Abortion Surveillance — United States, 2021

Problem/Condition CDC conducts abortion surveillance to document the number and characteristics of women obtaining legal induced abortions and number of abortion-related deaths in the United States. Period Covered 2021. Description of System Each year, CDC requests abortion data from the central health agencies for the 50 states, the District of Columbia, and New York City. For 2021, a total of 48 reporting areas voluntarily provided aggregate abortion data to CDC. Of these, 47 reporting areas provided data each year during 2012–2021. Census and natality data were used to calculate abortion rates (number of abortions per 1,000 women aged 15–44 years) and ratios (number of abortions per 1,000 live births), respectively. Abortion-related deaths from 2020 were assessed as part of CDC’s Pregnancy Mortality Surveillance System (PMSS). Results A total of 625,978 abortions for 2021 were reported to CDC from 48 reporting areas. Among 47 reporting areas with data each year during 2012–2021, in 2021, a total of 622,108 abortions were reported, the abortion rate was 11.6 abortions per 1,000 women aged 15–44 years, and the abortion ratio was 204 abortions per 1,000 live births. From 2020 to 2021, the total number of abortions increased 5% (from 592,939 total abortions), the abortion rate increased 5% (from 11.1 abortions per 1,000 women aged 15–44 years), and the abortion ratio increased 4% (from 197 abortions per 1,000 live births). From 2012 to 2021, the total number of reported abortions decreased 8% (from 673,634), the abortion rate decreased 11% (from 13.1 abortions per 1,000 women aged 15–44 years), and the abortion ratio decreased 1% (from 207 abortions per 1,000 live births). In 2021, women in their 20s accounted for more than half of abortions (57.0%). Women aged 20–24 and 25–29 years accounted for the highest percentages of abortions (28.3% and 28.7%, respectively) and had the highest abortion rates (19.7 and 19.4 abortions per 1,000 women aged 20–24 and 25–29 years, respectively). By contrast, adolescents aged <15 years and women aged ≥40 years accounted for the lowest percentages of abortions (0.2% and 3.6%, respectively) and had the lowest abortion rates (0.4 and 2.5 abortions per 1,000 women aged <15 and ≥40 years, respectively). However, abortion ratios were highest among adolescents (aged ≤19 years) and lowest among women aged 30–39 years. From 2020 to 2021, abortion rates increased among women aged 20–39 years, decreased among adolescents aged 15–19 years, and did not change among adolescents aged <15 years and women aged ≥40 years. Abortion rates decreased from 2012 to 2021 among all age groups, except women aged 30–34 years for whom it increased. The decrease in the abortion rate from 2012 to 2021 was highest among adolescents compared with any other age group. From 2020 to 2021, abortion ratios increased for women aged 15–24 years, decreased among adolescents aged <15 years and women aged ≥35 years and did not change for women aged 25–34 years. From 2012 to 2021, abortion ratios increased among women aged 15–29 years and decreased among adolescents aged <15 years and women aged ≥30 years. The decrease in abortion ratio from 2012 to 2021 was highest among women aged ≥40 years compared with any other age group. In 2021, the majority (80.8%) of abortions were performed at ≤9 weeks’ gestation, and nearly all (93.5%) were performed at ≤13 weeks’ gestation. During 2012–2021, the percentage of abortions performed at >13 weeks’ gestation remained ≤8.7%. In 2021, the highest percentage of abortions were performed by early medication abortion at ≤9 weeks’ gestation (53.0%), followed by surgical abortion at ≤13 weeks’ gestation (37.6%), surgical abortion at >13 weeks’ gestation (6.4%), and medication abortion at >9 weeks’ gestation (3.0%); all other methods were uncommon (<0.1%). Among those that were eligible (≤9 weeks’ gestation), 66.6% of abortions were early medication abortions. In 2020, the most recent year for which PMSS data were reviewed for pregnancy-related deaths; six women died as a result of complications from legal induced abortion. Interpretation Among the 47 areas that reported data continuously during 2012–2021, overall decreases were observed during 2012–2021 in the total number, rate, and ratio of reported abortions; however, from 2020 to 2021, increases were observed across all measures. Public Health Action Abortion surveillance can be used to help evaluate programs aimed at promoting equitable access to patient-centered quality contraceptive services in the United States to reduce unintended pregnancies.


Introduction
This report summarizes data on legal induced abortions for 2021 that were provided voluntarily to CDC by the central health agencies of 48 reporting areas (46 states, the District of Columbia, and New York City, excluding California, Maryland, New Hampshire, and New Jersey) and comparisons over time for the 47 reporting areas that reported each year during 2012-2021 (46 states and New York City).This report also summarizes abortion-related deaths reported voluntarily to CDC for 2020 as part of the Pregnancy Mortality Surveillance System (PMSS).Since 1969, CDC has conducted abortion surveillance to document the number and characteristics of women obtaining legal induced abortions in the United States.After nationwide legalization of abortion in 1973, the total number, rate (number of abortions per 1,000 women aged 15-44 years), and ratio (number of abortions per 1,000 live births) of reported abortions increased rapidly, reaching the highest levels in the 1980s, before decreasing at a slow yet steady pace (1,2).During 2006-2008, a break occurred in the previously sustained pattern of decrease (3,4), although this break was followed in subsequent years by even greater decreases (5,6).However, from 2018 to 2019, increases of 1%-3% were observed across all measures (7).From 2019 to 2020, decreases were observed in the total number and rate of reported abortions; however, a 2% increase was observed in the total abortion ratio (8).Abortion incidence and practices have varied over the years and continue to vary across subpopulations (9)(10)(11)(12)(13)(14), highlighting the utility of continued surveillance.

Description of the Surveillance System
Each year, CDC requests aggregate data from the central health agencies of the 50 states, the District of Columbia, and New York City to document the number and characteristics of women obtaining legal induced abortions in the United States.Not all persons who obtain abortions identify as women; the term "women" has been maintained in this report to be consistent with the collection and reporting of denominator data used to calculate abortion rates and ratios.This report contains data voluntarily reported to CDC as of June 15, 2023.For the purpose of surveillance, legal induced abortion is defined as an intervention performed within the limits of state and jurisdiction law by a licensed clinician (e.g., a physician, nurse-midwife, nurse practitioner, or physician assistant) intended to terminate a suspected or known intrauterine pregnancy and that does not result in a live birth.This definition excludes management of intrauterine fetal death, early pregnancy failure or loss, ectopic pregnancy, or retained products of conception.All abortions in this report are considered to be legally induced unless stated otherwise.
In most states and jurisdictions, the collection of abortion data is facilitated by a legal requirement for hospitals, facilities, or physicians to report abortions to a central health agency (15); however, reporting is not complete in all areas, including in certain areas with reporting requirements (16).The reporting of abortion data to CDC is voluntary and many reporting areas have developed their own data collection forms and might not collect or provide all the information requested by CDC.As a result, the level of detail reported by CDC might vary from year to year and by reporting area.To encourage uniform collection of data, the National Association for Public Health Statistics and Information Systems (NAPHSIS) with technical assistance from CDC developed technical guidance for vital statistics personnel who collect and summarize abortion data within the United States (17).

Variables and Categorization of Data
Each year, CDC sends a suggested template to central health agencies in the United States for compilation of aggregate abortion data among women obtaining legal induced abortions.Aggregate abortion numbers, without individuallevel records, are requested for the following variables: • Age group in years of women obtaining legal induced abortions (<15, 15 or three or more) • Residence (the state, jurisdiction, territory, or foreign country in which the women obtaining the abortion lived, or, if additional details are unavailable, in-reporting area versus out-of-reporting area) In addition, the template provided by CDC requests that aggregate abortion numbers for certain variables be crosstabulated by a second variable.The cross-tabulations presented in this report include weeks of gestation separately by method type, by age group, and by race and ethnicity.
Beginning with 2014 data, instead of reporting the clinicians' estimate of gestational age or estimates of gestational age based on last menstrual period, certain areas have reported "probable postfertilization age," "clinician's estimate of gestation based on date of conception," and "probable gestational age" to CDC.To facilitate consistency between data reported as postfertilization age and the data collection practices for gestational age recommended by CDC's National Center for Health Statistics (18), 2 weeks were added to probable postfertilization age.This method was used to account for time after last menstrual period until ovulation in a standard 28-day cycle because fertilization occurs around the time of ovulation (19).No modifications were made to data reported as clinician's estimate of gestational age based on date of conception or data reported as probable gestational age.
In this report, medication and surgical abortions are further categorized by gestational age when available in the categories reported to CDC.Early medication abortion is defined as the administration of medications (typically mifepristone followed by misoprostol) to induce an abortion at ≤9 completed weeks' gestation, consistent with U.S. Food and Drug Administration (FDA) labeling for mifepristone that was implemented in 2016 (20).CDC collects information only on the estimated number of weeks (not days) of gestation and acknowledges the conventional use of completed weeks of gestation to describe pregnancy duration; therefore, CDC's category of ≤9 weeks' gestation includes abortions through 9 weeks and 6 days.Medications (typically serial prostaglandins, sometimes administered after mifepristone) also might be used to induce an abortion at >9 weeks' gestation.Surgical abortions, which include uterine aspiration (i.e., dilation and curettage, aspiration curettage, suction curettage, manual vacuum aspiration, menstrual extraction, or sharp curettage) and dilation and evacuation procedures, are categorized as having been performed at ≤13 weeks' gestation or at >13 weeks' gestation because of differences in surgical technique at these gestational ages (21).Finally, because intrauterine instillations are unlikely to be performed early in gestation (22), abortions reported to have been performed by intrauterine instillation at ≤12 weeks' gestation are excluded from calculation of the percentage of abortions by known method type and are grouped with unknown type.

Measures of Abortion
Four measures of abortion are presented in this report: 1) the number of abortions in a specific population, 2) the percentage of abortions by selected characteristics, 3) the abortion rate (number of abortions per 1,000 women within a specific population), and 4) the abortion ratio (number of abortions per 1,000 live births within a specific population).Abortion rates adjust for differences in population size.Abortion ratios measure the relative number of pregnancies in a specific population that end in abortion compared with live birth.
U.S. Census Bureau estimates of the resident female population were used as the denominator for calculating abortion rates (23)(24)(25)(26)(27)(28)(29)(30)(31)(32).Overall abortion rates were calculated from the population of women aged 15-44 years living in the reporting areas that provided continuously reported data.For adolescents aged <15 years, abortion rates were calculated using the number of adolescents aged 13-14 years as the denominator; for women aged ≥40 years, abortion rates were calculated using the number of women aged 40-44 years as the denominator.For the calculation of abortion ratios, live birth data were obtained from CDC natality files and included births to women of all ages living in the reporting areas that provided abortion data (33,34).For calculation of the total abortion rates and total ratios only, women with unknown data on selected characteristics (e.g., age, race and ethnicity, and marital status) were distributed according to the distribution of abortions among those with known information on the characteristic.For calculation of totals only, abortions for women with an unknown gestational age of pregnancy but known method type were distributed according to the distribution of abortions among those with known information on method type by gestational age to the following categories: surgical, ≤13 weeks' gestation; surgical, >13 weeks' gestation; medication, ≤9 weeks' gestation; and medication, >9 weeks' gestation.

Data Presentation and Analysis
This report provides aggregate and reporting area-specific abortion numbers, rates, and ratios for the 48 areas that reported to CDC for 2021, which excluded California, Maryland, New Hampshire, and New Jersey.In addition, this report describes characteristics of women who obtained abortions in 2021.The data in this report are presented by the reporting area in which the abortions were performed.
The completeness and quality of data received vary by year, by variable, and by reporting area; this report only describes the characteristics of women obtaining abortions in reporting areas that met CDC reporting standards (i.e., reported at least 20 abortions overall, provided data categorized in accordance with requested variables, and had <15% unknown values for a specific characteristic).Cells with a numerical value in the range of 1-4 and cells that would allow for calculation of these values have been suppressed in this report to maintain confidentiality in tables presented by reporting area of occurrence.
The percentage change in abortion measures (number, rate, and ratio of reported abortions) from the most recent past year (2020 to 2021) and during the 10-year period of analysis (2012-2021) were calculated for the 47 areas that reported every year during 2012-2021.The percentage change was also calculated and reported for abortions by age group, weeks of gestation, and early medication abortions (≤9 completed weeks' gestation) for areas that met reporting standards for these variables every year during 2012-2021.As a result, aggregate measures for 2021 in percentage change analyses might differ from the point estimates reported for 2021.These data describe the percentage changes in abortion measures over time and abortion measures among groups for each characteristic.No statistical testing was performed.Comparisons do not imply statistical significance, and lack of comment regarding the difference between values does not imply that no statistically significant difference exists.

Abortion Mortality
CDC has reported data on abortion-related deaths periodically since information on abortion mortality first was included in the 1972 abortion surveillance report (8,35).An abortion-related death is defined as a death resulting from a direct complication of an abortion (legal or illegal), an indirect complication caused by a chain of events initiated by an abortion, or an aggravation of a pre-existing condition by the physiologic effects of abortion.An abortion is categorized as legal when it is performed by a licensed clinician within the limits of state or jurisdiction law.
Since 1987, CDC has monitored abortion-related deaths through PMSS, which includes data from all 50 states, the District of Columbia, and New York City (36).Sources of data to identify abortion-related deaths have included state or jurisdiction vital records; media reports, including computerized searches of full-text newspaper and other media databases; and individual case reports by public health agencies, including maternal mortality review committees, and any additional data when available.For each death that is possibly related to abortion, CDC requests clinical records and autopsy reports.Two medical epidemiologists independently review these reports to determine the cause of death and whether the death was abortion related.Discrepancies are discussed and resolved by consensus.Each death is categorized by abortion type as legal induced, illegal induced, spontaneous, or unknown type.
This report provides PMSS data on induced abortion-related deaths that occurred in 2020, the most recent year for which PMSS data are available.For 1998-2020, abortion surveillance data reported to CDC cannot be used alone to calculate national case-fatality rates for legal induced abortions (number of legal induced abortion-related deaths per 100,000 reported legal induced abortions in the United States) because eight reporting areas did not report abortion data every year during this period (Alaska, 1998(Alaska, -2000;;California, 1998California, -2020; the District of Columbia, 2016;Louisiana, 2005;Maryland, 2007Maryland, -2020;;New Hampshire, 1998-2020;Oklahoma, 1998Oklahoma, -1999;;andWest Virginia, 2003-2004).Thus, denominator data for calculation of national legal induced abortion case-fatality rates for 1998-2020 were obtained from a published report by the Guttmacher Institute that includes estimated total numbers of abortions in the United States from a national survey of abortion-providing facilities (37).Because rates determined on the basis of a numerator <20 are unstable (38), national case-fatality rates for legal induced abortion were calculated for consecutive 5-year periods during 1973-2012 and then for a consecutive 8-year period during 2013-2020.

Total Abortions Reported to CDC by Occurrence
Among the 48 reporting areas that provided data for 2021, a total of 625,978 abortions were reported.Of these abortions, 622,108 were from 47 reporting areas that provided data every year during 2012-2021.In 2021, these continuously reporting areas had an abortion rate of 11.6 abortions per 1,000 women aged 15-44 years and an abortion ratio of 204 abortions per 1,000 live births (Table 1).From 2020 to 2021, the total number of reported abortions increased 5% (from 592,939 total abortions), the abortion rate increased 5% (from 11.1 abortions per 1,000 women aged 15-44 years), and the abortion ratio increased 4% (from 197 abortions per 1,000 live births).From 2012 to 2021, the total number of reported abortions decreased 8% (from 673,634), the abortion rate decreased 11% (from 13.1 abortions per 1,000 women aged 15-44 years), and the abortion ratio decreased 1% (from 207 abortions per 1,000 live births) (Figure).
In 2021, the range by reporting area of occurrence in abortion rates was considerable (from 0.1 to 21.8 abortions per 1,000 women aged 15-44 years in Missouri and the District of Columbia) and abortion ratios (from two to 447 abortions per 1,000 live births in Missouri and the District of Columbia) (Table 2).The percentage of abortions obtained by out-of-area residents also varied by reporting areas (from 0.6% in Arizona to 70.8% in the District of Columbia).

Age Group, Race and Ethnicity, and Marital Status
Among the 48 areas that reported abortion numbers by women's age for 2021, women in their 20s accounted for more than half of abortions (57.0%) (Table 3).Women aged 20-24 and 25-29 years accounted for the highest percentages of abortions (28.3% and 28.7%, respectively) and had the highest abortion rates (19.7 and 19.4 abortions per 1,000 women aged 20-24 and 25-29 years, respectively).By contrast, adolescents aged <15 years and women aged ≥40 years accounted for the lowest percentages of abortions (0.2% and 3.6%, respectively) and had the lowest abortion rates (0.4 and 2.5 abortions per 1,000 women aged <15 and ≥40 years, respectively).However, abortion ratios were highest among adolescents ( Among the 43 reporting areas that provided data each year by women's age for 2012-2021, the highest percentages of abortions and the highest abortion rates occurred among women aged 20-29 years and the lowest percentages of abortions and lowest abortion rates occurred among adolescents aged <15 years and women aged ≥40 years (Table 4).From 2020 to 2021, abortion rates increased among women aged 20-39 years, decreased among adolescents aged 15-19 years, and did not change among adolescents aged <15 years and women aged ≥40 years.
From 2012 to 2021, abortion rates decreased among all age groups, except women aged 30-34 years for whom it increased.The decrease in the abortion rate was highest among adolescents (50% and 41% for adolescents aged <15 and 15-19 years, respectively) compared with any other age group.From 2020 to 2021, abortion ratios increased for women aged 15-24 years, decreased among adolescents aged <15 years and women aged ≥35 years and did not change for women aged 25-34 years.From 2012 to 2021, abortion ratios increased among women aged 15-29 years and decreased among adolescents aged <15 years and women aged ≥30 years.The decrease in abortion ratio from 2012 to 2021 was highest among women aged ≥40 years compared with any other age group.
Among the 46 areas that reported age by individual year among adolescents for 2021, adolescents aged 18-19 years accounted for the highest percentage (72.0%) of adolescent abortions and had the highest abortion rates (8.3 and 12.0 abortions per 1,000 adolescents aged 18 and 19 years, respectively) (Table 5).Among adolescents, those aged <15 years accounted for the lowest percentage of abortions (2.7%) and had the lowest abortion rate (0.4 abortions per 1,000 adolescents aged 13-14 years).The abortion ratio for adolescents was highest among those aged <15 years (789 abortions per 1,000 live births) and was lowest among those aged 17-19 years (352, 400, and 329 abortions per 1,000 live births among adolescents aged 17, 18, and 19 years, respectively).
Among the 33 areas that reported race by ethnicity data for 2021, non-Hispanic White (White) women and non-Hispanic Black (Black) women accounted for the highest percentages of all abortions (30.2% and 41.5%, respectively), and Hispanic women and non-Hispanic women in the other race category accounted for lower percentages (21.8% and 6.5%, respectively) (Table 6).White women had the lowest abortion rate (6.4 abortions per 1,000 women aged 15-44 years) and ratio (116 abortions per 1,000 live births), and Black women had the highest abortion rate (28.6 abortions per 1,000 women aged 15-44 years) and ratio (498 abortions per 1,000 live births).
For 2021, among the 37 areas that reported by marital status, 12.7% of women who obtained an abortion were married, and 87.3% were unmarried (Table 7).The abortion ratio was 41 abortions per 1,000 live births for married women and 404 abortions per 1,000 live births for unmarried women.

Previous Live Births and Previous Induced Abortions
For 2021, among the 42 areas that reported the number of previous live births, 39.3%, 24.3%, 20.0%, 9.8%, and 6.6% of abortions reported were among women who had zero, one, two, three, or four or more previous live births, respectively (Table 8).Among the 42 areas that reported the number of previous induced abortions, 57.3%, 24.5%, 10.5%, and 7.7% of abortions reported were among women who had had zero, one, two, or three or more previous induced abortions, respectively (Table 9).

Weeks of Gestation and Method Type
For 2021, among the 41 areas that reported gestational age at the time of abortion, 80.8% of abortions were performed at ≤9 weeks' gestation, and 93.5% were performed at ≤13 weeks' gestation (Table 10).Fewer abortions were performed at 14-20 weeks' gestation (5.7%) or at ≥21 weeks' gestation (0.9%).Among the 35 reporting areas that provided data every year on gestational age for 2012-2021, the percentage of abortions performed at ≤13 weeks' gestation changed from 91.7% in 2012 to 92.9% in 2021 (Table 11).However, within this gestational age range, a shift occurred toward earlier gestational ages, with the percentage of abortions performed at ≤6 weeks' gestation increasing 13% and the percentage of abortions performed at 7-9 weeks' and 10-13 weeks' gestation decreasing 0.5% and 19%, respectively.
Among the 46 areas that reported by method type for 2021 and included medication abortion on their reporting form, 53.0% of abortions were early medication abortions (a nonsurgical abortion at ≤9 weeks' gestation), 37.6% were surgical abortions at ≤13 weeks' gestation, 6.4% were surgical abortions at >13 weeks' gestation, and 3.0% were medication abortions at >9 weeks' gestation; other methods, including intrauterine instillation and hysterectomy/hysterotomy, were rare (<0.1%) (Table 12).During 2012−2021, a total of 37 reporting areas (excludes California, the District of Columbia, Florida, Hawaii, Illinois, Louisiana, Maine, Maryland, Missouri, New Hampshire, New Jersey, New Mexico, Tennessee, Wisconsin, and Wyoming) provided continuous data and included medication abortion on their reporting form.Among these 37 areas, use of early medication abortion increased 3% from 2020 to 2021 (from 50.6% to 52.3% of abortions) and 137% from 2012 to 2021 (from 22.1% to 52.3% of abortions) (data not shown).

Weeks of Gestation by Age Group and Race and Ethnicity
In reporting areas that provided data that met CDC reporting standards, abortions that were categorized by weeks of gestation were further categorized by age and by race and ethnicity (Table 14).In every subgroup for these characteristics, the highest percentage of abortions occurred at ≤9 weeks' gestation.In 41 reporting areas, by age, 59.5% of adolescents aged <15 years and 74.8% of adolescents aged 15-19 years obtained an abortion at ≤9 weeks' gestation, compared with ≥80.2% among women aged ≥20 years.Conversely, 19.5% of adolescents aged <15 years and 8.9% of adolescents aged 15-19 years obtained an abortion after 13 weeks' gestation, compared with 5.7%-7.2%for women aged ≥20 years.In 31 reporting areas, by race and ethnicity, 80.2% of abortions obtained by Black women occurred at ≤9 weeks' gestation, compared with 81.8% of non-Hispanic women in the other race category, 81.7% of White women, and 83.3% of Hispanic women.Conversely, 5.8% of abortions obtained by Hispanic women occurred after 13 weeks' gestation, followed by 6.1% of Black women, 6.5% of White women, and 6.8% of non-Hispanic women in the other race category.

Abortion Mortality
Using national PMSS data (36), CDC identified six abortion-related deaths for 2020, the most recent year for which data were reviewed for abortion-related deaths (Table 15).Investigation of these cases indicated all deaths were related to legal abortion.
The annual number of deaths related to legal induced abortion has fluctuated from year to year since 1973 (Table 15).During 2013-2020, the national case-fatality rate for legal induced abortion was 0.45 deaths related to legal induced abortions per 100,000 reported legal abortions.This case-fatality rate was lower than the rates for the previous 5-year periods.

Discussion
For 2021, a total of 625,978 abortions were reported to CDC by 48 areas.Among the 47 continuously reporting areas, for 2021, the abortion rate was 11.6 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 204 abortions per 1,000 live births.From 2020 to 2021, the number of abortions increased 5%, the abortion rate increased 5%, and the abortion ratio increased 4%.
Abortion measures differ by age group.Among areas that reported data continuously by age during 2012-2021, women aged 20-29 accounted for the highest percentages of abortions and had the highest abortion rates, whereas adolescents aged <15 years accounted for the lowest percentage of abortions and had the lowest abortion rate.Adolescents aged <15 years and 15-19 years had the highest abortion ratios.During 2012-2021, women aged ≥40 years accounted for a small percentage of reported abortions (≤3.7%).However, the abortion ratio among women aged ≥40 years continues to be higher than among women aged 25-39 years.
The percentage changes in adolescent abortions described in this report are important for monitoring changes in adolescent pregnancies in the United States.From 2012 to 2021, national birth data indicate that the birth rate for adolescents aged 15-19 years decreased 53% (34), and the data in this report indicate that the abortion rate for the same age group decreased 41%.These findings highlight that decreases in adolescent births in the United States have been accompanied by large decreases in adolescent abortions.
As in previous years, abortion rates and ratios differed across racial and ethnic groups.For example, in 2021 compared with White women, abortion rates and ratios were 4.5 and 4.3 times higher among Black women and 1.9 and 1.6 times higher among Hispanic women, respectively.Similar differences by race and ethnicity have been demonstrated in other U.S.-based studies (2,(9)(10)(11)(12).The factors leading to higher abortion rates among certain racial and ethnic minority groups are complex.In addition to disparities in rates of unintended pregnancies (58), structural factors, including unequal access to quality family planning services (59,60) and economic inequities, as well as mistrust of the medical system (61), can contribute to observed differences.
Changes in clinical practices have facilitated the trend of obtaining abortions earlier in pregnancy.Research conducted in the United States during the 1970s indicates that surgical abortion procedures performed at ≤6 weeks' gestation, compared with 7-12 weeks' gestation, were less likely to result in successful termination of the pregnancy (73).However, subsequent advances in technology (e.g., improved transvaginal ultrasonography and sensitivity of pregnancy tests) have allowed very early surgical abortions to be performed with completion rates exceeding 97% (74)(75)(76)(77).Likewise, the development of early medication abortion regimens has allowed for abortions to be performed early in gestation, with completion rates for regimens that combine mifepristone and misoprostol reaching 96%-98% (77)(78)(79)(80).
Trends for early medication abortions are reported to monitor any changes in clinical practice that might have occurred with the accumulation of evidence on the safety and effectiveness of medication abortion past 63 days of gestation (8 completed weeks' gestation) (81), changes in professional practice guidelines (82,83), and the 2016 FDA extension of the gestational age limit for the use of mifepristone for early medication abortion from 63 days to 70 days (9 completed weeks' gestation) (84).Among abortions occurring at ≤9 weeks' gestation in 2021, two thirds (66.6%) of abortions were reported as early medication abortions.In 2021, the most common method among abortions reported overall was early medication abortion at ≤9 weeks' gestation (53.0%).Among continuously reporting areas that reported by method type and included medication abortion on their reporting form, the percentage of all abortions performed by early medication abortion increased 137% from 2012 to 2021 and increased 3% from 2020 to 2021.
Because the annual number of deaths related to legal induced abortion is small and statistically unstable, case-fatality rates were calculated for consecutive 5-year periods during 1973-2012 and then for a consecutive 8-year period during 2013-2020.The national case-fatality rate for legal induced abortion was 0.45 per 100,000 abortions during 2013-2020.Since 1978, all rates for the preceding 5-year periods have been fewer than 1 death per 100,000 abortions, demonstrating the low risk for death associated with legal induced abortion.

Limitations
The findings in this report are subject to at least four limitations.First, because reporting to CDC is voluntary and reporting requirements vary by the individual reporting areas (15,16), CDC is unable to report the total number of abortions performed in the United States.Of the 52 areas from which CDC requested data for 2021, California, Maryland, New Hampshire, and New Jersey did not submit abortion data.In 2020, the most recent year for which data are available through the Guttmacher Institute's national survey of abortion-providing facilities, abortions performed in these states accounted for approximately 25% of all abortions in the United States (37).CDC receives aggregated data from the central health agencies of reporting areas, which might result in different estimates than reported by the Guttmacher Institute.In addition, even in reporting areas that legally require clinicians to submit a report for every abortion performed, enforcement of this requirement varies (15).
Second, many states and jurisdictions use abortion reporting forms that differ from the technical guidance that NAPHSIS developed with technical assistance from CDC.Consequently, certain reporting areas do not collect all variables requested by CDC (e.g., age, race, ethnicity) or do not report the data in a manner consistent with this guidance (e.g., gestational age).Missing demographic information can reduce the extent to which the statistics in this report represent women who have had abortions.Only 33 reporting areas reported race and ethnicity data to CDC that met CDC's reporting standards.Certain areas that either do not report to CDC (e.g., California) or do not report race and ethnicity data (e.g., Illinois) have sufficiently large populations of racial and ethnic minority groups that the absence of data from these areas reduces the representativeness of CDC data for these variables.In addition, because of the variability in data collection for race and ethnicity among reporting areas, data for specific racial and ethnic groups beyond White, Black, and Hispanic are not requested or reported.In addition, certain areas collect gestational age data that are based on estimated date of conception or probable postfertilization age, which are not consistent with medical conventions for gestational age reporting.Without medical guidance on how to report these data, the validity and reliability of gestational age for these reporting areas is uncertain.
Third, abortion data are compiled and reported to CDC by the central health agency of the reporting area in which the abortion was performed rather than the reporting area in which the person lived.Thus, the available population (23)(24)(25)(26)(27)(28)(29)(30)(31)(32) and birth data (33,34), which are organized by the states or jurisdictions in which women live, might differ from the population of women who undergo abortions in a specific reporting area.This likely results in an overestimation of abortions for reporting areas in which a higher percentage of abortions are obtained by out-of-area residents and an underestimation of abortions for reporting areas where residents more frequently obtain abortions out of area.Limited abortion services, stringent regulatory requirements for obtaining an abortion, or geographic proximity to services in another state or jurisdiction might influence where women obtain abortion services (85,86).
Finally, CDC reporting of sociodemographic characteristics of women obtaining abortions is limited to data collected on state or jurisdiction reporting forms.Therefore, the examination of additional demographic variables (e.g., income and education) is not possible.

Public Health Implications
Ongoing surveillance of legal induced abortion is important for several reasons.First, abortion surveillance can be used to help evaluate programs aimed at promoting equitable access to patient-centered contraceptive care in the United States to reduce unintended pregnancies.Up to 42% of pregnancies in the United States are unintended (58), and use of effective contraception is a strategy to reduce unintended pregnancy (87).Efforts to improve contraceptive access have been associated with declines in the rate of abortion (39)(40)(41).Providing contraception at low or no cost can increase contraceptive access and use (88)(89)(90).Improvements in provider reimbursement and training, patient-centered counseling, youth-friendly services, and client awareness of available contraceptive methods might also help to improve contraceptive access (91)(92)(93), ensure equitable access to patient-centered contraceptive care, and promote equitable reproductive health in the United States (94).
Second, routine abortion surveillance can be used to assess changes in clinical practice patterns over time.Information in this report on the number of abortions performed through different methods (e.g., medication or surgical) and at different gestational ages provides the denominator data that are necessary for analyses of the relative safety of abortion practices (95).Finally, information on the number of pregnancies ending in abortion is used in conjunction with data on births and fetal losses to estimate the number of pregnancies in the United States and determine rates for various outcomes of public health importance (58).Adolescents aged 13-14 years were used as the denominator for the group of adolescents aged <15 years, and women aged 40-44 years were used as the denominator for the group of women aged ≥40 years.Abortions for women of unknown age were distributed according to the distribution of abortions among women of known age.† Number of abortions obtained by women in a specific age group per 1,000 live births to women in that same age group.Abortions for women of unknown age were distributed according to the distribution of abortions among women of known age.§ Data from 43 reporting areas; excludes nine reporting areas (California, District of Columbia, Florida, Maine, Maryland, New Hampshire, New Jersey, Tennessee, and Wyoming) that did not report, did not report by age, or did not meet reporting standards for ≥1 year.¶ By year, the total number of abortions represent 99.5%-99.7% of all abortions reported to CDC among the areas that met reporting standards for age during 2012-2021; reporting standards for age were applied to abortions for residents of Illinois only during 2012-2019 and 2021.* Data from 46 reporting areas; excludes six reporting areas (California, Connecticut, Illinois, Maryland, New Hampshire, and New Jersey) that did not report, did not report age among adolescents by individual year, or did not meet reporting standards.† Percentages for the individual component categories might not add to 100% because of rounding.§ Cells with a numerical value in the range of 1-4 and cells that would allow for calculation of these small values have been suppressed.¶ Includes residents only.** Number of abortions obtained by women in a specific age group per 1,000 women in that same age group.Adolescents aged 13-14 years were used as the denominator for the group of adolescents aged <15 years.For the total abortion rate only, abortions for women of unknown age were distributed according to the distribution of abortions among women of known age.† † Number of abortions obtained by women in a specific age group per 1,000 live births to women in that same age group.For the total abortion ratio only, abortions for women of unknown age were distributed according to the distribution of abortions among women of known age.New Jersey, New York State, North Dakota, Ohio, Oklahoma, Pennsylvania, Rhode Island, Washington, and Wisconsin) that did not report, did not report by race and ethnicity, or did not meet reporting standards.† Including Alaska Native, American Indian, Asian (Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or other Asian), Native Hawaiian and other Pacific Islander (Native Hawaiian, Guamanian or Chamorro, Samoan, or other Pacific Islander), other races, and multiple races.§ Percentages for the individual component categories might not add to 100% because of rounding.¶ Percentage is calculated as the number of abortions reported by known race and ethnicity divided by the sum of abortions reported by known and unknown race and ethnicity.Values ≥99.95% are rounded to 100.0%.** Cells with a numerical value in the range of 1-4 and cells that would allow for calculation of these small values have been suppressed.
† † Reporting form contains only one question for race and ethnicity; therefore, abortions reported for women of White, Black, and other races (Asian and American Indian) are not explicitly identified as non-Hispanic.§ § Percentage based on a total of 415,791 abortions reported among the areas that met reporting standards for race and ethnicity.¶ ¶ Number of abortions obtained by women in a specific racial and ethnic group per 1,000 women aged 15-44 years in that same racial and ethnic group.For the total abortion rate only, abortions for women of unknown race and ethnicity were distributed according to the distribution of abortions among women of known race and ethnicity.*** Number of abortions obtained by women in a specific racial and ethnic group per 1,000 live births to women in that same racial and ethnic group.For the total abortion ratio only, abortions for women of unknown race and ethnicity were distributed according to the distribution of abortions among women of known race and ethnicity.New Jersey, New York State, Pennsylvania, and Wisconsin) that did not report, did not report by weeks of gestation, did not meet reporting standards, or did not have medication abortion as a specific category on their reporting form.† For each gestational age category, percentages of all method types might not add to 100% because of rounding.§ Includes uterine aspiration (might also be called dilation and curettage, aspiration curettage, suction curettage, manual vacuum aspiration, menstrual extraction, sharp curettage) and dilation and evacuation procedures.¶ The administration of medication or medications to induce an abortion; at ≤9 weeks' gestation, typically involves the use of mifepristone and misoprostol; at >9 weeks' gestation, typically involves the use of vaginal prostaglandins.** Intrauterine instillations reported at ≤12 weeks' gestation have not been included with known values.
Abbreviation: NA = not applicable.*Data from 40 reporting areas; excludes 12 reporting areas (California, Connecticut, District of Columbia, Illinois, Maryland, Massachusetts, Missouri, New Hampshire, New Jersey, New York State, Pennsylvania, and Wisconsin) that did not report, did not report by weeks of gestation, did not meet reporting standards, or did not have medication abortion as a specific category on their reporting form.† For each gestational age category, percentages of all method types might not add to 100% because of rounding.§ Includes uterine aspiration (might also be called dilation and curettage, aspiration curettage, suction curettage, manual vacuum aspiration, menstrual extraction, sharp curettage) and dilation and evacuation procedures.¶The administration of medication or medications to induce an abortion; at ≤9 weeks' gestation, typically involves the use of mifepristone and misoprostol; at >9 weeks' gestation, typically involves the use of vaginal prostaglandins.** Intrauterine instillations reported at ≤12 weeks' gestation have not been included with known values.

Number, rate,* and ratio † of abortions performed, by year -selected reporting areas, § United States, 2012-2021
FIGURE.† Number of abortions per 1,000 live births.§Data are for 47 reporting areas; excludes California, District of Columbia, Maryland, New Hampshire, and New Jersey.
. During the past 10 years, this percentage increased from 74.8% in 2012 to 79.1% in 2021.Moreover, among areas that reported abortions at ≤13 weeks' gestation by individual week, the distribution of abortions by gestational age continued to shift toward earlier weeks of gestation, with the percentage of abortions performed at ≤6 weeks' gestation increasing from 35.0% in 2012 to 39.5% in 2021.Previous research indicates that the distribution of abortions by gestational age differs by various sociodemographic characteristics

TABLE 1 . Number, rate,* and ratio † of reported abortions -selected reporting areas, United States, 2012-2021 Year Selected reporting areas § Continuously reporting areas ¶
For all years, excludes reporting areas that did not report abortion numbers every year during the analysis period: California, District of Columbia, Maryland, New Hampshire, and New Jersey. ¶

TABLE 2 . Number, rate,* and ratio † of reported abortions, by reporting area of occurrence and number of abortions obtained by out-of-area residents § -United States, 2021 ¶ Area Abortions reported by area of occurrence** Abortions obtained by out-of-area residents
† † Residents of New York State who had abortions in New York City and residents of New York City who had abortions in New York State were excluded from the number and percentage of abortions obtained by out-of-area residents in New York.

544,986 531,041 520,602 508,565 497,249 500,974 508,955 502,481 514,695 NA NA Abbreviation
: NA = not applicable.* Number of abortions obtained by women in a specific age group per 1,000 women in that same age group.

TABLE 6 . Number and percentage of reported abortions, by known race and ethnicity and reporting area of occurrence -selected reporting areas,* United States, 2021 Area Non-Hispanic Hispanic Total abortions reported by known race and ethnicity
* Data from 33 reporting areas; excludes 19 reporting areas (California, Colorado, Hawaii, Illinois, Iowa, Louisiana, Maryland, Massachusetts, Nebraska, New Hampshire,

TABLE 10 . Number and percentage of reported abortions, by known weeks of gestation* and reporting area of occurrence -selected reporting areas, † United States, 2021
Gestational age based on clinician's estimate (Alaska, Arizona, Colorado, Delaware, Florida, Georgia, Hawaii, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Mexico, New York City, North Carolina, North Dakota, Ohio, Oregon, Rhode Island, South Dakota, Tennessee, Vermont, Washington, West Virginia, and Wyoming); gestational age calculated from the last normal menstrual period (Oklahoma and Utah); clinician's estimate of gestation based on estimated date of conception (Virginia); and probable postfertilization age (Alabama, Arkansas, South Carolina, and Texas).†Datafrom41 reporting areas; excludes 11 reporting areas (California, Connecticut, District of Columbia, Illinois, Maryland, Massachusetts, New Hampshire, New Jersey, New York State, Pennsylvania, and Wisconsin) that did not report, did not report by gestational age, or did not meet reporting standards.§Percentagesforthe individual component categories might not add to 100% because of rounding.¶Percentage is calculated as the number of abortions reported by known gestational age divided by the sum of abortions reported by known and unknown gestational age.Values ≥99.95% are rounded to 100.0%.**Two weeks were added to the probable postfertilization age to provide a corresponding measure to gestational age based on the clinician's estimate.†† Cells with a numerical value in the range of 1-4 and cells that would allow for calculation of these small values have been suppressed.
* § § Percentage based on a total of 477,911 abortions reported among the areas that met reporting standards for gestational age.

TABLE 11 . Percentage of reported abortions, by known weeks of gestation and year -selected reporting areas,* United States, 2012-2021 Weeks of gestation
Data from 35 reporting areas; excludes 17 areas (California, Connecticut, District of Columbia, Florida, Illinois, Maine, Maryland, Massachusetts, Nebraska, New Hampshire, New Jersey, New York State, Pennsylvania, Rhode Island, Tennessee, Wisconsin, and Wyoming) that did not report, did not report by weeks of gestation, or did not meet reporting standards for ≥1 year.† Percentages for the individual component categories might not add to 100% because of rounding.§ By year, the total number of abortions represent 72.3%-91.1% of all abortions reported to CDC among the areas that met reporting standards for gestational age during 2012-2021. *

TABLE 12 . Number and percentage of reported abortions, by known method type and reporting area of occurrence -selected reporting areas,* United States, 2021 Area Surgical † Medication Intrauterine instillation § Hysterectomy or hysterotomy Total abortions reported by known method type
See table footnotes on the next page.