causes of poverty research paper

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Poverty, Racism, and the Public Health Crisis in America

Bettina m. beech.

1 Department of Health Systems and Population Health Science, University of Houston College of Medicine, Houston, TX, United States

Chandra Ford

2 Department of Community Health Sciences, Center for the Study of Racism, Social Justice and Health at the University of California, Los Angeles, Los Angeles, CA, United States

Roland J. Thorpe, Jr.

3 Department of Health, Behavior, and Society, Program for Research on Men's Health, Hopkins Center for Health Disparities Solutions, Johns Hopkins Alzheimer's Disease Resource Center for Minority Aging Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States

Marino A. Bruce

4 Program for Research on Faith, Justice, and Health, Department of Behavioral and Social Sciences, University of Houston College of Medicine, Houston, TX, United States

Keith C. Norris

5 Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States

Associated Data

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

The purpose of this article is to discuss poverty as a multidimensional factor influencing health. We will also explicate how racism contributes to and perpetuates the economic and financial inequality that diminishes prospects for population health improvement among marginalized racial and ethnic groups. Poverty is one of the most significant challenges for our society in this millennium. Over 40% of the world lives in poverty. The U.S. has one of the highest rates of poverty in the developed world, despite its collective wealth, and the burden falls disproportionately on communities of color. A common narrative for the relatively high prevalence of poverty among marginalized minority communities is predicated on racist notions of racial inferiority and frequent denial of the structural forms of racism and classism that have contributed to public health crises in the United States and across the globe. Importantly, poverty is much more than just a low-income household. It reflects economic well-being, the ability to negotiate society relative to education of an individual, socioeconomic or health status, as well as social exclusion based on institutional policies, practices, and behaviors. Until structural racism and economic injustice can be resolved, the use of evidence-based prevention and early intervention initiatives to mitigate untoward effects of socioeconomic deprivation in communities of color such as the use of social media/culturally concordant health education, social support, such as social networks, primary intervention strategies, and more will be critical to address the persistent racial/ethnic disparities in chronic diseases.

I used to think I was poor, then they told me I wasn't poor, I was needy. Then they told me it was self-defeating to think of myself as needy, I was deprived. Then they told me underprivileged was overused, that I was disadvantaged. I still don't have a dime, but I have a great vocabulary—From a Jules Feiffer cartoon, 1965 .

Poverty is one of the most significant, yet understudied social conditions of the 21st century ( 1 ). This social condition can be defined in a number of ways; however, it can be summarized as the lack of resources necessary to meet basic human needs. Prosperity has been a primary focus in recent years with the rise in overall global wealth ( 2 ). But, the growth in economic and financial resources has not been equally distributed. The gap in resources between the affluent and the poor has been steadily increasing and global extreme poverty (individual income < United States [U.S.] $1.90/day) increased in 2020, the first time in over two decades to 9.2%, after falling to a low of 8% in 2019 ( 3 ). Over 40% of the world lived on less than the U.S. $5.50 a day in 2017 with most of the extreme poverty concentrated in Africa ( 3 ). The prevalence of extreme poverty in the U.S. is very low by global standards ( 3 ). However, the U.S. has one of the highest rates of poverty in the developed world and the worst index of health and social problems as a function of income inequality ( 4 ). For each additional household member, the level increases by $4,480 a year. The level of relative poverty in the U.S. is determined by the federal poverty level (FPL), and for a single-person household, the 2020 poverty level was $12,760 a year, or just under $35 a day. The prevalence of communities being below the FPL varies by race and ethnicity with 24.2% American Indian/Alaskan Native, 21.2% of Black, 17.2% of Hispanic, 9.7% of Asian/Pacific Islander/Native Hawaiian, and 9% of White American families falling below 100% of the FPL ( 5 ). Furthermore, the inequities in wealth are even greater than income differences across racial and ethnic groups.

Black families in the U.S. have about one-twentieth the wealth of their White peers on average ( 6 ). For every dollar of wealth in White families, the corresponding wealth in Black households is five cents. Wealth inequality is not a function of work ethic or work hour difference between groups. Rather, the widening gap between the affluent and the poor can be linked to unjust policies and practices that favor the wealthy ( 2 , 7 – 9 ). The impact of this form of inequality on health has come into sharp focus during the COVID-19 pandemic as the economically disadvantaged were more likely to get infected with SARS CoV-2 and die ( 10 ).

For many health providers, the link between poverty and health among health care providers has been primarily grounded in access to health care with several downstream effects of poverty that may include poor nutrition and substandard housing. This understanding is often influenced and perhaps confounded by the correlation between race and poverty, or racism and classism ( 11 ). A common narrative for the relatively high prevalence of poverty in marginalized minority communities is predicated on notions about them having poor work ethics and poor innate inabilities to achieve wealth. An over-reliance on the myth of meritocracy and a failure to understand root causes of poverty operating at community and individual levels can exacerbate poor patient-provider relations and perpetuate suboptimal patient outcomes among marginalized minority groups. Racial and economic marginalization has contributed to public and population health crises in the United States (U.S.) and across the globe ( 12 , 13 ). However, poverty is much more than just a low household income. Poverty has been characterized in the following three ways: (1) economic well-being, commonly linked to income; (2) ability to navigate society as a function of an education or health status of the individual; and/or (3) social exclusion as a result of institutional behaviors, practices, and policies ( 1 , 14 ). The purpose of this article is to discuss poverty as a multidimensional factor influencing health and explicate how racism contributes to and perpetuates the economic and financial inequality that diminishes prospects for population health improvement among marginalized racial and ethnic groups. We believe this discussion will help to inform a realistic way forward in the pursuit of health equity.

Poverty and Health Disparities, A Historical Perspective

In the mid-1800's, Dr. James McCune Smith was the leading voice in the medical profession to argue that the health of the person was not primarily a consequence of their innate constitution, but instead reflected their intrinsic membership in groups created by a race structured society ( 15 – 17 ). This articulation of health disparities being linked to the racial caste system of America and inequitable social conditions is one of the earliest written descriptions of racism as the cause of health inequities and ultimately health disparities by a member of the American healthcare community. His arguments were scientifically validated when Dr. William Edward Burghardt Dubois reported his findings in 1899 from the first sociological study of Blacks in America, The Philadelphia Negro, demonstrating that racial differences in mortality in Philadelphia were explained by social factors (e.g., economic, sanitary, and education) and not innate racial traits or tendencies ( 18 ). Dr. Dubois documented how white supremacy policies, actions, and beliefs leading to discrimination, oppression, and more contributed to structural poverty and increased levels of despair, disease, and death ( 19 ). Thus, Drs. James and Dubois are considered by many to be the true pioneers who laid the foundation for future work clarifying racism rather than race as the cause of health disparities ( 20 , 21 ).

Explicit notions of Black biological, intellectual, and moral inferiority often categorized as scientific racism have gradually moved from the mainstream to the margins over the last century as social movements advocated for the full citizenship of Black Americans. Despite the passing of civil rights legislation in the U.S. prohibiting discrimination in public arenas and civic engagement (e.g., Civil Rights Bill of 1866, Civil Rights Act of 1964, Voting Rights Act of 1965, and Civil Rights Act of 1968), structural racism, discrimination, and other harmful forms of bias continue to persist today ( 22 – 24 ). Many factors, such as explicit and implicit provider biases, medical and institutional mistrust (due to historic and contemporary mistreatment), and low self-esteem and stereotype threat, from internalized racism continue to impact our nation and further contribute to the genesis and perpetuation of health disparities ( 25 ). This was reified in the 1985 Report of the Secretary of the U.S. Department of Health and Human Services (U.S. DHHS) Task Force on Black and Minority Health, known as the Heckler Report, the first government-sanctioned assessment of racial health disparities ( 26 ), followed nearly two decades thereafter by the Institute of Medicine (IOM) Report on Unequal Treatment ( 25 ). The Heckler Report noted mortality inequity was linked to six leading causes of preventable excess deaths for the Black compared to the White population (cancer, cardiovascular disease, diabetes, infant mortality, chemical dependency, and homicide/unintentional injury) ( 26 ). The IOM Report focused on health care disparities and highlighted the role interpersonal racism can have on health outcomes for members of minoritized groups ( 25 ). These reports and others ( 9 , 27 – 35 ) have led to a more robust focus on population health over the last few decades that has included a renewed interest in the impact of racism and social factors, such as poverty on clinical outcomes ( 1 , 33 ).

Poverty and the MYTH of Meritocracy

The race is an antecedent and major determinant of socioeconomic status (SES) in the U.S.; therefore, it is not surprising that the successful implementation of discriminatory race-based policies premised on racial inferiority would produce racial disparities in SES. The term structural racism is used to capture the ways in which inequities are perpetuated through the racialized differential access to resources, opportunities, and services that are codified in laws, policies, practices, and societal norms ( 23 , 32 , 33 , 36 – 40 ). This system harms marginalized populations at the expense of affording greater resources, opportunities, and other privileges to the dominant White society ( 23 , 32 , 33 , 36 – 40 ). Importantly, a single identifiable perpetrator is not visible making its denial easy and its identification and dissolution challenging ( 41 ).

However, the role of structural racism in creating and sustaining poverty is rarely discussed in scholarly and public circles despite the publishing of seminal works, such as Caste, Class and Race, Black Metropolis , and An American Dilemma during the mid-20th century ( 42 – 44 ). These groundbreaking books laid the foundation for several sociological studies documenting key structurally racist policies and practices (i.e., residential segregation) that created communities comprised of racial and ethnic minorities that are beset with poverty and related factors, including high unemployment, poor schools, substandard housing, and limited social mobility ( 45 – 47 ). Most White Americans were not exposed to this scholarship nor the overwhelming financial and economic disadvantages faced by African Americans and other marginalized groups. As such, public discourse has been largely shaped by a narrative of meritocracy which is laced with ideals of opportunity without any consideration of the realities of racism and race-based inequities in structures and systems that have locked individuals, families, and communities into poverty-stricken lives for generations. Pervasive public policies spanning from slavery to voter suppression have and continue to severely limit opportunities for social mobility among marginalized groups, thereby perpetuating and hardening vast inequities in power, status, and resources that define our racial caste system and structure ( 9 , 34 , 48 – 50 ).

The narrative of meritocracy has also been extended to immigrants, but it is framed through a narrative of European immigrants who work hard and become successful. However, immigrants from Mexico, Central and South America, in particular as well as many refugees from poor Asian and African countries are also exposed to laws and policies that create and perpetuate a life confronting persistent inequality and perceptions of inferiority.

These practices of race-based, community-level disinvestment in each of the domains of the social determinants coupled with a lack of a national health program condemn oppressed populations such as Black and Hispanic Americans, American Indians, and disproportionately non-English speaking immigrants and refugees to remain in poverty and suffer from suboptimal health. Thus, poverty represents a critical public health condition that is both determined by and perpetuated by structural racism.

Conceptual Framework of Poverty and Health

Socioeconomically disadvantaged populations across the globe bear a disproportionate burden of chronic diseases and are least likely to receive evidence-based care leading to optimal clinical outcomes ( 51 , 52 ). A basic understanding of the vulnerabilities of the marginalized and oppressed populations will facilitate the adaptation and adoption of the necessary policies to support disease treatment and prevention guidelines ( 52 ). The WHO has identified three key tenets to improving health at a global level that each reinforces the impact of socioeconomic factors: (1) improve the conditions of daily life; (2) tackle the inequitable distribution of power, money, and resources, the structural drivers of those conditions of daily life, globally, nationally, and locally; and (3) develop a workforce trained in the social determinants of health and raise public awareness about social needs and the social determinants of health ( 53 ). Social factors and health behaviors have contributed substantially to the growing non-communicable disease epidemics (e.g., obesity, diabetes, hypertension, and mental health disorders). A deeper understanding and integration of social and behavioral sciences is needed to equip medical and public health communities to address the challenge of providing quality care in the setting of contrasting financial and public health policies to control costs ( 54 ). A conceptual framework emphasizing the key pathways through which poverty and structural racism may influence wellness and health outcomes is shown in Figure 1 .

A conceptual framework emphasizing the key pathways through which poverty and structural racism may influence wellness and health outcomes [adapted from Wen et al. ( 55 )].

Perniciousness of Persistent Poverty

The Social Determinants of Health (SDoH) are macro-level factors that shape the economic, physical, psychological, and social environments in which people live ( 56 ). They are often viewed as having the capacity to enhance or diminish the resources available to individuals to promote health, including but not limited to the food supply, housing, economic and social relationships, transportation, employment, criminal justice, education, and health care, whose distribution across populations effectively determines length and quality of life and the programs and policies that direct them ( 23 ). The World Health Organization Commission on Social Determinants of Health has found that the poor health status of low resource persons, communities, and nations is directly related to the unequal distribution of power, income, goods, and services ( 53 ). Social structures and institutions with unequal and unfair social policies, economic arrangements, and practices have contributed to much of the health inequity present in the world. A brief overview of select medical conditions follows.

Communicable diseases: Poverty can contribute to many communicable diseases including many acute and chronic infectious diseases. Poverty and the associated disadvantage of personal and social resources often lead to unsafe habitation and lack of cleanliness, unhealthy diets, and malnutrition (including maternal-fetal), poor water quality, increased exposure to infectious diseases, environmental pollution and toxins, and more ( 57 ). The rates of infectious disease morbidity and mortality in low resource households, communities, and nations over decades bear witness to the considerable impact of economic inequality on health ( 53 ).

Maternal and child health: Poverty has been strongly linked with poor reproductive outcomes, both independently and in combination with exposure to discrimination ( 58 – 61 ). Maternal and child health among low-income and racial/ethnic minority groups are particularly susceptible to psychological stress, nutrition, substance use, and more ( 58 , 62 , 63 ).

Incarcerated youth: Globally and in the US, incarceration rates are higher among poor and marginalized groups ( 64 ). For children within the criminal justice system or otherwise deprived of liberty are at particularly high risk of violence, rape and sexual assault, sexually transmitted diseases, substance use disorders, mental illnesses, and physical disorders, many of which will continue throughout the life course ( 65 , 66 ). Furthermore, adult incarceration can create health deficits in familial youth ( 64 ).

Chronic non-communicable diseases: Similar patterns of disparities negatively are observed in the incidence and prevalence of chronic diseases, such as cardiovascular disease, diabetes, kidney disease, and others ( 67 – 70 ). Poverty can also have indirect implications for health ( 5 , 71 ). Race-based economic disadvantages can influence other social determinants as the intersection with poverty can further limit housing, educational, and employment opportunities, and these have also been linked to worse health outcomes ( 58 , 72 – 74 ). Poverty can also influence individual perceptions and behaviors ( 75 ). Relative and absolute economic deprivation can shape expectations and perceived life chances in a manner that individuals focus on surviving rather than thriving.

Mental health: In addition to the more traditional mental health conditions that may limit daily functioning, the additional chronic stress associated with navigating basic needs in a state of poverty can impair cognitive processing and the ability to remember and to perform implementation tasks ( 76 ), along with mistrust which may impact the ability of the individual to follow up on medical appointments, provider recommendations and more to conspire to limit health outcomes ( 77 ).

In summary, the impact of poverty on both the physical and psychological aspects of a person can play an important role in the many dimensions associated with the development and progression of diseases. The socioeconomic status of the individual may considerably impact the perception of the individual of many life issues, such as food, education, language, and time ( 75 ). While these concepts may be apparent and easily recognizable in other social disciplines, their presence and implications may be lost or concealed to many health care providers. Therefore, an understanding of how poverty may influence worldviews is critical for health professionals to truly understand the diverse group of patients they care for and how to better connect with those in an impoverished situation to optimize the effectiveness of traditional and alternative health strategies and recommendations. Table 1 highlights the influence of socioeconomic class including income on the context of patient-specific needs, values, and preferences, as well as considerations as to how racism may be operating in that setting.

Socioeconomic class and values of key determinants of health [adapted from Payne and Blair ( 75 )].

Poverty, Refugee, and Migration

As a large nation founded by immigrants, the United States inevitably and receives a large number of refugees, documented, and undocumented immigrants seeking a better life. The national narrative is that immigrants will find employment, gain some measure of socioeconomic equity and become eligible for health insurance. Unfortunately, this ideal only holds true for a subset of preferred immigrants largely from wealthy European countries. Individuals from formerly colonized nations in Central or South America, Asia, or Africa who come to the United States are often beset with persistent marginalization, poverty, and poor health ( 78 , 79 ). Furthermore, the likelihood that groups will be placed in such a situation is grounded in racial and ethnic discrimination as well as religious discrimination ( 11 ). Many immigrants with limited resources experience a combination of stressors, including discrimination, isolation, uncertainty, and mental health disorders from posttraumatic stress symptoms, depression, anxiety alcohol, and substance use to posttraumatic stress symptoms ( 80 , 81 ). In addition to researchers, providers have acknowledged the importance of poverty, discrimination, and other structural barriers on the lived experiences of immigrant clients and how it may impact their health ( 80 ).

What Might be the Way Forward?

An aphorism commonly attributed to the former Center for Medicare and Medicaid Services (CMS) director Don Berwick is “Every system is perfectly designed to achieve the results it gets.” Our society has been outstanding in perpetuating the conditions that lead to and maintain poverty for a disproportionately high percentage of people of color. Unlike many narratives about poverty and the innate values of people of color, no one wakes up wanting to be poor or sick. Similar to most other major institutions, the health profession has chosen to work around the margins of poverty and to study and practice what is the best way to treat patients with limited resources, limited social support, and multiple exposures that develop or worsen the disease. While the stature of the health profession has given it an immense level of privilege and power that could be used to achieve different results in a nation with immense wealth, we have chosen as a collective not to address the root causes because it would conflict with the white supremacy ideology of a caste-based society. Continuing the same approach to medical education in the setting of our rapidly increasing wealth gap will lead to training physicians and other healthcare providers on how to most effectively care for fewer and fewer people. Creating a new generation of healthcare providers dedicated to mitigating the many social factors that conspire to perpetuate health disparities is one important step toward how the profession can rebuild patient trust and ultimately improve patient outcomes.

The solutions must involve stakeholders from across diverse sectors ( 82 ). The medical community and related stakeholders should adopt a strategic approach to address the financial and related public policy issues that will enable the delivery of appropriate clinical care to marginalized patient populations including low those with low SES, minoritized communities, and non-European immigrants and refugees ( 40 , 48 , 54 , 83 ). The Affordable Care Act (ACA) was one such policy that dramatically increased the insurance coverage eligibility for a large number of low-income young Americans ( 84 ), with important consequences for mitigating health disparities as well as possibly reducing bankruptcy related to health care costs ( 85 ), although other data suggest that there has been no impact on bankruptcy ( 86 ). Barcellos et al. ( 87 ) reported persons with a lower income (100–250% FPL) were 31% less likely to score above the median on ACA knowledge and 54% less likely to score above the median on health insurance knowledge vs. persons with higher income levels (>400% FPL). These findings highlight the need to not only implement health policies to increase access to care for lower-income individuals but also the need to ensure such policies and associated programs are reaching those in need. The ACA may set the stage for not only more available care but also more structured medical care systems which can help improve health outcomes ( 88 ). However, improved outreach and education of the potential benefits of and access to the ACA in lower-income communities and support to ensure people are enrolled is still required ( 87 ).

A major challenge for the broader medical community is to reconceptualize how it might improve each domain that impacts health outcomes, beyond those limited to a procedure or prescription. Increasing the awareness of environmental and social factors that contribute to health disparities must be followed by actions, such as cost-effective policies, to improve disease prevention and care in impoverished communities, especially in the setting of increasing inequities in wealth and many of the other SDoH ( 88 – 92 ). Healthcare providers can directly address many of the factors crucial for closing the health disparities gap by recognizing and trying to mitigate the race-based implicit biases many physicians carry ( 93 ), as well as leveraging their privilege to address the elements of institutionalized racism entrenched within the fabric of our society, starting with social injustice and human indifference ( 91 , 94 ). Examples of evidence-based initiatives to mitigate untoward effects of socioeconomic deprivation include the use of videos and/or novellas ( 95 , 96 ), the use of social support, such as social networks ( 97 ), and primary intervention strategies including the use of mobile clinics, lay health workers, and patient navigators to address chronic diseases ( 98 – 101 ). Finally, the healthcare sector should not miss the opportunity to learn important lessons as it strives to advance the necessary policies to improve social welfare and health outcomes, as the existence of health inequities provides unique, unrecognized opportunities for understanding biological, environmental, sociocultural, and healthcare system factors that can improve clinical outcomes ( 88 – 92 ).

“ Overcoming poverty is not a gesture of charity. It is an act of justice. It is the protection of a fundamental human right, the right to dignity and a decent life”—Nelson Mandela former President of South Africa .

Data Availability Statement

Author contributions.

KN wrote the first draft of the manuscript. BB, MB, CF, and RT wrote sections of the manuscript. All author contributed to conception and design of the study, contributed to manuscript revision, read, and approved the submitted version.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Funding. This work was supported in part by NIH grants K02AG059140-02S1 (MB), P30AG059298 (MB and RT), R25HL126145 (MB, BB, KN, and RT), UL1TR000124 (KN), P30AG021684 (KN), K02AG059140 (RT), and U54MD000214 (RT). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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What the data says about abortion in the U.S.

Pew Research Center has conducted many surveys about abortion over the years, providing a lens into Americans’ views on whether the procedure should be legal, among a host of other questions.

In a  Center survey  conducted nearly a year after the Supreme Court’s June 2022 decision that  ended the constitutional right to abortion , 62% of U.S. adults said the practice should be legal in all or most cases, while 36% said it should be illegal in all or most cases. Another survey conducted a few months before the decision showed that relatively few Americans take an absolutist view on the issue .

Find answers to common questions about abortion in America, based on data from the Centers for Disease Control and Prevention (CDC) and the Guttmacher Institute, which have tracked these patterns for several decades:

How many abortions are there in the U.S. each year?

How has the number of abortions in the u.s. changed over time, what is the abortion rate among women in the u.s. how has it changed over time, what are the most common types of abortion, how many abortion providers are there in the u.s., and how has that number changed, what percentage of abortions are for women who live in a different state from the abortion provider, what are the demographics of women who have had abortions, when during pregnancy do most abortions occur, how often are there medical complications from abortion.

This compilation of data on abortion in the United States draws mainly from two sources: the Centers for Disease Control and Prevention (CDC) and the Guttmacher Institute, both of which have regularly compiled national abortion data for approximately half a century, and which collect their data in different ways.

The CDC data that is highlighted in this post comes from the agency’s “abortion surveillance” reports, which have been published annually since 1974 (and which have included data from 1969). Its figures from 1973 through 1996 include data from all 50 states, the District of Columbia and New York City – 52 “reporting areas” in all. Since 1997, the CDC’s totals have lacked data from some states (most notably California) for the years that those states did not report data to the agency. The four reporting areas that did not submit data to the CDC in 2021 – California, Maryland, New Hampshire and New Jersey – accounted for approximately 25% of all legal induced abortions in the U.S. in 2020, according to Guttmacher’s data. Most states, though,  do  have data in the reports, and the figures for the vast majority of them came from each state’s central health agency, while for some states, the figures came from hospitals and other medical facilities.

Discussion of CDC abortion data involving women’s state of residence, marital status, race, ethnicity, age, abortion history and the number of previous live births excludes the low share of abortions where that information was not supplied. Read the methodology for the CDC’s latest abortion surveillance report , which includes data from 2021, for more details. Previous reports can be found at  stacks.cdc.gov  by entering “abortion surveillance” into the search box.

For the numbers of deaths caused by induced abortions in 1963 and 1965, this analysis looks at reports by the then-U.S. Department of Health, Education and Welfare, a precursor to the Department of Health and Human Services. In computing those figures, we excluded abortions listed in the report under the categories “spontaneous or unspecified” or as “other.” (“Spontaneous abortion” is another way of referring to miscarriages.)

Guttmacher data in this post comes from national surveys of abortion providers that Guttmacher has conducted 19 times since 1973. Guttmacher compiles its figures after contacting every known provider of abortions – clinics, hospitals and physicians’ offices – in the country. It uses questionnaires and health department data, and it provides estimates for abortion providers that don’t respond to its inquiries. (In 2020, the last year for which it has released data on the number of abortions in the U.S., it used estimates for 12% of abortions.) For most of the 2000s, Guttmacher has conducted these national surveys every three years, each time getting abortion data for the prior two years. For each interim year, Guttmacher has calculated estimates based on trends from its own figures and from other data.

The latest full summary of Guttmacher data came in the institute’s report titled “Abortion Incidence and Service Availability in the United States, 2020.” It includes figures for 2020 and 2019 and estimates for 2018. The report includes a methods section.

In addition, this post uses data from StatPearls, an online health care resource, on complications from abortion.

An exact answer is hard to come by. The CDC and the Guttmacher Institute have each tried to measure this for around half a century, but they use different methods and publish different figures.

The last year for which the CDC reported a yearly national total for abortions is 2021. It found there were 625,978 abortions in the District of Columbia and the 46 states with available data that year, up from 597,355 in those states and D.C. in 2020. The corresponding figure for 2019 was 607,720.

The last year for which Guttmacher reported a yearly national total was 2020. It said there were 930,160 abortions that year in all 50 states and the District of Columbia, compared with 916,460 in 2019.

• How the CDC gets its data: It compiles figures that are voluntarily reported by states’ central health agencies, including separate figures for New York City and the District of Columbia. Its latest totals do not include figures from California, Maryland, New Hampshire or New Jersey, which did not report data to the CDC. ( Read the methodology from the latest CDC report .)
• How Guttmacher gets its data: It compiles its figures after contacting every known abortion provider – clinics, hospitals and physicians’ offices – in the country. It uses questionnaires and health department data, then provides estimates for abortion providers that don’t respond. Guttmacher’s figures are higher than the CDC’s in part because they include data (and in some instances, estimates) from all 50 states. ( Read the institute’s latest full report and methodology .)

While the Guttmacher Institute supports abortion rights, its empirical data on abortions in the U.S. has been widely cited by  groups  and  publications  across the political spectrum, including by a  number of those  that  disagree with its positions .

These estimates from Guttmacher and the CDC are results of multiyear efforts to collect data on abortion across the U.S. Last year, Guttmacher also began publishing less precise estimates every few months , based on a much smaller sample of providers.

The figures reported by these organizations include only legal induced abortions conducted by clinics, hospitals or physicians’ offices, or those that make use of abortion pills dispensed from certified facilities such as clinics or physicians’ offices. They do not account for the use of abortion pills that were obtained  outside of clinical settings .

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The annual number of U.S. abortions rose for years after Roe v. Wade legalized the procedure in 1973, reaching its highest levels around the late 1980s and early 1990s, according to both the CDC and Guttmacher. Since then, abortions have generally decreased at what a CDC analysis called  “a slow yet steady pace.”

Guttmacher says the number of abortions occurring in the U.S. in 2020 was 40% lower than it was in 1991. According to the CDC, the number was 36% lower in 2021 than in 1991, looking just at the District of Columbia and the 46 states that reported both of those years.

(The corresponding line graph shows the long-term trend in the number of legal abortions reported by both organizations. To allow for consistent comparisons over time, the CDC figures in the chart have been adjusted to ensure that the same states are counted from one year to the next. Using that approach, the CDC figure for 2021 is 622,108 legal abortions.)

There have been occasional breaks in this long-term pattern of decline – during the middle of the first decade of the 2000s, and then again in the late 2010s. The CDC reported modest 1% and 2% increases in abortions in 2018 and 2019, and then, after a 2% decrease in 2020, a 5% increase in 2021. Guttmacher reported an 8% increase over the three-year period from 2017 to 2020.

As noted above, these figures do not include abortions that use pills obtained outside of clinical settings.

Guttmacher says that in 2020 there were 14.4 abortions in the U.S. per 1,000 women ages 15 to 44. Its data shows that the rate of abortions among women has generally been declining in the U.S. since 1981, when it reported there were 29.3 abortions per 1,000 women in that age range.

The CDC says that in 2021, there were 11.6 abortions in the U.S. per 1,000 women ages 15 to 44. (That figure excludes data from California, the District of Columbia, Maryland, New Hampshire and New Jersey.) Like Guttmacher’s data, the CDC’s figures also suggest a general decline in the abortion rate over time. In 1980, when the CDC reported on all 50 states and D.C., it said there were 25 abortions per 1,000 women ages 15 to 44.

That said, both Guttmacher and the CDC say there were slight increases in the rate of abortions during the late 2010s and early 2020s. Guttmacher says the abortion rate per 1,000 women ages 15 to 44 rose from 13.5 in 2017 to 14.4 in 2020. The CDC says it rose from 11.2 per 1,000 in 2017 to 11.4 in 2019, before falling back to 11.1 in 2020 and then rising again to 11.6 in 2021. (The CDC’s figures for those years exclude data from California, D.C., Maryland, New Hampshire and New Jersey.)

The CDC broadly divides abortions into two categories: surgical abortions and medication abortions, which involve pills. Since the Food and Drug Administration first approved abortion pills in 2000, their use has increased over time as a share of abortions nationally, according to both the CDC and Guttmacher.

The majority of abortions in the U.S. now involve pills, according to both the CDC and Guttmacher. The CDC says 56% of U.S. abortions in 2021 involved pills, up from 53% in 2020 and 44% in 2019. Its figures for 2021 include the District of Columbia and 44 states that provided this data; its figures for 2020 include D.C. and 44 states (though not all of the same states as in 2021), and its figures for 2019 include D.C. and 45 states.

Guttmacher, which measures this every three years, says 53% of U.S. abortions involved pills in 2020, up from 39% in 2017.

Two pills commonly used together for medication abortions are mifepristone, which, taken first, blocks hormones that support a pregnancy, and misoprostol, which then causes the uterus to empty. According to the FDA, medication abortions are safe  until 10 weeks into pregnancy.

Surgical abortions conducted  during the first trimester  of pregnancy typically use a suction process, while the relatively few surgical abortions that occur  during the second trimester  of a pregnancy typically use a process called dilation and evacuation, according to the UCLA School of Medicine.

In 2020, there were 1,603 facilities in the U.S. that provided abortions,  according to Guttmacher . This included 807 clinics, 530 hospitals and 266 physicians’ offices.

While clinics make up half of the facilities that provide abortions, they are the sites where the vast majority (96%) of abortions are administered, either through procedures or the distribution of pills, according to Guttmacher’s 2020 data. (This includes 54% of abortions that are administered at specialized abortion clinics and 43% at nonspecialized clinics.) Hospitals made up 33% of the facilities that provided abortions in 2020 but accounted for only 3% of abortions that year, while just 1% of abortions were conducted by physicians’ offices.

Looking just at clinics – that is, the total number of specialized abortion clinics and nonspecialized clinics in the U.S. – Guttmacher found the total virtually unchanged between 2017 (808 clinics) and 2020 (807 clinics). However, there were regional differences. In the Midwest, the number of clinics that provide abortions increased by 11% during those years, and in the West by 6%. The number of clinics  decreased  during those years by 9% in the Northeast and 3% in the South.

The total number of abortion providers has declined dramatically since the 1980s. In 1982, according to Guttmacher, there were 2,908 facilities providing abortions in the U.S., including 789 clinics, 1,405 hospitals and 714 physicians’ offices.

The CDC does not track the number of abortion providers.

In the District of Columbia and the 46 states that provided abortion and residency information to the CDC in 2021, 10.9% of all abortions were performed on women known to live outside the state where the abortion occurred – slightly higher than the percentage in 2020 (9.7%). That year, D.C. and 46 states (though not the same ones as in 2021) reported abortion and residency data. (The total number of abortions used in these calculations included figures for women with both known and unknown residential status.)

The share of reported abortions performed on women outside their state of residence was much higher before the 1973 Roe decision that stopped states from banning abortion. In 1972, 41% of all abortions in D.C. and the 20 states that provided this information to the CDC that year were performed on women outside their state of residence. In 1973, the corresponding figure was 21% in the District of Columbia and the 41 states that provided this information, and in 1974 it was 11% in D.C. and the 43 states that provided data.

In the District of Columbia and the 46 states that reported age data to  the CDC in 2021, the majority of women who had abortions (57%) were in their 20s, while about three-in-ten (31%) were in their 30s. Teens ages 13 to 19 accounted for 8% of those who had abortions, while women ages 40 to 44 accounted for about 4%.

The vast majority of women who had abortions in 2021 were unmarried (87%), while married women accounted for 13%, according to  the CDC , which had data on this from 37 states.

In the District of Columbia, New York City (but not the rest of New York) and the 31 states that reported racial and ethnic data on abortion to  the CDC , 42% of all women who had abortions in 2021 were non-Hispanic Black, while 30% were non-Hispanic White, 22% were Hispanic and 6% were of other races.

Looking at abortion rates among those ages 15 to 44, there were 28.6 abortions per 1,000 non-Hispanic Black women in 2021; 12.3 abortions per 1,000 Hispanic women; 6.4 abortions per 1,000 non-Hispanic White women; and 9.2 abortions per 1,000 women of other races, the  CDC reported  from those same 31 states, D.C. and New York City.

For 57% of U.S. women who had induced abortions in 2021, it was the first time they had ever had one,  according to the CDC.  For nearly a quarter (24%), it was their second abortion. For 11% of women who had an abortion that year, it was their third, and for 8% it was their fourth or more. These CDC figures include data from 41 states and New York City, but not the rest of New York.

Nearly four-in-ten women who had abortions in 2021 (39%) had no previous live births at the time they had an abortion,  according to the CDC . Almost a quarter (24%) of women who had abortions in 2021 had one previous live birth, 20% had two previous live births, 10% had three, and 7% had four or more previous live births. These CDC figures include data from 41 states and New York City, but not the rest of New York.

The vast majority of abortions occur during the first trimester of a pregnancy. In 2021, 93% of abortions occurred during the first trimester – that is, at or before 13 weeks of gestation,  according to the CDC . An additional 6% occurred between 14 and 20 weeks of pregnancy, and about 1% were performed at 21 weeks or more of gestation. These CDC figures include data from 40 states and New York City, but not the rest of New York.

About 2% of all abortions in the U.S. involve some type of complication for the woman , according to an article in StatPearls, an online health care resource. “Most complications are considered minor such as pain, bleeding, infection and post-anesthesia complications,” according to the article.

The CDC calculates  case-fatality rates for women from induced abortions – that is, how many women die from abortion-related complications, for every 100,000 legal abortions that occur in the U.S .  The rate was lowest during the most recent period examined by the agency (2013 to 2020), when there were 0.45 deaths to women per 100,000 legal induced abortions. The case-fatality rate reported by the CDC was highest during the first period examined by the agency (1973 to 1977), when it was 2.09 deaths to women per 100,000 legal induced abortions. During the five-year periods in between, the figure ranged from 0.52 (from 1993 to 1997) to 0.78 (from 1978 to 1982).

The CDC calculates death rates by five-year and seven-year periods because of year-to-year fluctuation in the numbers and due to the relatively low number of women who die from legal induced abortions.

In 2020, the last year for which the CDC has information , six women in the U.S. died due to complications from induced abortions. Four women died in this way in 2019, two in 2018, and three in 2017. (These deaths all followed legal abortions.) Since 1990, the annual number of deaths among women due to legal induced abortion has ranged from two to 12.

The annual number of reported deaths from induced abortions (legal and illegal) tended to be higher in the 1980s, when it ranged from nine to 16, and from 1972 to 1979, when it ranged from 13 to 63. One driver of the decline was the drop in deaths from illegal abortions. There were 39 deaths from illegal abortions in 1972, the last full year before Roe v. Wade. The total fell to 19 in 1973 and to single digits or zero every year after that. (The number of deaths from legal abortions has also declined since then, though with some slight variation over time.)

The number of deaths from induced abortions was considerably higher in the 1960s than afterward. For instance, there were 119 deaths from induced abortions in  1963  and 99 in  1965 , according to reports by the then-U.S. Department of Health, Education and Welfare, a precursor to the Department of Health and Human Services. The CDC is a division of Health and Human Services.

Note: This is an update of a post originally published May 27, 2022, and first updated June 24, 2022.

Support for legal abortion is widespread in many countries, especially in Europe

Nearly a year after roe’s demise, americans’ views of abortion access increasingly vary by where they live, by more than two-to-one, americans say medication abortion should be legal in their state, most latinos say democrats care about them and work hard for their vote, far fewer say so of gop, positive views of supreme court decline sharply following abortion ruling, most popular.

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