Access Denied: The Proliferation of American Medical Abortion Laws, 2000–2018

  • Sarah J. Tomlinson
    Address correspondence to: Sarah J. Tomlinson, JD, MBA, Department of Health Policy and Health Services Research, Temple University College of Public Health, Bell Building (TECH Center), 3rd Floor, 1101 West Montgomery Avenue, Philadelphia PA 19122.
    Department of Health Policy and Health Services Research, Temple University College of Public Health, Philadelphia, Pennsylvania
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Published:February 18, 2021DOI:


      Medical abortion is a safe, effective, and often preferred method of terminating an unintended pregnancy, but access can be made difficult by the laws of a state. Despite modern efforts to prevent unintended pregnancies in the U.S., they comprise almost half of pregnancies and 95% of abortions, signifying that abortion is a necessary and desired healthcare service. This study's purpose is to describe the proliferation of American medical abortion access laws between 2000 and 2018.


      Policy surveillance methods were used in 2018 to collect 7 types of U.S. medical abortion access restriction laws in place as of December 1, 2018. Statutory histories were reviewed in 2019 to record the laws’ years of enactment, substantive amendment, and repeal.


      A total of 35 states restricted medical abortion access as of 2018. Medical abortion laws increased from 16 in 2000 to 96 by 2018, and only 1 was repealed. A total of 25 states had multiple laws restricting medical abortion access in 2018. Medical abortion access laws surged from 2010 to 2017, but none were passed in 2018. Medical abortion access is generally most restricted in Midwestern and Southern states and least restricted in Western and Northeastern states.


      Although evidence demonstrates medical abortion's safety and efficacy, its access is increasingly limited by law in many states. Further research examining the impacts of these laws on women's health and the consequences of unintended births on women, children, families, and society is needed.
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        • Jatlaoui TC
        • Eckhaus L
        • Mandel MG
        • et al.
        Abortion surveillance - United States, 2016.
        MMWR Surveill Summ. 2019; 68: 1-41
        • GuttmacherInstitute
        Induced abortion in the United States.
        Guttmacher Institute, New York, NYPublished September 2019
        • WHO
        Clinical practice handbook for safe abortion.
        WHO, Geneva, Switzerland2014
      1. Little B. The science behind the “abortion pill.” Smithsonian Magazine. Published June 23, 2017. Accessed May 3, 2020.

        • Roberts SCM
        • Upadhyay UD
        • Liu G
        • et al.
        Association of facility type with procedural-related morbidities and adverse events among patients undergoing induced abortions.
        JAMA. 2018; 319: 2497-2506
        • Donovan MK.
        Self-managed medication abortion: expanding the available options for U.S. abortion care.
        Guttmacher Policy Rev. 2018; 21: 41-47
      2. Medication abortion. Guttmacher Institute. Updated January 1, 2021. Accessed 25 October 2020.

        • Kaiser Family Foundation
        The availability and use of medication abortion.
        Kaiser Family Foundation, San Franscisco, CAPublished June 8, 2020
      3. Jones RK, Boonstra H. The public health implications of the FDA's update to the medication abortion label. Health Affairs Blog. Published June 30, 2016. Accessed August 16, 2020.

        • Jones RK
        • Ingerick M
        • Jerman J.
        Differences in abortion service delivery in hostile, middle-ground, and supportive states in 2014.
        Womens Health Issues. 2018; 28: 212-218
        • Finer LB
        • Zolna MR.
        Declines in unintended pregnancy in the United States, 2008-2011.
        N Engl J Med. 2016; 374: 843-852
        • GuttmacherInstitute
        Unintended pregnancy in the United States.
        Guttmacher Institute, New York, NYPublished January 2019
        • Kost K
        • Finer LB
        • Singh S.
        Variation in state unintended pregnancy rates in the United States.
        Perspect Sex Reprod Health. 2012; 44: 57-64
        • Kost K.
        Unintended pregnancy rates at the state level: estimates for 2010 and trends since 2002.
        Guttmacher Institute, New York, NYPublished January 2015
        • Jones RK
        • Darroch JE
        • Henshaw SK.
        Contraceptive use among U.S. women having abortions in 2000-2001.
        Perspect Sex Reprod Health. 2002; 34: 294-303
        • Sonfield A
        • Kost K.
        Public costs from unintended pregnancies and the role of public insurance programs in paying for pregnancy-related care: national and state estimates for 2010.
        Guttmacher Institute, New York, NYPublished February 2015
        • Trussell J.
        The cost of unintended pregnancy in the United States.
        Contraception. 2007; 75: 168-170
        • Espey E
        • Dennis A
        • Landy U.
        The importance of access to comprehensive reproductive health care, including abortion: a statement from women's health professional organizations.
        Am J Obstet Gynecol. 2019; 220: 67-70
      4. 2020 Topics and objectives: family planning., Office of Disease Prevention and Health Promotion, HHS. Updated October 8, 2020. Accessed 3 May 2020.

        • Shepherd L
        • Turner HD.
        The over-medicalization and corrupted medicalization of abortion and its effect on women living in poverty.
        J Law Med Ethics. 2018; 46: 672-679
        • Burris S
        • Hitchcock L
        • Ibrahim J
        • Penn M
        • Ramanathan T.
        Policy surveillance: a vital public health practice comes of age.
        J Health Polit Policy Law. 2016; 41: 1151-1173
        • Hodge Jr, JG
        The promise (and pitfalls) of public health policy surveillance.
        J Health Polit Policy Law. 2016; 41: 1175-1183
      5. Medication abortion requirements. The Policy Surveillance Program, A LawAtlas Project. Updated August 31, 2020. Accessed 17 August, 2019.

      6. State partisan composition. National Conference of State Legislatures. Updated September 8, 2020. Accessed 3 May 2020.

      7. Abortion access in the United States, 2017.
        Updated September 11, 2019 (Guttmacher Institute)
      8. Maps: population density for counties and Puerto Rico Municipios: July 11, 2011. U.S. Census Bureau. Updated December 17, 2020. Accessed 3 May 2020.

      9. Map: poverty in the United States. U.S. Census Bureau. Updated September 15, 2016. Accessed May 13, 2020

      10. Population distribution by race/ethnicity. Kaiser Family Foundation.,%22sort%22:%22asc%22%7D. Updated October 28, 2020. Accessed 3 May 2020.

      11. Teen birth rate by state. Centers for Disease Control and Prevention. Updated April 28, 2020. Accessed 3 May 202.

        • Raymond EG
        • Grimes DA.
        The comparative safety of legal induced abortion and childbirth in the United States.
        Am J Obstet Gynecol. 2012; 119: 215-219
      12. Bixby Center for Global Reproductive Health, University of California San Francisco. Abortion restrictions put women's health, safety and well-being at risk. San Francisco, CA: Bixby Center for Global Reproductive Health, University of California San Francisco. Accessed 3 May 2020.

        • Cooney C
        • Hercher L
        • Bajaj K.
        Genetic counselors’ perception of the effect on practice of laws restricting abortion.
        J Genet Couns. 2017; 26: 1059-1069
      13. Sex and HIV education. Guttmacher Institute. Updated January 1, 2021. Accessed October 29, 2020.

      14. Insurance coverage of contraceptives. Guttmacher Institute. Updated January 1, 2021. Accessed 29 October 2020.

        • Ramaswamy A
        • Weigel G
        • Sobel L
        • Salganicoff A.
        Medication abortion and telemedicine: innovations and barriers during the COVID-19 emergency.
        Kaiser Family Foundation, San Francisco, CAPublished June 8, 2020