Abortion Surveillance, United States, 1984-1985

Herschel W. Lawson, M.D. Hani K. Atrash, M.D., M.P.H. Audrey F. Saftlas, Ph.D., M.P.H. Lisa M. Koonin, M.N., M.P.H. Merrell Ramick Jack C. Smith, M.S. Division of Reproductive Health Center for Chronic Disease Prevention and Health Promotion Summary

Since 1983, the number of legal abortions reported to CDC increased by 5% to 1,333,521 in 1984; in 1985, that number decreased by less than 1% to 1,328,570. The national abortion rate was the same for both years--24 per 1,000 females ages 15-44 years. The abortion ratio for 1984 was 364 legally induced abortions per 1,000 live births; the ratio for 1985 was 354 per 1,000. Abortion ratios were higher among women of black and other minority races and among women younger than 15 years of age. Women undergoing legally induced abortions tended 1) to be young, white, and unmarried, 2) to have had no previous live births, and 3) to be having the procedure for the first time. Curettage was the procedure used in 96% of the reported cases. Eleven deaths were associated with legally induced abortions in 1984, and six in 1985. The case-fatality rate in 1985 was 0.5 deaths per 100,000 legally induced abortions, down from the 0.8 per 100,000 reported in 1983 and 1984. Overall, since 1980, the numbers and rates of abortion have had only slight year-to-year fluctuations. The steady increase in the percentage of repeat abortions since 1972 reflects the ongoing availability of legal abortions. Since the beginning of CDC's abortion mortality surveillance, the number of deaths related to legal abortions has decreased 75%, from 24 deaths in 1972 to six deaths in 1985. INTRODUCTION

In 1969, CDC began abortion surveillance to document the number and characteristics of women obtaining abortions and to assist in efforts to eliminate preventable morbidity and mortality associated with abortions. This report presents abortion data reported to CDC for 1984 and 1985. MATERIALS AND METHODS

For 1984 and 1985, CDC received statistics from 52 reporting areas: 50 states, New York City, and the District of Columbia. Central health agencies reported data for 44 areas, and hospitals and other medical facilities reported data for the other eight. Total numbers of abortions were available from all reporting areas, most of which also provided information on the characteristics of women obtaining abortions (Tables 1 and 2). After unknown values were excluded, percentage distributions were calculated for these characteristics. Data are reported by state of occurrence unless otherwise noted.  Abortion-related deaths reported to CDC are investigated by medical epidemiologists to determine the type of abortion, the cause of death, and possible contributing factors that may have been preventable. Deaths are first classified as abortion related or not abortion related. Abortion-related deaths are further classified into induced (legally or illegally) or spontaneous abortions. Classification of all deaths is based on information obtained from death certificates, medical records, and autopsy reports. Since CDC began abortion mortality surveillance in 1972, approximately two-thirds of abortion-related deaths have been reported by state health agencies. The remainder have been identified through other sources--CDC's National Center for Health Statistics, state and local maternal mortality committees, the Commission on Professional and Hospital Activities, case histories published in professional journals, and other private sources. RESULTS

In 1984, 1,333,521 legal abortions were reported--5% more than the number reported for the previous year (1). In 1985, the number decreased to 1,328,570, a reduction of less than 1% from the 1984 figure. The national abortion rate increased from 23 abortions per 1,000 women ages 15-44 in 1983 to 24 per 1,000 in both 1984 and 1985. The abortion ratio increased from 349 abortions per 1,000 live births in 1983 to 364 per 1,000 in 1984, and then fell to 354 per 1,000 in 1985 (Table 1, Figures 1-3).

In 1984 and 1985, as in previous years, California reported the highest number of abortions, followed by New York City and Texas (2). Wyoming had the lowest number of abortions in those years--498 in 1984 and 436 in 1985. The abortion rates in those years ranged from four abortions per 1,000 women ages 15-44 in Kentucky and Wyoming to more than 100 per 1,000 in the District of Columbia. The abortion ratios were highest in the District of Columbia and New York City (the only reporting areas that are not states) and lowest in Kentucky and Wyoming.

Approximately 92% of women obtaining abortions had the procedure done within their state of residence. The percentage of abortions obtained by out-of-state residents ranged from approximately 50% in the District of Columbia during 1984 and 1985 to approximately 1% in Hawaii, Illinois, and Wyoming in 1984 and Hawaii and Wyoming in 1985 (Tables 3 and 4). Data on the percentage of abortions obtained by out-of-state residents are not available for eight reporting areas.

In 1984, 36 states, the District of Columbia, and New York City reported legal abortions by age; in 1985, 37 states, the District of Columbia, and New York City reported those figures. In both years, women 15-29 years of age had approximately 80% of all abortions, whereas women younger than 15 years of age had approximately 1% (Tables 5 and 6). The abortion ratio was highest for women under 15 years of age and second highest for women 15-19 years of age. The abortion ratio for women under 15 years of age was 1,439 abortions per 1,000 live births in 1984 and 1,376 per 1,000 in 1985; the ratio for women 15-19 years of age was 697 per 1,000 live births in 1984 and 688 per 1,000 in 1985 (Figure 4). Although teenagers' abortion ratios were the highest during 1984-1985, the proportion of legal abortions they obtained continued to decrease. In 1984 and 1985, teenagers had 26% of all legal abortions. Among that age group, the abortion ratio was lowest among 19-year-olds and highest among those younger than 15 years old (Tables 7 and 8).

In 1984 and 1985, approximately 48% of reported legal abortions were performed before 8 weeks of gestation, and 87% were done at or before 12 weeks of gestation (Tables 9 and 10). Less than 4% of the abortions for those 2 years were performed at 16-20 weeks of gestation, and less than 1% at 21 or more weeks of gestation.

In both years, approximately 96% of legal abortions were performed by curettage (Tables 11 and 12). In less than 2%, the method used was intrauterine saline or prostaglandin instillation.

In 1984 and 1985, approximately two-thirds of women obtaining legal abortions were white (Table 13); this finding continued a previously noted trend (2). The abortion ratio, however, was higher for black women and women of other minority races than for white women: 475 versus 288 abortions per 1,000 live births in 1984 and 472 versus 277 abortions per 1,000 in 1985.

The percentage of women undergoing legal abortions who were unmarried rose from 73% in 1983 to 78% in 1984, and then to almost 80% in 1985. The abortion ratio was 14 times higher for unmarried women than for married women: 1,267 versus 93 abortions per 1,000 live births in 1984 and 1,174 versus 80 per 1,000 in 1985 (Table 14).

In both years, more than 55% of the women obtaining legal abortions had had no previous live births, and about 91% had had two or fewer live births (Table 15). In both 1984 and 1985, the abortion ratio was highest for women who had had no live births and lowest for women who had had one live birth.

Approximately 58% of women obtaining abortions in 1984 and 1985 had the procedure for the first time, but more than 13% had had at least two previous abortions (Table 16).

When the proportions of women undergoing abortions were analyzed by age group and marital status, few differences were reported between white women and women of black and other minority races (Tables 17 and 18). However, the proportion of black and other minority women less than 15 having abortions was more than twice that of white women in this age group.

When analyzed by gestational age, more than 99% of abortions at 12 weeks of gestation or less were performed by curettage (Tables 19 and 20). After 12 weeks of gestation, the most common procedure was dilatation and evacuation (D&E). Most intrauterine instillations involved the use of saline and were performed at 16 weeks of gestation or later.

In 1984, according to information reported to CDC, 18 women died as a result of abortion (Table 21). Of the 18 deaths, 11 were associated with a legally induced abortion, and six with a spontaneous abortion. In 1985, 14 women died as a result of abortion. Of these, six were associated with a legally induced abortion, six with a spontaneous abortion, one with an illegally induced abortion, and one could not be classified. The updated total for 1983 showed 18 deaths as a result of abortion. Included in this total were two additional reported deaths associated with legal abortion, raising the preliminary case-fatality rate for legal abortion from 0.7 deaths per 100,000 abortions to 0.8 deaths per 100,000 for that year. In 1984, the case-fatality rate remained at 0.8 deaths per 100,000 legally induced abortions, but then fell to 0.5 per 100,000 in 1985. DISCUSSION

From 1969 to 1982, the reported number of legal abortions in the United States increased every year (Figure 1); the largest percentage increase occurred in the period 1969-1973. From 1976 to 1982, this annual increase declined continuously, reaching a low of 0.2% for 1981-1982. Although in 1983 the reported number of legal abortions declined for the first time since abortion surveillance began, since 1980 the numbers, as well as the rates and ratios of abortion, have had only small year-to-year fluctuations (1).

From 1969 to 1980, the abortion ratio increased each year, but from 1980 to 1983 it declined each year (Figure 2). Although this ratio increased in 1984 to 364 abortions per 1,000 live births, it fell to 354 per 1,000 in 1985. The abortion rate also increased each year through 1980, when it reached 25 abortions per 1,000 females ages 15-44; it declined to 24 per 1,000 in 1981. Since that time, the rate has remained stable at approximately 24 per 1,000 (Figure 3).

The numbers of legal abortions reported to CDC in 1984 and 1985 were probably lower than the numbers actually performed. These numbers are based primarily on information provided by central health agencies, whose totals have been consistently lower than those obtained by direct surveys. For instance, in both 1984 and 1985, the total number of abortions reported by CDC was approximately 16% lower than that reported by the Alan Guttmacher Institute, a private organization that obtains information by direct survey of abortion providers (3). Because of the consistency of CDC's data collection method, however, the characteristics reported here are believed to reflect the overall characteristics of women obtaining abortions in the United States.

In each year from 1975 to 1985, at least 89% of abortions were performed in the woman's state of residence. In addition, the number of women obtaining an abortion in their state of residence increased from 89% in 1975 to 93% in 1983, but then fell to approximately 92% for both 1984 and 1985.

In 1972, the women obtaining abortions were almost evenly distributed among three age groups: 19 years of age or less, 20-24 years of age, and 25 or more years of age. Between 1972 and 1985, the number of teenagers obtaining abortions decreased steadily from 33% to 26%. Upward shifts in the age of women in the population may account for the continuing greater proportion, in 1984 and 1985, of abortions obtained by women 20 years of age and older. In 1975, approximately 78% of women ages 15-44 were over age 20. In 1980, that figure increased to 80%, and by 1985 the proportion of women over 20 had increased to approximately 84% (4,5).  Of the women who obtained abortions between 1972 and 1985, the proportion who were unmarried women increased steadily, from 70% to 81%. The percentages who were black or of other minority races increased from 23% to 33%, and the percentage who had had one or no previous live births increased from 67% to 77%. When abortions are studied by gestational age, the percentage distribution has been stable since 1977.

In 1984 and 1985, the trend continued for fewer women to obtain abortions for the first time; these women had accounted for 87% of all abortions in 1974 but accounted for only 57% in 1985. During this 11-year period, the percentage of women who previously had had one induced abortion increased from 11.3% to 25.0%; those who had had two induced abortions increased from 1.5% to 9.6%; and those who had had three or more induced abortions increased from 0.4% to 4.7%. These increases reflect both the ongoing availability of abortions and the fact that women who have had an abortion are more likely to have another (6-8).

Between 1972 and 1985, the percentage of abortions performed by curettage increased from 88.6% to 97.5%. Surveillance during the same period showed declines in the percentages of abortions performed by intrauterine instillation (from 10.4% to 1.7%) and by hysterectomy and hysterotomy (from 0.6% to 0.1%).

Between 1975 and 1985, the percentage of second-trimester abortions performed by D&E increased from 33% to 77%. During the same period, the percentage of second-trimester abortions performed by intrauterine instillation decreased from 57% to 16%. These changes most likely reflect improved technology and physicians' awareness that a lower risk of complications is associated with D&Es than with instillation procedures (9).

Since CDC's surveillance of abortion mortality began in 1972, 93% fewer deaths have occurred. In 1972, 90 women died as a result of abortion. Of those, 24 (27%) were related to a legally induced abortion and 39 (43%) to an illegal abortion. In 1985, seven women died as a result of induced abortion; of those, six resulted from a legal abortion and one from an illegal abortion. In addition to the 75% drop in the number of deaths resulting from legal abortions, the case-fatality rate fell from 4.1 to 0.5 deaths per 100,000 legal abortions.

References

1. CDC. Abortion surveillance: preliminary analysis--United States, 1984, 1985. MMWR 1988; 37:713-4.

2. CDC. Abortion surveillance, 1982-1983. In: CDC Surveillance Summaries, February 1987. MMWR 1987;36(no. 1SS):11SS-42SS.

3. Henshaw SK, Forrest JD, VanVort J. Abortion services in the United States, 1984 and 1985. Fam Plann Perspect 1987;19:63-70.

4. Estimates of population of the United States by age, sex, and race: 1974 to 1976. Current population reports, series P-25, no. 643. Washington, DC: Bureau of Census, US Department of Commerce, 1977:14.

5. Estimates of population of the United States by age, sex, and race: 1980 to 1987. Current population reports, series P-25, no. 1022. Washington, DC: Bureau of Census, US Department of Commerce, 1988:13-7.

6. Tietze C. Repeat abortion--why more? Fam Plann Perspect  1978;10:286-8.

7. Tietze C, Jain A. The mathematics of repeat abortion: explaining the increase. Stud Fam Plann 1978;9:294-9.

8. Tietze C, Bougaarts J. Repeat abortion in the United States: new insights. Stud Fam Plann 1982;13:373-9.

9. Cates W Jr, Schulz KF, Grimes DA, et al. Dilatation and evacuation procedures and second-trimester abortion: the role of physician skill and hospital setting. JAMA 1982;248: 559-63.

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