Fewer women are having abortions. Why?
In the first half of 2019, several states have passed some of the most restrictive abortion bans since Roe v. Wade legalized the procedure in 1973. The new laws are part of a nearly decade-long wave of anti-abortion legislation that pro-life activists see as key to reducing and eventually eliminating abortion in the U.S.
Is it working?
A 2018 report from the Centers for Disease Control and Prevention shows the national abortion rate declined 26% between 2006 and 2015, reaching a historic low. But the CDC did not credit a single driver. Is it the proliferation of restrictive abortion laws? Increased access to contraception? More comprehensive sex education?
Mary Ziegler, a professor at the Florida State University College of Law who specializes in the legal history of reproduction, says it's likely all of it.
"The picture is messy and complicated and cannot be reduced to talking points," she said.
Better birth control and more of it
The vast majority of abortions are a result of unplanned pregnancies, according to the CDC. Its data shows the number of unintended pregnancies decreased from 51% in 2008 to 45% between 2011 and 2013, noting that more women using contraception and more effective forms of contraception like intrauterine devices, might be factors.
Elizabeth Nash, senior state issues manager at the Guttmacher Institute, a research and policy organization that advances sexual and reproductive health and rights, says Obamacare could also be contributing to the decline. The Affordable Care Act's federal contraceptive coverage guarantee applies to most private health plans, requiring coverage for a wide array of contraceptives used by women without any out-of-pocket costs.
The change made it possible, Nash said, for women to choose the method of contraception that best suited them, versus what they could afford.
Pro-life advocates tend to be skeptical about contraception.
"I think we have to be careful trying to assign this as the silver bullet — that this is what's driving the abortion decline," said Melanie Israel, a research associate at the Heritage Foundation's DeVos Center for Religion and Civil Society.
Ginny Ehrlich, chief executive officer of Power to Decide, a campaign to prevent unplanned pregnancy, says while contraception is more widely available, there are still more than 20 million women in need of publicly funded contraception — which refers to government programs that provide contraception to low-income women. She said 19.5 million of those women currently live in so-called contraceptive deserts, defined as lacking "reasonable access in their county to a health center that offers the full range of contraceptive methods."
Many of these areas are in states passing some of the most restrictive abortion laws.
In Alabama, which passed a near-total abortion ban in May, more than 300,000 women need publicly funded contraception but live in contraceptive deserts, according to Power to Decide. In Missouri, which could become the only state without an abortion facility, that number is nearly 400,000. In Ohio, lack of access affects more than 700,000 women, and in Georgia, nearly 650,000 women are affected.
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The CDC says providing free contraception to women would likely further reduce unwanted pregnancies and in turn abortion rates. It's why Power to Decide and other groups are advocating to make oral contraceptives available over the counter for free.
A 2018 study found nearly one in four adults and teens who aren't using contraception said they would use it if it was available over the counter.
So why hasn't it happened yet? The medical community is largely behind it, and the conversion also appears to have bipartisan support.
Ehrlich said no drug maker has fully completed the Food and Drug Administration's approval process.
A coalition of organizations, including Power to Decide, the American College of Obstetricians and Gynecologists, and Planned Parenthood, is working with a drug maker to have an OTC birth control pill approved by the FDA.
A focus on comprehensive sex education
Between 2006 and 2015, the abortion rate for girls between 15 and 19 plummeted 54%. Teen pregnancy rates are also down, reaching a record low in 2017.
The CDC says evidence suggests that more teens are abstaining from sex and that more teens who are sexually active are using birth control.
Some experts point to comprehensive sex education, defined as "age-appropriate, medically-accurate information on a broad set of topics related to sexuality," as one factor that may be changing behaviors that put teens at risk of pregnancy.
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"If you think about those years, that's when we were putting more funding into comprehensive sex ed. There was more funding available for programs that discussed condoms and contraception," said Jennifer Driver, state policy director at the Sexuality Information and Education Council of the United States (SIECUS). "During that period, we were moving away from abstinence-until-marriage programs."
Research shows teens who receive comprehensive sex education are significantly less likely to become pregnant than those who receive abstinence-only or no sex education.
Driver said many states with restrictive abortion laws, including Alabama and Georgia, also heavily stress abstinence-until-marriage in their sex ed programs.
More restrictive laws
Experts say the surge in abortion restrictions is making the procedure more difficult to access for women who live in states that pass them, especially poor women.
The CDC's 2018 report on the declining abortion rate says that in addition to more contraceptive use, the availability of abortion providers and regulations such as mandatory waiting periods and parental consent could also be contributing to fewer women having abortions.
Texas, for example, has passed a number of restrictions on abortion in the last several years and saw a 28% decline in the abortion rate between 2011 and 2014, according to Guttmacher.
If the recent surge of abortion restrictions goes into effect, Nash said "it might make it impossible for a number of patients to get the care they need."
Abortion decline isn't a shared goal
In the 1990s, President Bill Clinton said abortion should be "safe, legal and rare," a slogan that persisted among Democrats for years. It was a position on which pro-choice and pro-life activists could ostensibly agree, since it implied abortion is something to avoid.
Pro-choice advocates have moved from framing abortion as something that should be "rare" to something that should be accessible to any woman who needs it, though they strongly advocate for policies that reduce the number of unwanted pregnancies, which in turn reduces the need for abortion. Pro-life advocates say eliminating abortion is a chief goal and they view pro-life legislation as a key way to accomplish it.
"The pro-life movement is ultimately seeking the day that every human being is both protected in law and welcomed in life," Israel said. "There's acknowledgment that there's a public policy piece of this, but there's also a cultural side. If abortion were suddenly illegal tomorrow, that's not going to change hearts and minds. The movement wants to make abortion unthinkable."
Meanwhile, pro-choice activists are focused on making abortion part of healthcare, a reproductive service any woman can access uneventfully if she chooses.
"Conversations about reducing the abortion rate can stigmatize people who have abortions," Nash said. "It's about giving people the access they need when they need it. We need to be able to trust people to make decisions they know are best for them."
There is no clear reason why abortion is declining in the U.S. And there isn't agreement that a decline is even desirable.
"We've changed what was an undeniable consensus — that reducing abortion was the goal," Ziegler said. "Now we're looking at whether the decline in abortion rates is something to be celebrated or worried about."
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