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Rogelio V. Solis, AP
In this April 15, 2013, photograph, a copy of the Jackson Women's Health Organization clinic's State Health Department issued license is displayed at the front desk next to the patient information forms in Mississippi's only abortion clinic, in Jackson, Mississippi. A federal judge on Monday temporarily blocked Mississippi from revoking the license of the state's only abortion clinic, saying the state cannot close the clinic while it still has a federal lawsuit pending to challenge the 2012 law. A trial date has not been set.

In Utah, more than a quarter of women who had abortions in 2013 were married. Nationwide, fewer than 15 percent were.

The difference is striking in a conservative state that is home to some of the nation's most restrictive abortion laws and has a population that values marriage and large families. It's a percentage that has remained high for more than two decades. Yet understanding what's behind the numbers and what it says about Utah is difficult to decipher.

In this Tuesday, Dec. 17, 2013, photo posters line a wall in an ultrasound exam room at a Planned Parenthood location in Boston. The Supreme Court of the United States will hear arguments in a constitutional challenge to the buffer zone Massachusetts has established around abortion clinics in the state. | Photo courtesy of AAPLOG

No research exists to explain why such a large share of women who choose abortion in Utah are married, but some experts speculate that the rate is the result of an ironic collision of pro-family factors, among them high birth and marriage rates and the nation's lowest age for a first marriage.

“We’re a marrying people,” said Pam Perlich, director of demographic research at the Kem C. Gardner Policy Institute at the University of Utah.

That said, she added, “That rate sounds way high. … It doesn't sound right."

But according to the Centers for Disease Control and Prevention, the numbers are sound, and not a statistical blip, but a pattern.

Utah led the nation in the percentage of women who had abortions who were married not only in 2013 (the last year for which federal statistics are available) but every year since 2004. Some years, the state exceeded the national average by 20 percentage points or more. Yet the number of abortions among married women in Utah is not as high as in other states.

In 2013, 746 married women had abortions in Utah, according to the CDC. In Kansas, another state with a population of about 3 million, 990 married women did, even though the 13.5 percent of Kansas women who had abortions who were married is close to the national average and much lower than Utah's.

In this Tuesday, Dec. 17, 2013, photo posters line a wall in an ultrasound exam room at a Planned Parenthood location in Boston. The Supreme Court of the United States will hear arguments in a constitutional challenge to the buffer zone Massachusetts has established around abortion clinics in the state. | Photo courtesy of AAPLOG

Utah's rate may well be the result of a high number of married women trying to conceive and encountering medical problems.

"All the abortions I perform are for maternal indications or fetal anomalies," said Dr. Cara C. Heuser, a Salt Lake City obstetrician who specializes in high-risk pregnancies.

But it's impossible to know for sure, since abortion providers vary in how they report the reasons their patients have abortions, and some believe that the reasons shouldn't be reported at all.

Abortion by the numbers

Not every state asks women who get abortions their marital status. In fact, not every state reports its abortions to the CDC, which releases its Abortion Surveillance report at the end of each year.

Forty-seven states and territories reported their abortions to the CDC in 2013, and of them 42, including Utah, gave the women's marital status.

Among women who had an abortion in Utah that year, 27.4 percent were married, more than 10 points higher than the national average of 14.8 percent. In 2011, when the national average was 14.5 percent, Utah's was even higher: 35.1 percent. And it topped 40 percent in 1993 and 1994.

Centers for Disease Control and Prevention, Abortion Surveillance 2013 | Aaron Thorup, Centers for Disease Control and Prevention, Abortion Surveillance 2013

In assessing the data, Eric J. Scheidler, executive director of the Pro-Life Action League, suggested that Utah's high rate of married women having abortions could be a result of fewer unmarried women having abortions than elsewhere in the country, which skews the overall numbers.

"This might be explained by the particular religious character of Utah," Scheidler said. "As the figures show, Utah women are far less likely to seek abortion. It also stands to reason that unmarried Utah women are less likely to be sexually active, and are therefore less likely to experience an unintended pregnancy."

Utah's overall abortion rate is 4.8 per 1,000 women; the only state lower is South Dakota at 4.7, according to the CDC.

"I would speculate that married Utah women are actually less likely to seek abortion than married woman nationally, but that unmarried Utah women are simultaneously less likely to have an unintended pregnancy and less likely to seek abortion when they do," Scheidler said. "But again, this is speculation."

Sixty-four percent of the population is "highly religious," making Utah the 11th most religious state, according to the Pew Research Center. The predominant faith in the state, The Church of Jesus Christ of Latter-day Saints, teaches that abortion for "personal or social convenience" is contrary to the will of God and members who "submit to, perform, encourage, pay for, or arrange for such abortions" may lose membership in the church.

Utah also has the nation's highest birth rate, the highest marriage rate and the earliest age at which women marry for the first time, all factors that may play a role in the number of married women who have abortions. The state's average age at first marriage is 24.3, compared to the national average of 27.8 years, making the pool of married women bigger when statistics are calculated.

And Utah couples' propensity for large families expands the window of years for child-bearing, making them more likely to experience a troubling prenatal screening that might lead to an abortion.

Photo courtesy of Planned Parenthood Association of UtahPhoto courtesy of Planned Parenthood Association of Utah

But Karrie Galloway, CEO and president of Planned Parenthood of Utah, said married women in Utah have abortions for the same reason that married women elsewhere have them: They believe it's the best decision for their personal circumstances, their family or their health.

“Our rate of abortion is lower than in many states, and I’ve always believed that people in Utah live their values, and I commend them for that," Galloway said.

“But the reality is, once women are pregnant, they look at the circumstances in their life and in their family’s life," Galloway said. "These are not careless decisions, they’re not capricious decisions, but it’s a decision a woman has the right to make.”

Dr. Christina Francis of Fort Wayne, Indiana, is chairwoman of the American Association of Pro-Life Obstetricians and Gynecologists.

She agrees that married women choose abortion for many of the same reasons that single women do, and she says a perceived lack of resources is a common one. One study has shown that nearly three-quarters of women who have abortions say they do so because they don't have enough money to raise the child, which is why some abortion opponents offer financial assistance to help convince women not to terminate their pregnancies.

Dr. Christina Francis, chair of the board of the American Association of Pro-Life Obstetricians & Gynecologists| Photo courtesy of AAPLOG

“They may also feel that they have as many children as they can handle, or maybe they feel like their family is complete,” Francis said, adding that she’s also encountered married women who wanted an abortion because the baby wasn’t the gender the parents wanted.

“That’s not common, but unfortunately, I’ve run across that before,” she said.

Francis said sophisticated prenatal testing may also contribute to the decision — as well as non-invasive prenatal screenings that aren't as reliable.

For example, maternal blood tests during pregnancy can indicate the odds of a child having Down syndrome, but the condition cannot be diagnosed without chorionic villus sampling and amniocentesis, an invasive procedure in which fluid is removed from the womb.

She recalled a former patient — a married woman with four children — who came to her practice after having had an abortion because of a blood test that suggested the child could have Down syndrome.

The National Down Syndrome Society has warned against such tests, which have been available since 2011, saying "there is concern that women are making life-changing decisions too early in a pregnancy based on these unregulated (blood) tests."

Of her patient, who regretted having had the abortion, Francis said, “Her story is probably not uncommon at all; I’m sure for a large portion of women, the reasons are very similar."

'A terrible event'

For Alyson Draper, the decision to terminate came much later in pregnancy and had nothing to do with the family's finances or a screening test.

Draper, of Midway, Utah, elected to end a much-wanted twin pregnancy at 22 weeks after her doctor determined that one of the babies had died, and the other was severely deformed.

A consultation room at the Trust Women South Wind Women's Center is pictured in Oklahoma City, Friday, Sept. 16, 2016. Trust Women opened its first clinic in Wichita, Kansas, in 2013 following the shooting death of abortion provider Dr. George Tiller. Despite facing some of the nation's strictest anti-abortion laws, Trust Women has opened a new facility in Oklahoma City, the first new abortion provider in the state in 40 years. (AP Photo/Sue Ogrocki)Sue Ogrocki, AP

Draper was married and had a blended family with six children, and she and her husband had spent nearly $50,000 on fertility treatments to achieve the pregnancy.

At the time Draper was active in her Mormon congregation (she has since left the faith), and she and her husband counseled with their church leaders, who supported their decision. But she still felt terribly guilty although her life would have been endangered by the dead fetus had she continued with the pregnancy, and that the other twin's brain had grown outside of his head and his spine was open to his waist because of severe spina bifida, a neural tube defect.

An attorney who has since remarried, Draper shared her experience on Facebook in a post that went viral during the 2016 presidential campaign after late-term abortion came up in a televised debate.

“I was very pro-life, and I still am. I’m not pro-abortion,” Draper said, although she has publicly decried efforts to end access to abortions after 20 weeks.

“My decision was the most terrible decision I’ve ever made — not terrible in the result, but the most horrible thing I ever dealt with. These babies were wanted, loved babies that were not going to live,” she said.

Reasons for abortion

While the rate of women having abortions who are married is high compared to other states, it’s low compared to the rest of the world. A study published last year in the medical journal The Lancet found that married women obtained 73 percent of abortions worldwide between 2010 and 2014.

Gilda Sedgh, the lead author and the principal research scientist at the Guttmacher Institute, told The New York Times that in many developing nations, contraception is discouraged and women are expected to bear children soon after marriage.

Abortion is declining both in the U.S. and in Utah, where the number of abortions dropped by 14 percent between 2011 and 2014. But among women who have abortions, the use of contraceptives is a “key predictor” of whether a woman will have an abortion, the Guttmacher Institute says.

Centers for Disease Control and Prevention, Abortion Surveillance 2013 | Aaron Thorup, Centers for Disease Control and Prevention, Abortion Surveillance 2013

In contrast to Draper's experience, most abortions involve unplanned pregnancies, which, according to Dr. Leah Torres, an ob-gyn and abortion provider in Salt Lake City, most often occur because contraception failed, not because couples were being irresponsible.

Intrauterine devices (IUDs), contraceptive implants and sterilization are more than 99 percent effective, Torres said, but "nothing is 100 percent guaranteed" even when used correctly. She said she has performed abortions on married women whose husbands had vasectomies.

“People come to me in this situation where they’re flabbergasted and say ‘I can’t believe I’m here,’ and I feel so horrible for them because obviously I can’t believe they’re here, either."

Guttmacher researchers say that few studies have addressed the reasons women have abortions, but in those that exist, women commonly say lack of a partner and unreadiness for parenthood are concerns that accompany those about money.

Such reasons would be considered "elective" in the questionnaire that abortion providers fill out in Utah, rather than "therapeutic," or for medical necessity — for example, a woman with kidney disease who could suffer renal failure if the pregnancy progresses. But "therapeutic" can also serve as a catch-all category that could include emotional distress.

"I'm not given an option of 'doesn't want to be pregnant.' If that box were there, I would check that box, and that box would be checked every time," Torres said.

Abortion providers can also choose "maternal life endangered," fetal malformation, rape, incest and "other" as the reason for an abortion. It's a reporting system that could be improved, said Heuser, the maternal/fetal medicine specialist in Salt Lake City.

"The data collection tools that we have for this kind of thing are imperfect, so the same thing may get categorized differently depending on who fills out the form," she said.

In 2013, 2,831 abortions in Utah were marked as therapeutic, 14 elective, 27 fetal malformation and 8 maternal life endangered.

Because Utah has the nation's highest birth rate, Utah mothers have a higher chance than women in other states to conceive a child with birth defects, according to the Utah Department of Health. The risk of fetal anomalies goes up as a woman ages, so the propensity for large families among Mormon families can contribute to that reason for abortion, too.

In this April 15, 2013, photograph, a copy of the Jackson Women's Health Organization clinic's State Health Department issued license is displayed at the front desk next to the patient information forms in Mississippi's only abortion clinic, in Jackson, Mississippi. | Sue Ogrocki, AP

“There may be some women who are going through marital difficulties, and maybe their marriage is on the rocks. And there are a few women who’ve had extramarital affairs, and that’s why they were seeking an abortion,” said Francis, of the American Association of Pro-Life Obstetricians & Gynecologists.

But Torres says there's essentially one reason behind every abortion, and it shouldn't require further explanation: "I'm pregnant, and I don't want to be."

A range of solutions

For parents-to-be confronting the likelihood of a severely deformed or sick child, Francis says perinatal hospice may be an alternative to abortion. The practice supports women who choose to continue their pregnancies after their fetuses are diagnosed with a life-threatening or life-shortening condition.

Communities should also offer a strong network of support for struggling families, encompassing everything from supplies (such as cribs, clothes, diapers, breastfeeding supplies and formula) to child care and parent mentoring, she said.

Scheidler, with the Pro-Life Action League, said the incidence of abortion among married women might decline if the law required that fathers know that the mother is seeking an abortion. Since the Supreme Court has ruled that fathers don't have to give consent, some abortions take place — among both married and unmarried women — when the father doesn't even know about the pregnancy.

It's a volatile issue. "However, with the composition of the Supreme Court likely to change in the coming years, it might be possible to reintroduce measures requiring a father be informed about abortion," Scheidler said.

For couples whose faith groups allow birth control (the Roman Catholic Church doesn't), diligent use of contraceptives works most of the time to prevent pregnancy. Natural family planning, also known as fertility awareness, helps more than 75 percent of couples avoid pregnancy if they use the method correctly, according to the U.S. Office of Population Affairs.

And Galloway points out that social policies that make people more financially secure, such as affordable health care and insurance, also make them less likely to choose abortion.

Couples, she said, “are much more eager to plan and expand their families in times when they feel economically confident.”