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Ensuring Minors’ Access to Confidential Abortion Services

Policy Date: 11/1/2011
Policy Number: 20115

The American Public Health Association (APHA) has a strong history of supporting reproductive and sexual health policies that clearly recognize the public health impact of unintended and unwanted pregnancy (Policy Statements 8901, 200314, and 6803). APHA policies have also been at the forefront of recognizing the complex issues that affect adolescents in accessing accurate and appropriate reproductive health services and information (Policy Statements 9003, 9001, 200610, 200027, 8224).

PROBLEM STATEMENT
Each year, 2% of women aged 15 to 44 terminate a pregnancy,[1] and the 2008 abortion rate was 19.6 per 1000 women in this age group.[2] Teenagers comprise 18% of US women obtaining abortions, and those younger than 17 years[3] account for just over 6% of all abortions.[4]

Thirty-six states have implemented laws requiring minors to involve their parents in their decision to have an abortion, of which 20 states require parental consent, 12 states require parental notification, and 4 states require both.[5] (For the purpose of this document and in most states, minors are defined as individuals aged 17 or younger who are not legally emancipated from their parents. Exceptions to this definition may vary across states—for example, a female younger than age 17 who has a child may no longer be classified as a minor). Only 16 of the 36 states with mandatory parental involvement provide exceptions for “cases of abuse, assault, incest or neglect,”[5] and sexually abused minors have shown an elevated likelihood of pregnancy compared with their peers who were not abused.[6] Parental involvement laws apply only to minors wishing to terminate a pregnancy, not to minors who opt to carry a pregnancy to term.[7]

Parental involvement laws do not promote family communication as intended, and can elevate pregnant minors’ risks by delaying access to care.[8,9] For example, parental involvement laws have been associated with some 17-year-olds’ delay in obtaining abortions until they reach age 18, sometimes pushing the procedure into the second or third term,[10,11] with higher risks and higher costs.[11] Additionally, these laws may displace abortions to other states,[12–15] delay abortions,[14] or discourage adolescents from seeking professional reproductive health care or advice.[16,17]

Other negative consequences of parental involvement laws can include the following: parentally coerced termination of pregnancy, physical violence between the parents or against the pregnant minor, the pregnant minor being forced to leave the home, damage to the parents’ health,[18] the pregnant minor being delayed in informing her parents, negative experiences when informing parents, the potential to aggravate family conflicts,[19] and pregnant minors from dysfunctional and nonsupportive families carrying unwanted pregnancies to term without receiving adequate prenatal care.[15]


All states have judicial bypass laws that, in theory, allow a minor to confidentially receive abortion care if a judge determines that the abortion is in her best interest or that she is mature enough to make her own decision. Judicial bypass laws presented a compromise by the US Supreme Court when it upheld parental involvement laws on the grounds that adolescent women would still have an option for confidential access to abortion.[20] However, in practice, the judicial bypass option is not accessible to many people who would seek it because of lack of awareness and information on the part of adolescents and courts, distance and lack of resources to travel, and courts’ inability or unwillingness to hear a bypass petition; it also results in unnecessary negative emotional consequences for adolescent women.[21]

Many minors voluntarily involve their parents in the decision of whether to have an abortion, especially younger minors.[8,16,22–25]
Furthermore, there is an absence of sound, consistently replicable research indicating that either parental notification or parental consent laws actually affect adolescents’ abortion rates[12] or decrease the pregnancy rate.[7,10–13,26,27]
Parental involvement laws have not successfully promoted family consultation and have instead encouraged pregnant minors to seek judicial bypass.[28]
As a result, the American Medical Association, the Society for Adolescent Medicine, APHA, the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and other health professional organizations stand in agreement against mandatory parental involvement in abortion decision making,[9,29–32] and most of these organizations suggest that pregnant minors should be encouraged but not legally required to involve parents in abortion decisionmaking.[9,29,32]


Therefore, APHA—
1. Urges groups working with pregnant minors to encourage voluntary involvement of one or both parents or a mature adult in abortion decision making, and to advocate that minors’ access to abortion services not be made conditional on parental involvement.
2. Urges that advocacy and policy groups educate providers and the public on minors’ right to confidential reproductive and sexual health services. Specific actions may include national, state, and local media campaigns targeting minors as well as places and individuals that provide adolescent health care and health information (including, but not limited to, clinics, school health systems, pediatricians, health educators, grassroots organizations, school counselors, etc.).
3. Urges that federal, state, and local policymakers and courts introduce or uphold measures that ensure minors’ right to privacy in accessing abortion counseling and services.
4. Urges that federal, state, and local policymakers and courts cease to mandate parental involvement in minors’ abortion decision making.

References
1. Jones RK, Kooistra K. Abortion incidence and access to services in the United States, 2008. Perspect Sex Reprod Health. 2011;43(1):41–50.
2. In Brief: Fact Sheet: Facts on Induces Abortion in the United States. New York, NY: Guttmacher Institute; January 2011.
3. Jones RK, Finer LB, Singh S. Characteristics of US Abortion Patients. New York, NY: Guttmacher Institute; 2010.
4. Wind R. Abortion rate increasing among poor women, even as it decreases among most other groups. New York, NY: Guttmacher Institute; May 23, 2011.
5. State Policies in Brief: Parental Involvement in Minors’ Abortions. New York, NY: Guttmacher Institute; May 1, 2011.
6. Saewyc EM, Magee LL, Pettingell SE. Teenage pregnancy and associated risk behaviors among sexually abused adolescents. Perspect Sex Reprod Health. 2004;36(3):98–105.
7. Zabin LS, Clark SD, Jr. Institutional factors affecting teenagers’ choice and reasons for delay in attending a family planning clinic. Fam Plann Perspect. 1983;15(1):25–29.
8. Davis AR, Beasley AD. Abortion in adolescents: epidemiology, confidentiality, and methods. Curr Opin Obstet Gynecol. 2009;21(5):390–395.
9. The adolescent’s right to confidential care when considering abortion. American Academy of Pediatrics. Committee on Adolescence. Pediatrics. May 1996;97(5):746–751.
10. Joyce T, Kaestner R, Colman S. Changes in abortions and births and the Texas parental notification law. N Engl J Med. 2006;354(10):1031–1038.
11. Colman S, Joyce T. Minors’ behavioral responses to parental involvement laws: delaying abortion until age 18. Perspect Sex Reprod Health. 2009;41(2):119–126.
12. Cartoof VG, Klerman LV. Parental consent for abortion: impact of the Massachusetts law. Am J Public Health. 1986;76(4):397–400.
13. Dennis A, Henshaw SK, Joyce TJ, Finer LB, Blanchard K. The Impact of Laws Requiring Parental Involvement for Abortion: A Literature Review. New York, NY: Guttmacher Institute; March 2009.
14. Ellertson C. Mandatory parental involvement in minors’ abortions: effects of the laws in Minnesota, Missouri, and Indiana. Am J Public Health. 1997;87(8):1367–1374.
15. Johannsen L. Adolescent abortion and mandated parental involvement. Pediatr Nurs. 1995;21(1):82–84.
16. Torres A, Forrest JD, Eisman S. Telling parents: clinic policies and adolescents’ use of family planning and abortion services. Fam Plann Perspect. 1980;12(6):284–292.
17. Reddy DM, Fleming R, Swain C. Effect of mandatory parental notification on adolescent girls’ use of sexual health care services. JAMA. 2002;288(6):710–714.
18. Henshaw SK, Kost K. Parental involvement in minors’ abortion decisions. Fam Plann Perspect. 1992;24(5):196–207, 213.
19. Griffin-Carlson MS, Schwanenflugel PJ. Adolescent abortion and parental notification: evidence for the importance of family functioning on the perceived quality of parental involvement in US families. J Child Psychol Psychiatry. 1998;39(4):543–553.
20. Bellotti v Baird, 443 US 622 (1979).
21. Bypassing Justice: Pregnant Minors and Parental-Involvement Laws. Washington, DC: National Partnership for Women & Families; 2010.
22. Rosen RH. Adolescent pregnancy decision-making: are parents important? Adolescence. 1980;15(57):43–54.
23. Finer LB, Frohwirth LF, Dauphinee LA, Singh S, Moore AM. Timing of steps and reasons for delays in obtaining abortions in the United States. Contraception. 2006;74(4):334–344.
24. Blum RW, Resnick MD, Stark TA. The impact of a parental notification law on adolescent abortion decision-making. Am J Public Health. 1987;77(5):619–620.
25. Webster RD, Neustadt AN, Whitaker AK, Gilliam ML. Parental involvement laws and parent-daughter communication: policy without proof. Contraception. 2010;82:310–313.
26. Colman S, Joyce T, Kaestner R. Misclassification bias and the estimated effect of parental involvement laws on adolescents’ reproductive outcomes. Am J Public Health. 2008;98(10):1881–1885.
27. Santee B. Article on parental notification law draws criticism. Definitions and comparisons flawed [author reply in Am J Public Health. 1992;82(5):759–760]. Am J Public Health. 1992;82(5):757–758.
28. Crosby MC, English A. Mandatory parental involvement/judicial bypass laws: do they promote adolescents’ health? J Adolesc Health. 1991;12(2):143–147.
29. ACOG Statement of Policy: Confidentiality in Adolescent Health Care. Washington, DC: American College of Obstetricians and Gynecologists (ACOG); 1988.
30. American Medical Association National Coalition for Adolescent Health. Policy Compendium on Confidential Health Services for Adolescents. Gans J, ed. Chicago, IL: American Medical Association; 1993.
31. American Public Health Association. Resolution 9001: adolescent access to comprehensive, confidential reproductive health care. American Journal of Public Health. 1991;81:241.
32. Mandatory parental consent to abortion. Council on Ethical and Judicial Affairs, American Medical Association. JAMA. 1993;269(1):82–86.