ABSTRACT
Background
Medication abortion has accounted for an increasing share of abortions in the United States (US) since the Food and Drug Administration's approval of mifepristone in 2000. This study offers updated estimates of medication abortions provided within the formal healthcare system in 2023 in US states without total abortion bans as well as a discussion of recent trends in medication abortion provision.
Methods
The Guttmacher Institute's Monthly Abortion Provision Study employs data from monthly samples of providers in a Bayesian hierarchical model to produce estimates of abortions provided within the formal healthcare system. We estimate the number and share of medication abortions provided in 2023 in states without total abortion bans and the share of abortions provided through telemedicine‐only clinics.
Results
Clinicians provided 648,500 medication abortions within the formal healthcare system in 2023 in states without total bans (90% uncertainty interval: 640,720–657,860), representing 63% of all abortions. Ten percent of all abortions were provided by telemedicine‐only clinics. The number of medication abortions provided in US states without total abortion bans increased by 19% between 2019 and 2020, and by 32% between 2020 and 2023.
Discussion
Medication abortion plays a critical role in the US abortion access landscape. Medication abortion provision has accelerated since 2019, likely due to COVID‐era policies that facilitated the expansion of telemedicine medication abortion provision. This shift has created essential access for individuals navigating abortion bans and other barriers to care since the removal of federal abortion protections.
1. Introduction
The United States (US) Food and Drug Administration (FDA) first approved mifepristone for use alongside misoprostol in a two‐drug regimen for medication abortion in 2000. Within the first year of mifepristone's approval, medication abortion represented 5% of abortions provided within the formal healthcare system; this figure increased to 31% in 2014 [1]. By 2020, for the first time, medication abortion accounted for most abortions in the US, 53% [2].
Since 2020, several legal and regulatory developments have facilitated access to medication abortion. Notably, in 2021, the FDA temporarily lifted medically unnecessary restrictions requiring in‐person provision of mifepristone. Made permanent in 2023, this change allowed US clinicians and online pharmacies to mail FDA‐approved abortion pills to patients in states where it is feasible to do so; it also allowed for the expansion of telemedicine‐only medication abortion clinics. In turn, the proportion of US providers offering medication abortion through telemedicine increased from 7% of all providers known to offer medication abortion in 2020 to 31% in 2022 [3].
The Supreme Court's June 2022 decision in Dobbs v. Jackson Women's Health Organization (Dobbs) removing federal protections for abortion has also likely increased reliance on medication abortion. Fourteen states banned abortion in almost all circumstances after the Dobbs decision, creating long wait times for appointments at clinics bordering these states [4]. Many abortion seekers may now rely on telemedicine to avoid wait times and other difficulties accessing in‐person care; regardless of wait times, they may also prefer the convenience and lower costs associated with telemedicine medication abortion care [5].
This study presents the number and proportion of medication abortions provided within the formal healthcare system, defined as those provided by a US clinician operating within their licensed scope of practice (i.e., providing FDA‐approved medications under the regulations of their state law), in 2023 to states without total abortion bans (as well as Washington, DC). We also offer insights into dynamics explaining prior increases in medication abortion provision in the US.
2. Methods
This analysis employs data from the Guttmacher Institute's Monthly Abortion Provision Study. Using a stratified sampling design, the Monthly Abortion Provision Study collects data from clinicians offering care within the formal healthcare system in states without total abortion bans. We include providers in one of two sampling arms. The first, surveyed every month, includes independent facilities playing key roles in abortion provision in their state (e.g., facilities that provided a majority or substantial minority of abortions in their state in 2019 and 2020, or new major independent facilities), as well as telemedicine‐only clinics with caseloads greater than 50 per month, and Planned Parenthood affiliates [6]. The monthly response rate for facilities surveyed in this arm is 90% and above; abortions provided at these facilities represent approximately 55% of our annual estimates.
The second arm consists of facilities drawn randomly from all remaining, known US abortion providers. Our sampling frame includes clinics with annual caseloads of 50 or more in 2019 or 2020, physician's offices with annual caseloads of 100 or more, and hospitals with annual caseloads of 300 or more. Each month, we sample 100 of these facilities. We target a 50% response rate for facilities in this arm; we have exceeded this target in all months of fielding since the study's inception in March 2023 (the average monthly response rate is 55%).
We ask all sampled facilities to provide data on caseloads, patient state of residence, and a rotating topic in a four‐question survey. In August and September 2023, we asked facilities to report the share of abortions provided via medication in the previous month; in February 2024, we asked facilities to report the share of abortions provided via medication in calendar year 2023. We did not collect data on the drug regimen provided (e.g., mifepristone and misoprostol, misoprostol only).
For any facility‐months for which we did not directly collect data, we estimate abortion counts using a Bayesian hierarchical model. Historical data, collected via Guttmacher's longtime Abortion Provider Census (APC) and throughout the course of the Monthly Abortion Provision Study, inform the model's estimates of abortion counts by facility and priors on variation over time and the extent to which trends in facility caseloads move together within and across states. The full model for estimating abortion counts is publicly available at https://osf.io/bng8s. Importantly, the model plays a relatively small role in estimating annual counts: 86% of our estimates for 2023 are from facilities that provided at least 2 months of data (and typically many more; randomly sampled facilities have provided, on average, 11 months of abortion caseloads throughout data collection).
Our counts of clinician‐provided medication abortions include those provided by brick‐and‐mortar facilities offering in‐person care—these facilities may or may not offer telemedicine or virtual care—and those mailed by telemedicine‐only clinics to patients in states without total bans. Our estimates also include abortion pills mailed by telemedicine‐only clinics operating under the protection of Shield Laws to patients in states without total bans (see Figure 1 and Table 1). 1
FIGURE 1.
Abortions provided under Shield Laws.
TABLE 1.
States where abortion was legal with restrictions that prohibited or deterred the mailing of medication abortion pills, 2023 [7, 8].
| State | In‐person counseling necessitates two trips | Must have in‐person visit with physician | 6‐week gestational ban | Mailing of abortion pills banned |
|---|---|---|---|---|
| Alaska | X a | |||
| Arizona | X | X | X | |
| Florida b | X | X | ||
| Georgia | X | |||
| Indiana c | X | X | ||
| Nebraska | X | |||
| North Carolina | X d | |||
| Ohio | X | X | X | |
| South Carolina | X | X e | ||
| Utah | X | X | ||
| Wisconsin | X | X |
Medication abortion must be provided in a hospital or facility approved by state Department of Health.
Florida implemented a 6‐week abortion ban in May 2024.
Indiana banned abortion in August 2023.
Implemented in July 2023.
Implemented in August 2023.
We report the estimated number of medication abortions provided by clinicians in 2023 in states without total bans, including as a share of all abortions, alongside 90% uncertainty intervals. We also report the share of abortions provided by telemedicine‐only clinics. Finally, we use figures from published APC surveys to examine trends in medication abortion and contextualize the recent increase in medication abortion provision.
3. Results
Clinicians provided 648,500 medication abortions within the formal healthcare system in states without total abortion bans in 2023 (90% uncertainty interval: 640,720–657,860), representing 63% of all abortions. Most of these medication abortions—84.8%—were provided by brick‐and‐mortar facilities and 15.1% were provided by telemedicine‐only clinics. Notably, medication abortion provided by telemedicine‐only clinics represented 9.5% of all abortions provided by clinicians in 2023.
Medication abortion has represented an increasing share of all abortions since 2001 (Table 2). Medication abortion provision within the formal healthcare system increased substantially between 2019 and 2020: from 45% to 53% of all abortions, and the number of medication abortions increased by 19%. Between 2020 and 2023, the number of medication abortions increased by 32%. However, data are not available for 2021 and 2022 and it is unclear whether this increase occurred incrementally or was concentrated in particular years.
TABLE 2.
Number of abortions, number of medication abortions, and % of all abortions that were medication abortions, US states without total abortion bans, 2000–2023.
| Year | Number | Medication abortions a (%) | |
|---|---|---|---|
| Abortions | Medication abortions | ||
| 2000 | 1,312,990 | ||
| 2001 | 1,291,000 | 70,500 | 5% |
| 2002 | 1,269,000 | ||
| 2003 | 1,250,000 | ||
| 2004 | 1,222,100 | ||
| 2005 | 1,206,200 | 161,100 | 13% |
| 2006 | 1,242,000 | ||
| 2007 | 1,209,640 | ||
| 2008 | 1,212,350 | 199,000 | 16% |
| 2009 | 1,151,600 | ||
| 2010 | 1,102,670 | ||
| 2011 | 1,058,490 | 239,400 | 23% |
| 2012 | 1,011,000 | ||
| 2013 | 958,700 | ||
| 2014 | 926,190 | 272,400 | 29% |
| 2015 | 899,500 | ||
| 2016 | 874,080 | ||
| 2017 | 862,320 | 339,640 | 39% |
| 2018 | 885,800 | ||
| 2019 | 916,460 | 412,130 | 45% |
| 2020 | 930,160 | 492,210 | 53% |
| 2021 | Not available | ||
| 2022 | Not available | ||
| 2023 | 1,032,600 | 648,500 | 63% |
Figures for 2001–2014 differ slightly from previously published figures, which used non‐hospital abortions as the denominator. These figures include all abortions as the denominator.
4. Discussion
In 2023, medication abortion accounted for almost two‐thirds of all abortions provided within the formal healthcare system in states without total bans. As a result, medication abortion plays a critical role in the US abortion access landscape.
Largely overlooked in prior research was the substantial one‐year increase in medication abortion provision that occurred between 2019 and 2020; the 19% increase in the number of medication abortions provided within the formal healthcare system over this one‐year period is greater than, or comparable to, increases seen over 3‐year periods in prior surveys (14% between 2011 and 2014 and 25% between 2014 and 2017) [2, 9, 10, 11]. This jump preceded the appearance of all but a few low‐volume, US‐based telemedicine‐only clinics and is partially attributable to changes in abortion provision at brick‐and‐mortar facilities during the COVID‐19 pandemic. To limit opportunities for viral transmission, some providers adopted evidence‐based practices that reduced in‐person visit requirements for medication abortion, including pre‐abortion ultrasound [12]. Others began to allow “quick pick‐up” of medication abortion or mailed abortion pills themselves or via online pharmacies [2] after a Federal District Judge temporarily blocked the FDA's in‐person dispensing requirement [13].
In 2021, the FDA permanently removed the in‐person requirement for dispensing mifepristone. This change allowed for the expansion of telemedicine medication abortion provision and telemedicine‐only medication abortion clinics within the formal healthcare system. The ability to obtain abortion pills virtually has offered a vital access point to individuals who do not live near a facility, or whose work, childcare, or other commitments prevent them from attending in‐person appointments.
Importantly, medication abortion may not be the preferred method for many abortion seekers. Some individuals pursue medication abortion because instrumentation abortion is not accessible. In 2021, 40% of facilities known to provide abortions nationwide offered only medication abortion [14]. In 2023, with abortion banned in 14 states in the wake of Dobbs, 17% of abortion patients traveled out‐of‐state for care; in the same year, abortion increased among residents of states without total bans [15]. These developments have strained clinic capacity, leading to wait times of 2 weeks or longer for appointments [16]. As a result, some individuals may opt to use telemedicine‐only clinics to avoid long wait times for appointments at brick‐and‐mortar facilities. These dynamics may disproportionately impact vulnerable populations, as research suggests that Black abortion patients [17] and those with incomes below the federal poverty level are less likely than others to prefer, and to have, a medication abortion relative to an instrumentation abortion [18].
The availability of medication abortion via in‐person and virtual channels likely contributed to the 11% increase in all clinician‐provided abortions documented by the Guttmacher Institute between 2020 and 2023 [15]. However, access to medication abortion is increasingly under threat. While the Supreme Court rejected a bid to reinstate in‐person dispensing requirements for mifepristone in June 2024, anti‐abortion groups have continued to challenge access to medication abortion via the courts and other means [19].
This analysis has several limitations. It is possible that our sample does not accurately represent the universe of US abortion providers, especially given the rapidly evolving policy context under which the study was fielded. Our uncertainty intervals reflect this potential for error in our estimates. Our medication abortion counts, particularly those provided by mail, reflect pills dispensed, but not necessarily completed abortions.
Abortion counts presented in this paper do not include medication abortions sourced from community networks or websites that sell pills without a clinical consultation from a US‐based provider [20]. They also do not include abortions pills mailed from Shield Law providers to people in states with total abortion bans in 2023 [21]. As such, medication abortion estimates presented here are an undercount.
5. Conclusions
Medication abortion has become a fundamental feature of abortion in the US, in part because clinicians have quickly adapted care provision in volatile public health and policy environments. The expansion of virtual access to medication abortion within the formal healthcare system is one such critical adaptation, which likely contributed to the recent national increase in clinician‐provided abortions despite the significant restrictions to abortion access posed by Dobbs.
Everyone seeking an abortion should have access to the full range of safe, effective options for care. Medication abortion, provided in‐person or via telemedicine, is a critical component of these options.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgments
The authors are grateful to the clinicians and clinic staff who provided data to the Monthly Abortion Provision Study, without whom this analysis would not be possible. We also thank Ava Braccia, Jesse Philbin, Marielle Kirstein, and the Monthly Abortion Provision Study fielding staff for their tireless and comprehensive efforts: Mariah Menanno, Lauren Mitchell, Aisiri Murulidhar, Priscille Osias, and Samira Sackietey. We gratefully acknowledge the critical feedback and contributions of the following Guttmacher colleagues: Amy Friedrich‐Karnik, Megan Kavanaugh, and Emma Stoskopf‐Erlich. The Monthly Abortion Provision Study is supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development, the Office of Research on Women's Health, and the Office of Behavioral and Social Sciences Research, under award number R61HD112921. The content is the sole responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Funding: The Monthly Abortion Provision Study is supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development, the Office of Research on Women's Health, and the Office of Behavioral and Social Sciences Research, under award number R61HD112921. The content is the sole responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Endnotes
In July 2023, select providers began offering abortion care via telemedicine to patients in states with bans or telemedicine restrictions under the protection of Shield Laws. We count these cases, when provided to states without total bans, in our estimates. We do not, however, include care by telemedicine providers to patients in states with telemedicine bans prior to July 2023, as we don't define these cases as occurring within the formal healthcare system. See Figure 1 for more information on Shield Law provision.
References
- 1. Jones R. K., Nash E., Cross L., Philbin J., and Kirstein M., “Medication Abortion Now Accounts for More Than Half of All US Abortions,” Guttmacher Institute, 2022, https://www.guttmacher.org/article/2022/02/medication‐abortion‐now‐accounts‐more‐half‐all‐us‐abortions.
- 2. Jones R. K., Kirstein M., and Philbin J., “Abortion Incidence and Service Availability in the United States, 2020,” Perspectives on Sexual and Reproductive Health 54, no. 4 (2022): 128–141, 10.1363/psrh.12215. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Advancing New Standards in Reproductive Health (ANSIRH), University of California San Francisco , “Availability of Telehealth Services for Medication Abortion in the U.S., 2020–2022,” Advancing New Standards in Reproductive Health (ANSIRH), University of California San Francisco,” 2023, https://www.ansirh.org/sites/default/files/2023‐06/AFD%20Telehealth%20Issue%20Brief%206‐14‐23%20Final.pdf.
- 4. Katz J., Sanger‐Katz M., and Cain M. C., “Florida's Abortion Ban Will Reach Well Beyond Florida,” The New York Times, 2024, https://www.nytimes.com/interactive/2024/05/01/upshot/florida‐abortion‐ban.html.
- 5. Upadhyay U. D., Schroeder R., Kaller S., Stewart C., and Berglas N. F., “Pricing of Medication Abortion in the United States, 2021–2023,” Perspectives on Sexual and Reproductive Health 56 (2024): 282–294, 10.1111/psrh.12280. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Guttmacher Institute , “Monthly Abortion Provision Study,” 2024, https://guttmacherinstitute.github.io/provision‐dashboard/.
- 7. Guttmacher Institute , “Counseling and Waiting Periods for Abortion,” 2023, https://www.guttmacher.org/state‐policy/explore/counseling‐and‐waiting‐periods‐abortion.
- 8. Guttmacher Institute , “Medication Abortion,” 2023, https://www.guttmacher.org/state‐policy/explore/medication‐abortion.
- 9. Jones R. K. and Jerman J., “Abortion Incidence and Service Availability in the United States, 2011,” Perspectives on Sexual and Reproductive Health 46 (2014): 3–14, 10.1363/46e0414. [DOI] [PubMed] [Google Scholar]
- 10. Jones R. K. and Jerman J., “Abortion Incidence and Service Availability in the United States, 2014,” Perspectives on Sexual and Reproductive Health 49, no. 1 (2017): 17–27, 10.1363/psrh.12015. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11. Jones R. K., Witwer E., and Jerman J., “Abortion Incidence and Service Availability in the United States,” Guttmacher Institute, 2019, https://www.guttmacher.org/report/abortion‐incidence‐service‐availability‐us‐2017.
- 12. Upadhyay U. D., Schroeder R., and Roberts S. C. M., “Adoption of No‐Test and Telehealth Medication Abortion Care Among Independent Abortion Providers in Response to COVID‐19,” Contracept: X 2 (2020): 100049, 10.1016/j.conx.2020.100049. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13. American College of Obstetricians & Gynecologists , “United States Food and Drug Administration,” 2020.
- 14. Schroeder R., Muñoz I., Kaller S., Berglas N., Stewart C., and Upadhyay U., “Trends in Abortion Care in the United States, 2017‐2021. Advancing New Standards in Reproductive Health (ANSIRH),” University of California San Francisco, 2022, https://www.ansirh.org/sites/default/files/2022‐06/Trends%20in%20Abortion%20Care%20in%20the%20United%20States%2C%202017‐2021.pdf.
- 15. Maddow‐Zimet I., Philbin J., DoCampo I., and Jones R., “Monthly Abortion Provision Study,” 2024, https://osf.io/k4x7t/.
- 16. Myers C., Bennett L., Vale F., and Nieto A., “Abortion Access Dashboard,” 2024, https://experience.arcgis.com/experience/6e360741bfd84db79d5db774a1147815.
- 17. Wingo E., Ralph L. J., Kaller S., and Biggs M. A., “Abortion Method Preference Among People Presenting for Abortion Care,” Contraception 103, no. 4 (2021): 269–275, 10.1016/j.contraception.2020.12.010. [DOI] [PubMed] [Google Scholar]
- 18. Jones R. K., Chiu D. W., and Kohn J. E., “Characteristics of People Obtaining Medication vs. Procedural Abortions in Clinical Settings in the United States: Findings From the 2021‐2022 Abortion Patient Survey,” Contraception 128 (2023): 110137, 10.1016/j.contraception.2023.110137. [DOI] [PubMed] [Google Scholar]
- 19. Belluck P., “States Revive Lawsuit to Sharply Curb Access to Abortion Pill,” The New York Times, 2024, https://www.nytimes.com/2024/10/21/health/abortion‐pill‐mifepristone‐lawsuit.html.
- 20. Aiken A. R. A., Wells E. S., Gomperts R., and Scott J., “Provision of Medications for Self‐Managed Abortion Before and After the Dobbs v Jackson Women's Health Organization Decision,” Journal of the American Medical Association 331, no. 18 (2024): 1558–1564, 10.1001/jama.2024.4266. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21. Society of Family Planning , “#WeCount Report: April 2022 to June 2024. Society of Family Planning,” 2024, https://societyfp.org/wp‐content/uploads/2024/10/WeCount‐Report‐8‐June‐2024‐data.pdf.