—safety and effectiveness—are particularly salient to the present study. Assessing both involves making relative judgments. There are no universally agreed-upon thresholds for defining care as “safe” versus “unsafe” or “effective” versus “not effective,” and decisions about safety and effectiveness have a great deal to do with the context of the clinical scenario. Thus, the committee’s frame of reference for evaluating safety, effectiveness, and other quality domains is of necessity a

relative one—one that entails not only comparing the alternative abortion methods but also comparing these methods with other health care services and with risks associated with not achieving the desired outcome.

Safety—avoiding injury to patients—is often assessed by measuring the incidence and severity of complications and other adverse events associated with receiving a specific procedure. If infrequent, a complication may be characterized as “rare”—a term that lacks consistent definition. In this report, “rare” is used to describe outcomes that affect fewer than 1 percent of patients. Complications are considered “serious” if they result in a blood transfusion, surgery, or hospitalization.

Note also that the term “effectiveness” is used differently in this report depending on the context. As noted in Box 1-3 , effectiveness as an attribute of quality refers to providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse, respectively). Elsewhere in this report, effectiveness denotes the clinical effectiveness of a procedure, that

is, the successful completion of an abortion without the need for a follow-up aspiration.

Finding and Assessing the Evidence

The committee deliberated during four in-person meetings and numerous teleconferences between January 2017 and December 2017. On March 24, 2017, the committee hosted a public workshop at the Keck Center of the National Academies of Sciences, Engineering, and Medicine in Washington, DC. The workshop included presentations from three speakers on topics related to facility standards and the safety of outpatient procedures. Appendix C contains the workshop agenda.

Several committee workgroups were formed to find and assess the quality of the available evidence and to draft summary materials for the full committee’s review. The workgroups conducted in-depth reviews of the epidemiology of abortions, including rates of complications and mortality, the safety and effectiveness of alternative abortion methods, professional standards and methods for performing all aspects of abortion care (as described in Figure 1-1 ), the short- and long-term physical and mental health effects of having an abortion; and the safety and quality implications of abortion-specific regulations on abortion.

The committee focused on finding reliable, scientific information reflecting contemporary U.S. abortion practices. An extensive body of research on abortion has been conducted outside the United States. A substantial proportion of this literature concerns the delivery of abortion care in countries where socioeconomic conditions, culture, population health, health care resources, and/or the health care system are markedly different from their U.S. counterparts. Studies from other countries were excluded from this review if the committee judged those factors to be relevant to the health outcomes being assessed.

The committee considered evidence from randomized controlled trials comparing two or more approaches to abortion care; systematic reviews; meta-analyses; retrospective cohort studies, case control studies, and other types of observational studies; and patient and provider surveys (see Box 1-4 ).

An extensive literature documents the biases common in published research on the effectiveness of health care services ( Altman et al., 2001 ; Glasziou et al., 2008 ; Hopewell et al., 2008 ; Ioannidis et al., 2004 ; IOM, 2011a , b ; Plint et al., 2006 ; Sackett, 1979 ; von Elm et al., 2007 ). Thus, the committee prioritized the available research according to conventional principles of evidence-based medicine intended to reduce the risk of bias in a study’s conclusions, such as how subjects were allocated to different types of abortion care, the comparability of study populations, controls

for confounding factors, how outcome assessments were conducted, the completeness of outcome reporting, the representativeness of the study population compared with the general U.S. population, and the degree to which statistical analyses helped reduce bias ( IOM, 2011b ). Applying these principles is particularly important with respect to understanding abortion’s

long-term health effects, an area in which the relevant literature is vulnerable to bias (as discussed in Chapter 4 ).

The committee’s literature search strategy is described in Appendix D .

ORGANIZATION OF THE REPORT

Chapter 2 of this report describes the continuum of abortion care including current abortion methods (question 1 in the committee’s statement of task [ Box 1-1 ]); reviews the evidence on factors affecting their safety and quality, including expected side effects and possible complications (questions 2 and 3), necessary safeguards to manage medical emergencies (question 6), and provision of pain management (question 7); and presents the evidence on the types of facilities or facility factors necessary to provide safe and effective abortion care (question 4).

Chapter 3 summarizes the clinical skills that are integral to safe and high-quality abortion care according to the recommendations of leading national professional organizations and abortion training curricula (question 5).

Chapter 4 reviews research examining the long-term health effects of undergoing an abortion (question 2).

Finally, Chapter 5 presents the committee’s conclusions regarding the findings presented in the previous chapters, responding to each of the questions posed in the statement of task. Findings are statements of scientific evidence. The report’s conclusions are the committee’s inferences, interpretations, or generalizations drawn from the evidence.

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Woodcock, J. 2016. Letter from the director of the FDA Center for Drug Evaluation and Research to Donna Harrison, Gene Rudd, and Penny Young Nance. Re: Docket No. FDA-2002-P-0364. Silver Spring, MD: FDA.

Zane, S., A. A. Creanga, C. J. Berg, K. Pazol, D. B. Suchdev, D. J. Jamieson, and W. M. Callaghan. 2015. Abortion-related mortality in the United States: 1998–2010. Obstetrics & Gynecology 126(2):258–265.

Abortion is a legal medical procedure that has been provided to millions of American women. Since the Institute of Medicine first reviewed the health implications of national legalized abortion in 1975, there has been a plethora of related scientific research, including well-designed randomized clinical trials, systematic reviews, and epidemiological studies examining abortion care. This research has focused on examining the relative safety of abortion methods and the appropriateness of methods for different clinical circumstances. With this growing body of research, earlier abortion methods have been refined, discontinued, and new approaches have been developed.

The Safety and Quality of Abortion Care in the United States offers a comprehensive review of the current state of the science related to the provision of safe, high-quality abortion services in the United States. This report considers 8 research questions and presents conclusions, including gaps in research.

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The Persistent Threat to Abortion Rights

By The Editorial Board

The editorial board is a group of opinion journalists whose views are informed by expertise, research, debate and certain longstanding values . It is separate from the newsroom.

The Supreme Court this week heard the first major challenge to abortion rights since it struck down Roe v. Wade two years ago — an attempt to severely limit access to mifepristone, the most commonly used abortion pill in the country, by a group of doctors who are morally opposed to the practice.

The justices seem prepared to throw out the lawsuit. During oral arguments, they questioned whether the doctors had suffered the harm necessary to bring the suit in the first place.

But that should come as small comfort to anyone concerned for the future of reproductive freedom in America. Judges at the state and federal levels are ready to further restrict reproductive options and health care access. The presumptive Republican nominee for president, Donald Trump, has indicated support for a 15-week national abortion ban. And while the Supreme Court, in overturning Roe, ostensibly left it to each state to decide abortion policy, several states have gone against the will of their voters on abortion or tried to block ballot measures that would protect abortion rights. Anti-abortion forces may have had a tough week in the Supreme Court, but they remain focused on playing and winning a longer game.

Even potential victories for reproductive freedom may prove short-lived: The mifepristone case, for instance, is far from dead. Another plaintiff could bring the same case and have it considered on the merits, a possibility Justice Samuel Alito raised during oral arguments.

“Is there anybody who could challenge in court the lawfulness of what the F.D.A. did here?” he asked the solicitor general, Elizabeth Prelogar. Such a challenge would be exceptionally weak, given that the F.D.A. provided substantial support for its approval and regulatory guidance on the use of mifepristone, but the right-wing justices on the Roberts court may be willing to hear it again anyway. The justices have already illustrated their hostility to the authority of administrative agencies, and that hostility may persist even in the face of overwhelming scientific evidence.

Then there is the Comstock Act, a 151-year-old federal law that anti-abortion activists are trying to revive to block the mailing of mifepristone and other abortion medication. During the oral arguments this week, Justices Alito and Clarence Thomas repeatedly expressed their openness to the use of the law, which was pushed by an anti-vice crusader decades before women won the right to vote. If anti-abortion activists can get themselves before a sympathetic court and secure a national injunction on this medication being mailed, they may well be able to block access to abortion throughout the country, including in states where it is legal.

However the mifepristone case turns out, the threats to reproductive rights the justices unleashed by overturning Roe go much further.

The anti-abortion movement is pursuing its aims on many legal fronts. One focus of intense activity is so-called fetal-personhood laws , which endow fetuses (and, in some cases, even fertilized eggs) with the same legal rights as living, breathing human beings. Last month, Alabama’s Supreme Court ruled that frozen embryos created through in vitro fertilization were to be protected as “extrauterine children,” relying in part on an 1872 state law. That sent lawmakers in Alabama scrambling to protect a procedure that is highly popular among Republicans and Democrats alike. Three weeks after the court ruling, they passed a law protecting patients and doctors who perform I.V.F. procedures from legal liability.

Fetal-personhood laws can also be used to target access to birth control, embryonic stem cell research and even women who suffer miscarriages.

In eliminating a woman’s constitutional right to choose what happens in her own body, the Supreme Court claimed to be respecting the democratic process by allowing state legislatures to determine whether abortion should be legal and what, if any, limits should be placed on it. Roe v. Wade had been “egregiously wrong” to wrest a fraught public debate from the American public, Justice Alito wrote in the majority opinion for Dobbs v. Jackson Women’s Health in 2022. It was “time to heed the Constitution and return the issue of abortion to the people’s elected representatives.”

Instead of being settled at the state level, less than two years since the Dobbs ruling, the issue of abortion has returned to the court and is likely to continue to do so for the foreseeable future.

The Dobbs ruling has forced a new public debate on abortion and galvanized Americans’ support for it, which has been strong for decades. Since 1975, a majority of Americans have supported legal abortion in some or all cases, according to polling by Gallup , and that support has increased slightly since Dobbs. The percentage of Americans who think abortion should be illegal in all cases has gone down.

Since Roe was overturned in 2022, in every state where reproductive rights have been on the ballot, from Vermont to Kentucky, the abortion rights side has won . This past Tuesday, the same day that the court heard the mifepristone case, voters in Alabama elected to the state legislature a Democrat who ran on a platform of protecting access to abortion and I.V.F. The candidate, Marilyn Lands, lost her race in 2022 by seven points; she won this week by 25 points.

There are limits to the state-by-state approach when it comes to protecting bodily autonomy. Some states don’t allow ballot initiatives of the type that have led to abortion rights victories elsewhere. In Ohio and other states, lawmakers have sought to block or overturn attempts by voters to protect abortion rights, and anti-abortion lawmakers in several states have sought to prosecute anyone who helps a woman travel to another state to get an abortion.

In short, there is no silver bullet for reproductive rights. The judiciary is no haven, not as long as the current Supreme Court majority holds; state and lower federal courts aren’t much better, going by the Alabama I.V.F. ruling and the decisions that pushed the mifepristone case to the Supreme Court. At the same time, voter support for reproductive rights won’t make a difference if they can’t use ballot measures to make that support known.

That is why any successful strategy to protect or restore abortion rights must understand reproductive rights and representative democracy as inextricably linked.

That means understanding the stakes of the elections in November. If Mr. Trump’s party wins solid control of the House and Senate, this could put Americans’ reproductive rights at further risk, especially if Republicans first decide to do away with the filibuster. That would lower the threshold for passing legislation such as a 15-week abortion ban , which Mr. Trump seems likely to support .

Voters will be faced with a stark choice: the choice of whether to protect not just reproductive rights but true equality for women.

Source photograph by Getty Images.

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Moskowitz Says Abortion Ballot Initiative Failure 'Not Foregone Conclusion'

Florida's abortion law is set to be on the ballot in November, but Governor Ron DeSantis ( R-FL ) recently suggested the pro-abortion side of the initiative will fail. However, in a comment to  The Floridian , Representative Jared Moskowitz ( D-FL ) predicted the measure would be far closer, "right on the cusp," and, "I don’t think that’s a foregone conclusion."

Gov. DeSantis said earlier in April at a Fort Lauderdale press conference that "Once voters figure out how radical both of those are...they are going to fail," referencing amendments to the Florida Constitution legalizing recreational marijuana for adults over 21 and protecting abortion access up to fetal viability.

The latter amendment, Amendment 4, was  allowed  to become a ballot initiative several days before by the Florida Supreme Court, although it also ruled that the 15-week abortion ban passed by Gov. DeSantis in 2022 was valid, which could trigger a 6-week abortion ban soon after. Anna Hochkammer, Executive Director of the Florida Women's Freedom Coalition, predicted the measure will mobilize pro-abortion voters.

As a result, Rep. Moskowitz suggested DeSantis's prediction of failure is uncertain, and he "would say, I think it’s a 57-62 issue like I don’t think this is a 70 percent issue and I don’t think it’s a 50 percent issue I think its right on the cusp. I think if there’s a significant turnout, it passes, but the idea that it is going to fail, I don’t think that’s a foregone conclusion."

Rep. Moskowitz had  previously  mocked the recent Arizona Supreme Court  ruling  from 1864 (back when Arizona was still a territory) almost fully outlawing abortion except in cases of the mother's life being in danger in another comment to  The Floridian , saying, "There is nothing like bringing back a rule from 175 years ago because the laws were so great back then. I think the problem that is going on right now is that some states allow healthcare for women and others are instituting laws right from the 1800s," said Moskowitz. “From a political standpoint, if we can’t beat Kari Lake on this, then Arizona is not really in play."

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Norway’s health minister accused of plagiarism in latest ethics scandal to rock the government

COPENHAGEN, Denmark (AP) — An academic probe said Thursday that Norway’s Health Minister Ingvild Kjerkol plagiarized parts of her masters’ degree thesis three years ago, the second such case this year in the Norwegian government and the latest allegation of unethical behavior to rock the center-left government.

The investigation by Nord University in Bodoe, northern Norway, found Kjerkol’s 2021 thesis contained “far more serious errors than sloppiness,” Norwegian broadcaster NRK reported. The broadcaster said the probe’s conclusion was to deprive Kjerkol of her master’s degree in health management.

The 48-year-old Kjerkol did not comment Thursday. But she has previously rejected the allegations, saying she and a co-author did not copy to parts of another student’s thesis from 2015.

Kjerkol has been in office since October 2021 when Prime Minister Jonas Gahr Støre presented a coalition government of his own Labor party and the junior Center Party.

The conclusion of Thursday’s probe immediately prompted the opposition to urge Gahr Støre to say whether he has trust in Kjerkol.

Jan Tore Sanner, a senior member of Norway’s main opposition party, Hoeyre, told Norwegian news agency NTB, that the prime minister must address “the matter of confidence” in Kjerkol.” Sylvi Listhaug, the leader of the anti-immigrant Progress Party, also called on Gahr Støre to “assess whether he has confidence in her.”

Kjerkol is the second government member to be entangled in academic plagiarism allegations this year. In January, Sandra Borch stepped down as minister for research and higher education after a student discovered that parts of Borch’s master’s thesis, including spelling mistakes, were copied without attribution from a different author.

Gahr Støre’s coalition has seen the departure of several ministers in recent months over other wrongdoings. In September, it was revealed that the husband of then Foreign Minister Anniken Huitfeldt had been trading in stocks for years behind her back and that could potentially enrich her.

The ruling social democratic Labor party was defeated in September in local elections by the Hoeyre for the first time since 1924. The party, which for decades was Norway’s largest party in local elections, came in second in the Sept. 11 elections for local councils in Norway’s 356 municipalities and 11 counties .

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Christopher Buccafusco receives 2024 Distinguished Teaching Award and Derrick Jeffries is named Distinguished Staff Member

Student-voted D.O.N.E. awards also went to George Naser Khoury ’24, Margaret Kruzner ’24, Casey Witte ’24, and three student groups

Christopher Buccafusco received the Distinguished Teaching Award and Derrick Jeffries was honored as Distinguished Staff Member at the 2024 D.O.N.E. Awards on April 10.

Buccafusco, the Edward & Ellen Schwarzman Distinguished Professor of Law, who teaches classes including Torts, Copyright Law, and Design Law, has had “an indelible academic impact” on his students and made them think about the law in a much deeper and sophisticated way, said one student who nominated him. 

Accepting the honor, Buccafusco said he was “incredibly impressed” with the students at Duke Law and grateful for his colleagues. 

“Getting to be a law professor anywhere is a kind of loophole in the universe. We are incredibly lucky to get to do this, but we are especially lucky to get to do this here at a place like Duke,” he said.

The D.O.N.E. Awards – D.O.N.E. stands for Duke Law Outstanding and Noteworthy Endeavors – are sponsored by the Duke Bar Association to honor students, student organizations, faculty members, and staff who have made significant contributions to the Duke Law community through their leadership, innovation, service and dedication. 

Nominations are submitted by students and winners are determined by a committee of students from all three JD class years and the LLM class.

DBA Academics Chair Jody Messick ’26 hosted the ceremony.

The first award, for Distinguished Staff Member, was presented by Emma Cline ’26 to Derrick Jeffries, a member of the Facilities staff and a positive and steadying presence in the halls of Duke Law. Jeffries, she said, consistently goes above and beyond for students — getting to know them, returning lost items, and, importantly, remembering what they share about themselves.

As his family and friends looked on, Jeffries took the podium amid loud applause from students, and spoke movingly about the power of a smile and a kind word.

“I don't do this for me. I do this for y’all. I take my job seriously,” Jeffries said with a catch in his voice. “All the students and staff, everybody I meet, I'll say ‘Good morning’ because you never know what kind of day a person had before. Greeting them with a smile or a good morning can change their mood, can change their day.

“I just try to be encouraging and show support to all the students. I see how hard it is. I see how there are late nights, there are early mornings, how they come in tired sometimes, and I just try to encourage them,” Jeffries said.

“Peace and your mental health are very important. So when you feel crammed and just overwhelmed, take a break but don't quit. Do something you enjoy doing. If it is going to get something to eat, getting something to drink, just sitting outside, just getting some sun, take a break but don't quit — and come back.”

Buccafusco, the Distinguished Teaching honoree, was described by a student as ‘simply the most amazing, iconic and incredible professor’ they have had at Duke, presenter Hamza Chaudhry ’25 said.

“Whether he is teaching 1L Torts or Copyright, this professor brings a unique analytical rigor to his classroom,” Chaudhry said. “[He] is also noteworthy for the energy and commitment he brings to Duke Law. … This year's award winner consistently goes the extra mile to show his love for our community.” 

As a student in Buccafusco’s Torts class, Chaudhry said, “my assumptions about the law were pushed to their limits in an environment that was both relaxing yet deeply enriching. [His] lecture on the intersection between disability rights, tort law, and measures of happiness is something that fundamentally shaped how I see the world.”

Buccafusco said he was deeply honored to receive the student-voted award and called being a law professor “a great job.”

“The kinds of people I get to work with here, my colleagues on the faculty who inspire me to write and think about new ideas in new ways, the staff that we have, are just the best possible people,” he told students. 

“All of these people make our lives infinitely better every single day that we come in, and we are incredibly lucky to get to work with them, but I feel especially lucky to get to work with you. I am just so incredibly impressed with your dedication, your thoughtfulness, and the ways in which you relate to one another.

“The law is enormously serious. The sorts of discussions that we have every day in class and outside of class determine the course of people's lives, affect how massive amounts of humanity co-exist with one another, and the extent to which you are all capable of taking those sorts of questions incredibly seriously, but also — and this is key for me, and I think for you — not necessarily taking yourselves all that seriously, this is a hugely valuable thing to do. Your ability to make sure that you are understanding that the stuff we do matters, but that we can all nonetheless engage with one another in a friendly, compassionate, thoughtful way has been hugely inspiring to me.”

Three student leaders were also recognized for their service and community-building efforts:

• Margaret Kruzner ’24 received the Outstanding Student Organization Leader Award for her “tireless” leadership of the Moot Court Board. “It is often a thankless job to be the leader of an organization like Moot Court because everyone wants to compete or have the honor on their resume, but she took on the mantle and oversaw several competitions and handled it all with grace,” Cline said. “I have gotten to know [Margaret] over the past semester and she has been an incredible role model for me.”
• Casey Witte ’24 received the Outstanding Contribution to the Duke Law Community award for consistently going above and beyond to cultivate a supportive and inclusive community for his peers. “Whether through organizing events, spearheading initiatives, or simply lending a listening ear, he has demonstrated a profound commitment to the wellbeing and success of his fellow students,” Messick said. “His impact extends far beyond the confines of our classroom and lecture halls. He has been a beacon of encouragement and support, inspiring others to strive for excellence and to embrace the values of collaboration.” 
• George Naser Khoury ’24 won the Richard Lin Service Above Self Award, which honors Lin, a member of the Class of 2016, and is given to a student who embodies Lin’s qualities of optimism, integrity, humility, and generosity of time and energy. “As Richard shared during his [Convocation] address in 2016 , this year's award winner is one of those ‘solid people who do the right thing on a daily basis and makes a world of a difference,’” Chaudhry said. “When one student had to defend her master's thesis on a random weekday afternoon and could not find childcare, he volunteered to watch her son for the afternoon in the office. And he did not just watch him, he fed him snacks, played iPad videos, and even blew his nose when his asthma kicked in.” George Khoury is “one of the most compassionate, kind and selfless individuals in our community.” 

Student organization awards were given to:

• First Class, honored for Greatest Role in Building Relationships. In a relatively short time, First Class has built strong relationships through activities such as bringing in guest speakers on topics like personal finance — and making sure each student had the relevant book — and inviting experienced lawyers and alumni for informal knowledge sharing with students over coffee. “This organization facilitates belonging in our community by bringing attention to critical life skills essential that are essential for every pre-professional student,” Messick said. “As first generation lawyers, these interactions have not only provided invaluable mentorship opportunities, but have also forged long lasting connections that extend beyond the confines of our campus.”
• The Duke Law Federalist Society was recognized for Outstanding Contribution to Civil Discourse. “The importance of creating spaces for informed discussion is more challenging than ever. The sheer number of events that this organization has hosted is impressive in its own right, but what's more, this organization has not shied away from tackling contentious issues like censorship, gender and sports and abortion on the constitution,” Messick said. “It has also delved into the complexities of judicial review and practicing law with integrity. … This organization's dedication to fostering open dialogue and intellectual engagement has left a mark on the Duke law community.”
• Broad Street Law, which leads interactive pre-law lessons twice a week for children in detention at the Durham Youth Home, received the award for Greatest Service to the Outside Community for “igniting an enthusiasm for learning in kids and teenagers. They strive to make legal concepts comprehensive, yet digestible, engaging, yet approachable on topics such as criminal law, copyright law, and more,” Messick said. “As one student said in their nomination, ’There were countless meaningful moments that underscored the impact of this program. The students at the Durham Youth Home consistently surprised and inspired us with their candor, curiosity, and eagerness to engage … These young minds grappled with complex legal and societal issues with maturity and insight.’”

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The farcical saga of an impeachment trial no one wants to convene

Why fail on a Thursday when you can instead drag out that failure four or five days later, for no apparent gain?

Senate Republicans were apoplectic in early January 2020. House Democrats had impeached Donald Trump and declared him a threat to democracy — but then refused to actually send the matter to the Senate.

Democrats naively thought they could withhold the articles of impeachment to leverage more favorable rules for the Senate trial, which Republicans had no intention of implementing.

“This delay is an abuse of power & denies POTUS his day in court,” Sen. Shelley Moore Capito (R-W. Va.), one of the more pragmatic GOP lawmakers, wrote on social media . “Send it or end it!”

The next day the House speaker at the time, Rep. Nancy Pelosi (D-Calif.), realized the error of this strategy and announced she’d send her impeachment managers across the Capitol the following week, beginning a trial almost four weeks after the House’s votes.

So much for any form of consistency more than four years later.

On Wednesday, House Republicans failed to march their articles of impeachment against Homeland Security Secretary Alejandro Mayorkas to the Senate, as Speaker Mike Johnson (R-La.) had previously announced for his plan.

Instead, we live in a political world in which the most fervent opponents of Mayorkas — who believe he should be convicted in a Senate trial and removed from office — are the ones actually delaying the start of the trial.

Now, sometime next week, maybe Tuesday or Wednesday, the trial will finally begin, more than two full months after the House took the unusual step and voted to impeach a cabinet member for the first time since 1876.

In impeaching Mayorkas, Republicans have turned the most powerful constitutional duty that Congress has — removing executive branch officials for “high crimes and misdemeanors” — into a farcical journey of blunder and mismanagement.

Sen. Joe Manchin III (D-W.Va.), who spent the first three years of President Biden’s tenure as a key swing vote who frustrated liberal activists, summed up the GOP mishandling of the entire saga in a floor speech Wednesday. Manchin pledged his full support to the Democratic plan to short circuit the trial quickly once Johnson finally sends the articles over and senators are sworn in as jurors.

“It is basically something that I can’t wait to vote against and get it out as soon as it comes here,” he said.

That vote was originally going to come Thursday afternoon, if the managers had delivered the articles Wednesday. Senate Majority Leader Charles E. Schumer (D-N.Y.) has laid out a plan to follow the more than century-old mandate for starting impeachment trials at 1 p.m. each day.

But Senate conservatives realized just how quickly defeat would come if they held a trial this week, and they used back channels to the House speaker to plead with him to delay the trial until next week.

In a stunning admission of how little traction their effort to oust Mayorkas had gained, these hard-line GOP senators explained that the Senate has become so duty-bound by their Thursday afternoon departure schedule that some Republicans might just leave town or agree to quickly dismiss the trial.

“We don’t want this to come over on the eve of the moment when members might be operating under the influence of jet fuel intoxication,” Sen. Mike Lee (R-Utah) said at a Tuesday news conference.

This bungled impeachment effort is only compounded by the fact that the underlying dispute — the crisis at the border of migrants flowing into the country — comes on the single best policy issue on the Republican side. Every poll shows critical independent voters, who will decide the November elections, giving Biden, Mayorkas and Democrats terrible grades for handling the border.

The House Republican effort to impeach Biden over financial impropriety by family members has crumbled amid witnesses getting indicted on a charge of trading secrets to Russia or going on the global lam to avoid charges here.

Instead, the Mayorkas impeachment took hold as the major oversight trophy the House GOP hoped to show for its incredibly weak hold on the majority the past 15 months.

Congressional Democrats, as well as quite a few Senate Republicans, have never agreed with the House GOP’s thesis that Mayorkas violated the Immigration and Nationality Act, which mandates the detention of any deportable migrant. These critics and skeptics essentially see this as a policy dispute, given a cabinet secretary’s broad discretion to enforce laws, and that the way to handle policy disputes is through elections.

Sen. Mitt Romney (R-Utah), who voted to impeach Donald Trump twice, told reporters Tuesday that the “standard has not been met for a conviction,” and he could join Democrats in dismissing the case at the outset of the trial.

That argument rang true to three House Republicans, which is why the Mayorkas impeachment began in such farcical fashion.

On Feb. 6, Johnson and his leadership team rolled the dice to hold the vote to impeach anyway believing there were only 211 Democrats present to vote — and that they would win 215-214, despite three defections from their side of the aisle.

House Minority Leader Hakeem Jeffries (D-N.Y.) had been in touch with a hospitalized Democrat, Rep. Al Green (Texas), and got him to the floor in time to cast a vote that left the House deadlocked 215-215 .

Rather than accept defeat, Johnson used a parliamentary tactic to hold a do-over the following week, calling House Majority Leader Steve Scalise (R-La.) back to Washington after he’d been at home recovering from a bone-marrow transplant.

One extra vote was all Republicans needed — so long as they held the vote early on the evening of Feb. 13.

They feared that, about two hours after their narrowest-possible-margin impeachment of Mayorkas, Democrats would win a special election on Long Island and their margin would disappear. Indeed, Democrats won that race, and if the House had to hold another vote now on Mayorkas, and all members showed up and voted as they had before, the impeachment articles would fail on another tie vote.

Johnson immediately took the Pelosi approach to handling impeachment articles, but far outdoing the slow-moving Democrats from four years ago. House Republicans adjourned for a two-legislative break, then spent almost a month fighting over government funding.

When they finally approved the remaining funding bills, on March 22, the House again adjourned for another two-week break.

Finally, a timeline appeared for the Senate to consider the impeachment trial, mapped out between the offices of Johnson and Schumer.

Senate Republicans, who have been bitterly divided the past six months over issues related to the border and funding Ukraine’s defense against Russia, came around on the idea that almost all of them would endorse the plan to force a full impeachment trial of the cabinet secretary.

Upon returning to the Capitol Monday, Sen. Thom Tillis (R-N.C.) told reporters he did not quite fully understand the House case against Mayorkas, doubting its validity, but would vote to hold a full trial.

Aside from Lee and a handful of his far-right allies, Senate Republicans give off the vibe that they want to get come credit for voting for a full trial from conservative activists.

At the same time, their statements give off a halfhearted nature that demonstrates, deep down, little desire to turn over the Senate floor to prominent MAGA lawmakers like Reps. Marjorie Taylor Greene (R-Ga.) and Andy Biggs (R-Ariz.), two of the House managers who would try the case if it went to a full trial.

Each day so far this week, Republicans have lined up to give long speeches about impeachment and the border crisis.

Capito delivered one of them Wednesday afternoon, noting that never before had an impeachment trial been dismissed at the outset. She made no mention of her own vote in January 2021 to dismiss charges against Trump for the Capitol riot , nor did she mention her January 2020 statements demanding a speedy trial or no trial at all for the first Trump impeachment.

“This time,” she said, “it should be no different.”

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Recent trend and correlates of induced abortion in China: evidence from the 2017 China Fertility Survey

School of Public Policy and Administration, Institute for Population and Development Studies, Xi’an Jiaotong University, Xi’an, China

Quanbao Jiang

Associated data.

The datasets generated and analyzed during the current study are not publicly available due to privacy or ethical restrictions but are available from the corresponding author on reasonable request.

Although there are more than 10 million induced abortions per year in China, there are few comprehensive, systematic, and characteristic-based data on induced abortions among Chinese women. This study aims to examine the overall trend in induced abortions in China and to analyze the correlation between induced abortions and some socio-economic factors.

Drawing from the 2017 China Fertility Survey, this study analyzed induced abortions using multiple indicators from period and cohort perspectives on a sample of 240,957 women. The indicators include the abortion rate and proportion, average age at the time of induced abortion, age-specific cumulative proportions, and the number of induced abortions by cohort. The analysis also differentiated based on residency, ethnicity, education level, and marital status. A binomial logistic regression model was used to examine the association between induced abortions and socio-economic factors.

Between 2006 and 2016, among women aged 15–49, there was an increase in the induced abortion rate and the average age of women who had induced abortions, but a decline in the proportion of abortions. The proportion of induced abortion was higher among premarital than post-marital pregnancies, among unintended than planned pregnancies. Women with induced abortion experiences accounted for less than 30% of all cohorts, and the cumulative number of induced abortions per woman in each cohort was less than 0.45. These indicators varied with birth cohort, residence, ethnicity, education level, and marital status. The results of binomial logistic regression confirmed the association between induced abortion and these socio-economic variables. Sex-selective abortions of female fetuses still exist, despite the government’s considerable efforts to eliminate them.

The practice of induced abortions differs by cohort and socio-economic characteristics. The profile of women who resort to abortions in China has shifted from well-educated urban women to rural, less-educated women. More effective measures should be taken by the government to reduce the number of induced abortions among women with higher abortion risks.

Introduction

A large number of induced abortions occur worldwide. In 2003, the total number of induced abortions was 42 million globally, and the induced abortion rate was 29 per 1000 women aged 15–44 years [ 1 ]. Between 2015 and 2019, the rate was 39 per 1000 women aged 15–49 years, with an average of 73 million induced abortions per year [ 2 ]. A large proportion of induced abortions occur in China [ 3 ]. In 2019, the number of induced abortions documented in China was 9.76 million [ 4 ]. However, given the underreporting and concealment of induced abortions that occur in private hospitals and clinics, the actual number is likely to be higher. The actual number of induced abortions per year was estimated at approximately 13 million [ 5 ]. According to a recent report by the United Nations Population Fund, almost half of all pregnancies are unintended, and many end in induced abortions [ 6 ]. Reducing unintended pregnancies and, by extension, induced abortions would entail improving women’s sexual and reproductive health through contraceptive services and access to sex education [ 7 , 8 ]. There has been a concerted effort in this regard from the government, academia, and the public to reduce induced abortion in China.

Previous research has shown that induced abortions are associated with individual characteristics and socio-economic factors [ 9 – 11 ]. First, age is an important factor: the average number of induced abortions increases with age [ 12 ], and high rates of repeat induced abortions are also associated with age [ 13 , 14 ]. Second, residence status is another factor associated with induced abortion. China is characterized by clear urban-rural differences in many areas, including access to healthcare and birth control policies. While the One-child Policy was strictly enforced among urban residents, it was adjusted to a “1.5-child policy” for rural residents (rural couples whose first child was a girl were permitted to have another child) [ 15 , 16 ]. Such policy variations have affected behaviors on fertility and induced abortion among women in urban and rural areas. Third, ethnicity is associated with women’s induced abortion in China [ 9 , 10 , 16 ]. A more relaxed birth control policy was implemented for ethnic-minority groups than for Han Chinese, causing more Han women to limit childbearing through induced abortions to conform to the implemented policy [ 11 , 17 ].

Education level also affects women’s induced abortion behaviors in China [ 9 , 11 , 17 ], although research conclusions diverge in this area. Some studies have shown that less-educated women have less knowledge of reproductive health and contraception and are more likely to undergo induced abortion and repeat induced abortions [ 12 , 18 , 19 ]. However, other studies have shown that women with higher levels of education have higher abortion rates [ 9 ]. Women with more education are more likely to postpone childbearing, use short-term contraceptive methods, and resort to induced abortion if that fails.

Women’s marital status and sex of existing children are also associated with induced abortion [ 14 , 15 ]. Married women and women with children are more likely to undergo repeat induced abortions in China [ 12 ]. In the past, induced abortions have generally occurred among married women constrained by the birth control policy. However, in recent times, abortions of premarital pregnancies have become widespread [ 20 , 21 ]. Given the deeply-entrenched son preference and constraints on the number of births, many couples have turned to sex-selective abortions. If the first child is a girl, parents who prefer sons are likely to abort a second female fetus in pursuit of a son, resulting in a high rate of induced abortions after the first birth [ 16 ].

The large-scale induced abortions in China have attracted the attention of all sectors of society. However, most recent studies have used data drawn from small-scale surveys of women who had induced abortions in hospitals. This study analyzed the overall trend in induced abortions using a nationally representative sample. The analyses explore differences based on the birth cohort and individual characteristics. In addition, we examine the association between induced abortions and some correlates using a binomial logistic regression model. We aimed to provide a comprehensive period and cohort dataset for induced abortions among Chinese women and re-examine the factors that correlate with induced abortion.

The Chinese context

The birth control policy.

Induced abortions are associated with China’s birth control policy. A stringent birth control policy was introduced in 1980, although enforcement was sometimes relaxed [ 15 ]. Many provincial family-planning regulations resort to induced abortion as a remedial measure for pregnancies out of the birth limit [ 22 ].

There were urban-rural differences in the implementation of the birth control policy. While couples with the urban Hukou-type (household registration) were permitted to have one child, rural Hukou-type couples in 19 provinces were allowed to have a second birth if the first child was a girl [ 15 , 16 ]. Furthermore, there were differences in how the birth policy applied to Han citizens, as opposed to ethnic-minority groups. China is a multi-ethnic country with 56 ethnic groups. In the 2020 census, the Han people accounted for 91.11% of the population, while the other 55 ethnic groups accounted for approximately 9%. For many years, the Chinese government’s birth control policy was more relaxed for ethnic-minority groups than for the Han people. Consequently, the prevalence of induced abortion was higher among Han women [ 11 , 17 ].

The stringent birth control policy has been gradually relaxed. In 2013, a selective two-child policy was adopted in which couples were permitted a second birth if either spouse was an only child. However, only 13.2% (1.45 million/11 million) of eligible couples had applied for permission to have a second child by May 2015 [ 23 ]. In 2016, a universal two-child policy was implemented for all citizens, regardless of Hukou-type or ethnicity. In 2021, China adopted a universal three-child policy. It remains to be seen how this policy relaxation will affect the trend of induced abortion [ 24 ].

Premarital pregnancy

Premarital pregnancy is widely frowned upon in China. Influenced by traditional Confucianism, Chinese society values female virginity and denounces premarital sex [ 20 , 25 ]. Owing to guilt and anxiety, some never-married young women who became pregnant were more likely to have induced abortions in private clinics or nonprofessional facilities to keep their families from knowing [ 26 – 28 ].

During the one-child policy era, out-of-wedlock births were labeled as “unauthorized” births and were ineligible for Hukou (household) registration. In China, many benefits and social welfare provisions are closely linked to the Hukou registration system [ 29 , 30 ]. People without Hukou registration cannot access education, the medical system, or other state welfare provisions. Therefore, premarital pregnancies are usually terminated.

Recently, premarital cohabitation and sex have become widespread in China, but premarital childbearing is still considered unacceptable and it is uncommon. In 2018, the overall percentage of births registered with unmarried mothers was 41% in Organization for Economic Co-operation and Development (OECD) countries [ 31 ], but remarkably low in China [ 32 ]. The proportion of women who gave birth before marriage in different birth cohorts in China slightly increased from 0.2% among women born before 1974 to 1.2% in recent birth cohorts born between 1980 and 1989. Almost all children are still born and raised within marriage in contemporary China [ 32 , 33 ]. Premarital pregnancies generally end in abortions, and unmarried women account for more than one-third of women undergoing induced abortions. Both the rate of induced abortion and the proportion of repeat induced abortions among young unmarried women continue to increase annually [ 34 , 35 ].

Sex-selective abortion

Sex-selective abortion also affects induced abortion in China. Given the strong preference for sons, some couples, especially in rural areas, turn to sex identification and selectively abort female fetuses to ensure a son within the birth control constraints [ 11 , 16 , 17 , 36 ]. The likelihood of induced abortion is significantly higher for women with only daughters [ 16 ]. One data analysis showed that more than 25% of female fetuses ended in induced abortion, compared to 1.6% of male fetuses [ 37 ].

As gender equality has become mainstream, with education for women leading to increasing social status, the preference for sons is markedly waning [ 16 ]. When the universal two-child policy was implemented in 2016, sex-selective abortion decreased significantly, as manifested in the decline of China’s sex ratio at birth (expressed as the number of live male births for 100 live female births) [ 23 , 38 ].

Materials and methods

The data used in this study were drawn from two sources. Data on annual induced abortions between 1980 and 2020 were obtained from the China Health Statistical Yearbook , an annual statistical publication that documents developments in China’s public health and the health status of residents. Data on the annual number of births, drawn from the China Statistical Yearbook , were calculated based on the total population and birth rate. The China Statistical Yearbook is an annual statistical publication that details China’s economic and social situation, covering population, employment, government finances, prices, and agriculture, among other topics.

Other data (including the main data), were collected from the 2017 China Fertility Survey, conducted by the former National Health and Family Planning Commission. This survey was conducted with a female population aged 15–60. Through stratified three-stage probability proportional to size (PPS) sampling, the final valid sample size was 243,951. The survey was conducted in two ways: through face-to-face interviews and network surveys. A computer-assisted personal interviewing system was used in the questionnaire design, personnel training, sampling frame preparation, sampling, household survey, and questionnaire review. The post-enumeration quality check, comparison, and verification of the case data showed that the survey was highly accurate [ 39 ]. From these data, we excluded people over 60 years of age (n = 2380, 0.98%), those whose marriage/cohabitation information was missing (n = 23, 0.01%), and those whose age at first marriage or first pregnancy was under 15 (n = 591, 0.24%). This produced a final sample of 240,957 women. Unless otherwise specified, the data were sourced from the 2017 China Fertility Survey.

The survey includes the women’s pregnancy history, such as the end date of each pregnancy and result, categorized as live male birth, live female birth, stillbirth, spontaneous abortion, or induced abortion (including medical abortion and induced labor). Regardless of marital status, the interviewees completed a “pregnancy history,” specifying whether each pregnancy was planned.

Various indicators were calculated to illustrate the overall trend and sample characteristics from a period and cohort perspective. Next, we conducted binomial logistic regression analysis to examine the association between induced abortions and correlates. All analyses were performed using the Stata version 15.

Period and cohort analysis

The indicators used for the induced abortion analysis included the number, rate, and proportion of induced abortions, as well as the ratio of births to abortions. Indicators, including the age-specific abortion rate and total abortion rate, were also applied [ 1 , 9 , 10 ]. In addition to period indicators, cohort indicators were also calculated, covering the rate and proportion of induced abortions. The main indicators of this study are as follows:

The induced abortion rate is defined as the number of induced abortions per 1000 women of childbearing age during a specified period (usually 1 year). Many studies in Western countries define women of childbearing age as 15–44 years old. [ 1 , 3 ] Some studies in China use a range of 15–49 years old [ 9 , 36 ]. In this study, we define childbearing age as 15–49 years old.

The proportion of induced abortions was defined as the proportion of pregnant women who experienced induced abortions during a specified period. Pregnant women included all women currently pregnant, as well as those who had experienced live male or female births, stillbirths, or induced abortions.

The age-specific cumulative proportion of induced abortion for a cohort refers to the proportion of all women in a cohort who have experienced at least “n” abortions by the corresponding age. For example, the “age-specific cumulative proportion of first abortion in a cohort” refers to the cumulative proportion of women in a cohort who have experienced at least one abortion by the corresponding age. This indicator can be calculated by residence, ethnicity, and education level.

The age-specific cumulative number of induced abortions per woman refers to the average number of abortions experienced by women in a cohort by the corresponding age. The numerator is the number of abortions experienced by women in a cohort by the corresponding age, and the denominator is the total number of women in the cohort. This also can be calculated by different factors.

Respondents were grouped into nine cohorts according to their age at the time of the survey. The cohorts were as follows: 15–19, 20–24, 25–29, 30–34, 35–39, 40–44, 45–49, 50–54, and 55–60. Due to the limited space, we used 25–29 or 30–34 cohorts, (women aged 25–29 or 30–34 at survey time) to represent the later birth cohort, and the 45–49 cohort (women aged 45–49 at survey time) to represent women in the earlier birth cohort.

We divided pregnancies into premarital and post-marital pregnancies. Pregnancy was recorded as premarital if the woman was unmarried or cohabitating at survey time. If a woman was married, we calculated the interval between the end of each pregnancy and the time of marriage. Pregnancies were regarded as post-marital if the interval was greater than eight months, otherwise premarital [ 25 , 40 ].

Regression analysis

A binomial logistic regression model was used to examine the correlation between induced abortions and various factors, including age, residence, ethnicity, education level, and premarital pregnancy experience.

Dependent variable

The dependent variable is binary, indicating whether a woman had experienced induced abortion by the time of the survey.

Independent variables

The factors included age, residence (urban or rural), ethnicity (Han or minority group), education level (junior middle school or below, high school, and college or above), and whether a pregnancy was premarital. Due to the limited space in the chart, we used a 10-year interval in the models to measure the birth cohort, producing 15–24, 25–34, 35–44, 45–54, and 55–60 cohorts.

We also controlled for potential confounders, including health status, employment status, and number of siblings. These confounders were measured with specificity to the time of the survey rather than the time of the induced abortion.

General induced abortion trends

Figure  1 shows the number and proportion of induced abortions, rate of induced abortions, proportion of induced abortions by residence, average age of women undergoing induced abortions, average age when women experience their first induced abortions, and average age of women who had induced abortions during their first pregnancies.

Trend in induced abortion. A Number and Proportion, 1980–2020. B Rate, 2006–2016. C Proportion, 2006–2016. D Age at abortion, 2006–2016. E Age at first abortion. F Age at first pregnancy which ended in abortion. Note: The proportion in Panel 1A is the number of induced abortions/(number of induced abortions + number of births); the research object of Panel 1B-1 F is women of 15–49 years old in the 2017 China Fertility Survey. The years in which the one-child policy (1980), the selective two-child policy (2013) and the universal two-child policy (2016) were introduced are specially marked in Panel 1A

Panel 1A shows that the number and proportion of induced abortions in China fluctuated greatly between 1980 and 2020, and can be divided into three stages. During the first stage (1980–1992), the annual number and proportion of induced abortions remained high. During the second stage (1993–2013), the annual number and proportion of induced abortions declined and remained at a low level. The third stage (2014–2020) was characterized by a return to a higher proportion and number.

Panels 1B and 1C show the rate and proportion of induced abortions, respectively, among women aged 15–49 between 2006 and 2016 in China. The rate fluctuated upward and was higher for urban women than for rural women. The proportion of induced abortions showed a downward trend, reflecting a reduction in unintended pregnancies, especially among urban women.

Panels 1D, 1E, and 1F show the average age of women undergoing induced abortions between 2006 and 2016. Panel 1D indicates an upward trend in age at the time of induced abortion, with urban women tending to be older than rural women. Panel 1E shows that the average age at the time of the first abortion increased from 28.49 to 2006 to 30.81 in 2016 for urban women, and from 28.01 to 29.70 for rural women. Panel 1F presents the average age of the women undergoing first-pregnancy induced abortions. For urban women, this age has increased over the decades, whereas for rural women, it has declined since 2013.

Age-specific cumulative proportion of induced abortion for a cohort

Figure  2 shows the age-specific cumulative proportion and progression ratio of induced abortions among women who experienced induced abortions by the corresponding age. Panel 2A indicates that less than 30% of the women in different cohorts ever experienced induced abortions.

Age-specific cumulative proportion of induced abortion in cohort. A By cohort. B By residence. C By ethnic groups. D By education level. E By abortion number. F By abortion number (progression). Note: C represents cohort. 45-49 C represents the cohort of women aged 45–49 at survey time. U, R for residence, J, H, C for education level. Han and Minorites mean Han women and ethnic minorities women. For example, H30–34C means the cohort of women with a high-school education aged 30–34 at survey time. In Panel 2E, 30–34C2 means women in the 30–34 cohort who have undertaken at least two induced abortion

Panel 2B shows that in the early birth cohort (45–49 years old at survey time), a higher proportion of urban women had experienced an induced abortion by a specific age than rural women. By contrast, in the late birth cohort (30–34 years old at survey time), more rural than urban women had experienced an induced abortion. Among urban women, the proportion of women in the late birth cohort was lower than that in the early birth cohort; however, the data showed a reverse pattern for rural women.

Panel 2C shows that in the early birth cohort, the proportion of Han women who had experienced an induced abortion by a specific age was higher than that of minority women, and this pattern was reversed for the late birth cohort. The proportion of Han women in the late birth cohort was roughly the same as that in the early birth cohort, while the proportion of minority women in the late birth cohort was higher by the corresponding age.

Panel 2D shows that in the early birth cohort, the higher the education level, the higher the proportion of women who experienced induced abortions by the corresponding age. In the late birth cohort, the proportion of women with a high-school education or below was higher than that of women with a college education or above by the corresponding age. Compared with the early birth cohort, the proportion of women with a high-school education or above in the late birth cohort was lower among women with corresponding educational levels by the corresponding age. However, a higher proportion of women with a junior middle-school education or below have experienced induced abortion in the late birth cohort than in the early birth cohort, showing an advance in age at induced abortion among women with lower education levels.

Panel 2E shows the cumulative proportion of women in the cohorts who have experienced a minimum of one, two, or three induced abortions by a specific age. The cumulative proportion of women who experienced at least one induced abortion was 26.29% by the age of 49. Over 70% of women had no abortion experience. Overall, 8.58% of the women in the cohort experienced at least two induced abortions, whereas 2.10% had experienced at least three induced abortions. Panel 2F shows the cumulative proportion of women in the cohort who had experienced one abortion, the progression ratio for women who experienced a second abortion (among women who had experienced a first abortion), and the progression ratio for women who had experienced three abortions (among those who had already had two abortions). Of the women who had experienced one abortion, more than 30% had experienced two or more abortions. Of the women who had experienced two abortions, approximately 25% experienced three or more abortions.

Age-specific cumulative number of induced abortion

Figure  3 shows the age-specific cumulative number of induced abortions per woman in the different cohorts.

Age-specific cumulative number of induced abortion per woman in cohort. A By cohort. B By residence. C By ethnic groups. D By education level Note: C represents cohort. 45–49C represents the cohort of women aged 45–49 at survey time. U, R for residence, J, H, C for education level, as defined in Fig.  2 . Han and Minorites mean Han women and ethnic minorities women. For example, H30–34C means the cohort of women with a high-school education aged 30–34 at survey time

Panel 3A shows that the cumulative number of induced abortions per woman is less than 0.45 by the age of 49 in both cohorts. Before the age of 30–34, there was little difference in cumulative numbers. After the age of 30–34, the later the birth cohort, the higher the cumulative number of induced abortions by a specific age.

Panel 3B shows that in the early birth cohorts, the cumulative number of abortions is higher among urban women than among rural women of the same age. However, the opposite is true for late birth cohorts. For urban women, the number for the late birth cohort was lower than that for the early birth cohort by the corresponding age. By contrast, the number for the late birth cohort in rural areas was higher than that for the early birth cohort.

Panel 3C shows that Han women in the early birth cohort had a higher cumulative number of induced abortions than ethnic-minority women, although there was little difference between them in the late birth cohort. Among Han women, the number of induced abortions in the late birth cohort was lower than that in the early birth cohort, whereas the opposite was true among ethnic-minority women.

Panel 3D shows that women with higher education levels in the early birth cohort experienced more induced abortions by a specific age. In the late birth cohort, women with a high-school education or below had more induced abortions than those with a college education or above. Compared with the early birth cohort, women in the late birth cohort with a high-school education or above had fewer cumulative numbers of induced abortions. By contrast, women in the late birth cohort with a junior middle-school education or below had more cumulative numbers of induced abortions than that in the early birth cohort.

Induced abortions of premarital and unintended pregnancies

Figure  4 shows the proportion of first-pregnancy induced abortions by birth cohort and marital status. Regardless of the residence, education level, or whether the pregnancy was planned, more induced abortions occurred before marriage than after.

First-pregnancy abortion by birth cohort and marital status. A By residence. B By education level. C Premarital pregnancies, planned or not. D Post marital, planned or not. Note: For legends here, U and R represent Urban and Rural; Pre and Post represent premarital or post-marital; J, H, and C represent junior middle school or below, high school, college or above. For example, in Panel 4A, U-Post = Urban women whose first pregnancy is post-marital pregnancy. H-Pre = Women with a high-school education whose first pregnancy is premarital

Panel 4A indicates that regardless of marital status, urban women had a higher proportion of first-pregnancy induced abortions than rural women in both cohorts. Panel 4B shows a positive correlation between education level and first-pregnancy induced abortions. When considering premarital first pregnancies, there was little difference in the proportion of induced abortions among women in both cohorts with a junior middle-school education or below. However, the difference is greater among women with a senior high-school education or above. As Panels 4C and 4D show, the proportion of induced abortions was much higher for unintended pregnancies than for planned pregnancies. The proportion of abortions is much higher for unintended premarital pregnancies than for unintended post-marital pregnancies. The proportion of induced abortions among planned pregnancies was relatively low, both before and after marriage.

Induced abortions in the next pregnancy by sex of the first child

Figure  5 shows the proportion of induced abortions in women’s next pregnancy (following the first childbirth) and the proportions of male and female live births. As Panel 5A shows, more induced abortions occurred following the first birth of a son than following the first birth of a daughter. Panels 5B and 5C show a higher proportion of male births following the first childbirth of a girl, but no significant gender difference following the first childbirth of a boy.

Sex of first child and next pregnancy. A Proportion of induced abortion in next pregnancy by sex of the first child. B Proportion of male and female births in next pregnancy for a first child of a girl. C Proportion of male and female births in next pregnancy for a first child of a boy. Note: 1B 30–34 C represents women in 30–34 cohort whose first child is a boy, 1G 30–34 C represents women in 30–34 cohort whose first child is a girl. 1G Male Birth 30–34 C represents the proportion of male births in the next pregnancy following a first childbirth of a girl in the 30–34 cohort; 1B Male Birth 30–34 C represents the proportion of male births in the next pregnancy following a first childbirth of a boy in the 30–34 cohort

Logistic regression results

We used a binomial logistic regression model to further examine the correlation between induced abortion experiences and associated factors.

Table  1 shows the percentage distribution of women. Overall, more than 22% of women in this sample had experienced at least one induced abortion at the time of the survey. The lower percentage of women with induced abortion experiences in the 15–24 birth cohort was because of the right censoring. A substantial number of induced abortions did not occur among women in this birth cohort.

Percentage distribution of women who experienced induced abortions or not

Table  2 presents the results of the binomial logistic regressions. Model 1 included women’s birth cohort, residence, ethnicity, education level, premarital pregnancy, and other confounders. The results showed that birth cohort, residence, education level, and premarital pregnancy were significantly associated with the experience of induced abortion.

Results of the binomial regression model for associated factors of induced abortion

AOR adjusted odds ratio, SE standard error; *** p  < .001; ** p  < .01; * p  < .05; Confounders include health status, employment status, and number of siblings for the women are omitted in the table

Based on Model 1, the interaction terms of birth cohort with residence, ethnicity, education level, and premarital pregnancy were added in Model 2 to examine the differences in the probability of women with different characteristics and across cohorts who experienced induced abortions. Moreover, we calculated the predicted hazards of having an induced abortion by residence, ethnicity, education level, and premarital pregnancy to better interpret the interaction effects in Model 2, as shown in Fig.  6 .

Predicted hazards of experiencing induced abortions. A By residence. B By ethnic groups. C By education level. D Premarital pregnancy or not. Note: J, H, and C represent junior middle school or below, high school education, and college or above

Figure  6 presents the average marginal effects of each interaction term based on Model 2 in Table  2 . Panel 6A shows that for the earlier birth cohorts (35–44, 45–54, and 55–60), the predicted hazards of induced abortion are higher for women in urban areas than for those in rural areas. However, in later birth cohorts (15–24, 25–34), rural women are more likely to undergo induced abortions, which is consistent with the above results. Panel 6B indicates that in earlier birth cohorts (35–44, 45–54, 55–60), Han women are more likely to experience induced abortions, while in later birth cohorts (15–24, 25–34), ethnic-minority women are more likely to experience induced abortions. Panel 6C shows that in earlier birth cohorts (35–44, 45–54, 55–60), well-educated women are more likely to experience induced abortions, while in later birth cohorts, women with lower education levels are more likely to experience more induced abortions, consistent with the results above. Panel 6D shows that women with premarital pregnancy experience are more likely to undergo induced abortions. Compared with early birth cohorts, women in late birth cohorts with premarital pregnancy experience and those without had a greater difference in the probability of having an induced abortion.

Conclusion and discussion

This study analyzed the number, rate, and proportion of induced abortions by women’s characteristics and birth cohorts, as well as various correlates and draws the following conclusions:

The number and proportion of induced abortions in China have significantly fluctuated since 1980, and the average age of women undergoing induced abortions increased between 2006 and 2016. From 2006 to 2016, the abortion rate for women aged 15–49 showed an upward trend, while the proportion of induced abortions showed a downward trend. The average age of women undergoing induced abortions showed an upward trend. Rural women were younger than urban women at the time of their first induced abortions. After the Chinese government began to strictly implement its family planning policy in the 1980s, induced abortion became prevalent [ 41 ]. Women turned to induced abortion when a pregnancy fell outside the limits established by the government’s birth control policy [ 22 , 36 ]. Since the mid-1990s, with the introduction of reproductive health and reproductive rights put forward by the Cairo Conference on Human Development in 1994, the Chinese government has promoted informed choice of contraception and birth control, partly reducing the number of unintended pregnancies, and thus the number of induced abortions [ 42 , 43 ]. Since 2014, the number of induced abortions has rebounded and remained stable. In 2016, when the universal two-child policy was implemented, the number of births increased and the proportion of induced abortions decreased. However, the policy effect disappeared in 2018. The number of births decreased and the proportion of induced abortions rebounded. Regarding age at induced abortion, the number of induced abortions experienced by each woman increases with age; repeat induced abortions occur mainly among women in the older group [ 12 , 17 ]. Although the minimum age at the time of induced abortion is declining [ 32 , 44 ], adolescents’ induced abortions still account for a relatively small proportion, contributing to the upward trend in the average age of women having induced abortions.

The proportion of women with induced abortion experiences was less than 30% in each cohort, although this figure changed for women with different characteristics, and the proportion of repeat induced abortions was relatively low. In the early birth cohort, the proportion of women who had experienced induced abortions was higher among urban women than rural women, higher among Han women than ethnic-minority women, and higher among well-educated than less-educated women. This trend is partly due to the fact that women in urban areas and of Han nationality are more tightly constrained by the one-child policy. In the late birth cohort, however, the proportion of women with induced abortion experiences was higher among rural than urban women, and higher among ethnic-minority women than Han women. With the relaxation of the stringent birth control policy, the influences of the one-child policy on induced abortions have been weakened for women in later birth cohorts. And women in urban areas and of Han nationality have greater access to sexual and reproductive health knowledge compared with women in rural areas and of ethnic minority groups, making women in urban areas less likely to undergo induced abortions. In terms of repeat induced abortion, 30.83% of the women in this study had experienced repeat abortions, a lower percentage than that reported in previous research. Many studies have argued that the repeat induced abortion incidence rate is very high in China [ 18 , 19 , 35 ]. A study involving 79,954 women who underwent induced abortion operations in 297 hospitals in 30 provinces in China showed that 65.2% of all induced abortions were repeat induced abortions [ 19 ]. Another meta-analysis found that 43.1% of all induced abortions investigated were repeat induced abortions [ 18 ]. This may reflect the fact that many studies have been based on small-scale survey data or data collected in hospitals, rather than estimates of nationally representative data.

The cumulative number of induced abortions per woman in each cohort was less than 0.45. In the early birth cohort, the number of abortions was higher for urban than for rural women, for Han than for ethnic-minority women, and for well-educated than for less-educated women. However, in the late birth cohort, these relationships were reversed. Few studies have investigated the number of abortions per woman. One synthetic indicator of the total abortion rate, used to measure the number of abortions a woman would experience if she were to go through her reproductive years experiencing the prevailing age-specific abortion rates, shows a downward trend [ 5 , 9 ], decreasing from 0.68 to 1993 to 0.37 in 2000 [ 6 ].

More induced abortions occur in premarital pregnancies than in post-marital pregnancies. During their first pregnancies, well-educated urban women are more likely to use induced abortion to terminate premarital or unintended pregnancies. In China, the phenomenon of premarital childbearing is not widely accepted, causing most premarital pregnancies to end in induced abortion [ 25 , 45 ]. One large-scale survey covering 295 hospitals in 30 provinces showed that 31% of more than 70,000 women who underwent induced abortions were unmarried [ 46 ]. Women usually choose to give birth when they first become pregnant after marriage; for this reason, the proportion of first-pregnancy induced abortions after marriage is low. The proportion of first-pregnancy induced abortions is higher among urban than among rural women; the higher the level of education, the higher the proportion of induced abortions, and the proportion of induced abortions is much higher in unintended pregnancies than in planned pregnancies.

The sex-selective abortion of female fetuses still exists. When the first child is a girl, the second child is far more likely to be a boy than a girl, indicating that some female fetuses have been aborted. Since the 1980s, with the strict birth control policy and the prevalence of gender-identification technology, the sex-selective abortion of female fetuses has emerged [ 47 ]. Sex-selective abortion is one dominant contributor to the higher sex ratio at birth [ 38 , 48 , 49 ]. In the context of a strong preference for sons amid birth-number constraints, the sex ratio at birth for first births was generally normal, but increased steeply for second births, indicating a severe abortion of female fetuses for second and higher birth orders [ 16 ]. The stringency of the birth control policy has influenced the extent of sex-selective abortions, as manifested in the provincial sex ratio at birth [ 50 ]. With the spontaneous decline in fertility, couples with son preference would selectively abort female fetuses for first births [ 51 ], which is confirmed not only in the 2010 census data, when a stringent birth control policy existed, but also by the sex ratio at birth of 113.17 for first births in the 2020 census data, following the introduction of the universal two-child policy in 2016. By contrast, the sex ratio at birth for second births dropped from 130.29 in the 2010 census to 106.78 in the 2020 census as the birth control policy was relaxed.

The finding from the regression analysis showing that age, residence, ethnicity, and education level are significantly associated with women’s induced abortion experiences confirms the findings of previous studies [ 9 , 12 , 14 , 52 , 53 ], and is consistent with our period and cohort results. The interaction terms in the regression results show that the profile of women who resort to abortion has shifted from well-educated urban women toward rural, less-educated women, contradicting Zheng et al. [ 9 ], who found a shift among women resorting to abortion from less-educated rural women to well-educated urban women. They calculated the total abortion rate (the total number of abortions that a woman would experience if she were to go through her reproductive years experiencing prevailing age-specific age abortion rates) based on data from four surveys in 1988, 1997, 2001, and 2006, which are earlier than data we used in this study. In addition, the group more likely to undergo induced abortions has shifted from Han to minority women, a result seldom mentioned in previous studies [ 9 , 12 , 14 , 17 ]. Premarital pregnancies are more likely to end in abortion, which is consistent with previous studies [ 20 , 25 ].

In summary, the above results reveal several problems requiring policy attention. The first is the increasing number of premarital pregnancies among young women, most of which end in abortion. The second is repeat induced abortion, which highlights the need to reduce the incidence of unintended pregnancies [ 19 , 35 ]. The third is the existence of sex-selective abortion of female fetuses in China, although the Chinese government has made efforts to combat sex identification and sex-selective abortion for non-medical reasons. Optimistically, the decline in the recent sex ratio at birth indicates a waning preference for sons. To prevent and reduce unwanted pregnancies and abortions, the government should implement more effective measures to promote sexual and reproductive health education among young people, provide higher-quality contraceptive and post-abortion care services, and crack down on sex-selective abortions.

This study has some limitations. First, the pregnancy histories used in this study were drawn from retrospective data, which may include underreporting and recall bias, especially among women in the early birth cohort [ 9 , 25 ]. Despite this, the survey data do reflect the overall levels and changing trends of induced abortion. Second, the survey recorded each woman’s education level at the time of data collection, not at the time of her induced abortion. As most people finish school before marriage and childbearing [ 25 ], we assume that the education level is unlikely to change significantly. However, some premarital young women with premarital pregnancies may continue to receive more education. Third, given the lack of data on unsafe abortions, we did not include analysis in this regard. We call on future surveys to consider the prospect of expanding data collection to allow for the analysis of unsafe abortions.

Acknowledgements

Not applicable.

Author contributions

QJ conceived the study, TW analyzed the data, TW and QJ wrote and finalized the paper. Both authors read and approved the final manuscript.

This study was funded by Social Science Fund Project of Shaanxi Province: Research on public service system and policy innovation of child care in Shaanxi Province (2021F002).

Availability of data and materials

Declarations.

This study was based on a secondary analysis of an existing dataset with all participant identifiers removed. Informed consent was obtained from all participants before the questionnaire was administered. All research methods were carried out in accordance with relevant guidelines and regulations, and human subject protection is not an issue here. The survey protocol and instruments followed the Helsinki guidelines and were approved by the Institutional Review Board (IRB) of the National Bureau of Statistics of China, a state organization. These disclaimers also apply to the data from the 2017 China Fertility Survey used here.

The authors declare that they have no competing interests.

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Contributor Information

Tian Wang, Email: nc.ude.utjx.uts@gnawtt .

Quanbao Jiang, Email: moc.621@bqj_esulcer .