An Overview of Scientific Literature on Parental Involvement and Minors’ Access to Reproductive Healthcare Services

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An Overview of Scientific Literature on Minors' Access to Reproductive Healthcare Services
September 2006
The American Medical Association, the Society for Adolescent Medicine, the American Public Health Association, the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics have all reached a consensus that minors should not be compelled or required to involve their parents in their decisions to obtain abortions, although they should be encouraged to discuss their pregnancies with their parents and other responsible adults. These conclusions result from objective analyses of data that indicate that legislation mandating parental involvement does not achieve the intended benefit of promoting family communication but does increase the risk of harm to the adolescent by delaying access to appropriate medical care.
Parental Involvement In the majority of circumstances, one or both parents of young women are aware of their daughters' pregnancy decisions. • A survey of 1,519 unmarried pregnant minors in states where parental involvement is not mandatory, found that 61% of parents are aware of their daughters' intentions to have abortions. Parents of younger minors were even more likely to have knowledge of their daughters' abortions (90% of those 14 years old or younger, 74% of those 15 years old). Forty-five percent of all minors voluntarily involved either one or both parents in their decision. Among minors whose parents were unaware of the pregnancy, 52% involved another adult and 22% a professional.1 A study of inner-city, black, pregnant teenagers found that 91% consulted a parent or "parent surrogate" about pregnancy decisions. The term "parent surrogate" refers to a close adult who is fulfilling a parental role. This person was often a grandmother, aunt or other relative who had "raised them" or with whom they lived, even if that adult was not the legal guardian.2
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Mandatory Parental Involvement Currently, 34 states require some parental involvement in a minor's decision to have an abortion. Proponents and opponents of this legislation disagree on the possible impact that these laws have on abortion and birth rates. Because of the difficulties that this type of research presents, there have been only a handful of empirical studies completed that examine the effects of parental involvement laws on the birthrate, in-state abortion rate, odds of interstate travel and odds of late term abortion for minors. The studies that do exist are fairly dated, further exemplifying the need for more research.3 • A 1986 study examined rates of interstate travel by minors confronted with a Massachusetts parental involvement mandate. The law stipulated that an unmarried woman under the age of 18 must obtain the consent of both parents before having an abortion. Researchers concluded that although half as many minors obtained abortions in the state during the 20 months after the law went into effect as had done so previously, more than 1,800 minors traveled to surrounding states for abortions. The authors assert that these numbers account for the reduction in in-state abortions.4 A 1995 study evaluated the impact of requirements for parental consent on minors' abortions in Mississippi. At the time, the Mississippi law required an un-emancipated minor seeking an abortion to first obtain the written consent of both parents. Unlike many other states that have parental involvement laws, it was easier to conduct a research study in Mississippi because the neighboring states collect information on most Mississippi women who travel there for abortion services. Data from this research concluded that in a comparison of Mississippi residents who had abortions during the five months before and the six months after the law went into effect, the ratio of minors to adults who sought abortions in the state declined by 13%, a decrease offset by a 32% increase in the ratio of minors to adults who obtained abortions out of state. There was also a 28% drop in the ratio of minors to adults from other states who had abortions in Mississippi. Finally, the parental consent requirement increased by 19% the ratio of minors to adults who obtained their procedure after 12 weeks of gestation.5 A 1997 study examined the effects of parental involvement laws on minors' abortion in Minnesota, Missouri and Indiana. Findings from the study indicated that in each state, the abortion rate for minors fell when parental involvement laws took effect. There was no evidence that the laws increased the birthrates for minors. Although data were incomplete, the laws appeared to increase the odds of a minor traveling out of state for an abortion. Additionally, the authors assert: "If one judges from the available data, minors who traveled out of state may have accounted for the entire observed decline in the in-state abortion rate, at least in Missouri." Finally, the study found that the parental notification laws
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appeared to delay minors' abortions past the eight week but probably not into the second trimester.6 Apart from whether mandatory consent laws affect birth and abortion rates, it is essential to consider the potential damaging effects these laws may have on an adolescent's health. According to the American Medical Association, the most damaging aspect of mandatory parental involvement laws is the fact that they can delay an adolescent's timely access to necessary care. (See delays caused by judicial bypass.) Additionally, many young women have very valid reasons for choosing not to involve their parents, including incest or abuse. According to the American Academy of Pediatrics, adolescents who are strongly opposed to informing parents tend to predict their family reactions accurately. Forcing a young woman to disclose her pregnancy to her parents can elicit severe parental anger that may result in the rejection of the young woman, a coerced pregnancy outcome and possibly violence. One-third of minors who do not inform parents fear physical violence between themselves and their parents (in many cases because it had already occurred), or they were afraid of being forced to leave home.7,8
Judicial Bypass The U.S. Supreme Court held that a state may require an unmarried minor who seeks an abortion to notify or obtain consent of her parents, provided that if she does not wish to do so, she must be able to obtain permission from a judge. The judge's authorization is to be based on a determination either that the minor is mature enough to make her own decision or that it is in the minor's best interest to have the abortion without informing her parents. • In a 1983 study examining the judicial bypass process in Massachusetts, Minnesota, and Rhode Island, interviews were conducted with nearly two dozen judges, public defenders, private attorneys, guardians, abortion providers and counselors. Findings indicated that more than 3,000 minors had pursued the judicial bypass option in Massachusetts between 1981, when the law was first enforced, and 1983. However, the judicial process itself posed risks of medical and psychological harm by delaying access to the abortion procedure and forcing women to endure a burdensome and humiliating ordeal. Despite requirements in these laws that the abortion petitions be handled expeditiously, a two-to-four day wait for a hearing was routine. In Massachusetts, the delay had sometimes been as long as seven days.9,10 A multi-state 1991 study found that court proceedings in Massachusetts delayed the termination of pregnancy by as much as six weeks and that average delay in Minnesota was one to three weeks.11 In the 1997 study previously referenced, the researcher's review of Minnesota, Missouri and Indiana asserted that the proportion of petitions
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granted varied by state. Minnesota judges tended to grant nearly all petitions, whereas judges in Missouri and Indiana created a stricter climate. The process also produces emotional stress and can be detrimental to the adolescent's psychological state.12
Not only does the judicial bypass option not fulfill its intended protective effect, it is, in and of itself, harmful to young women. As argued by the American Academy of Pediatrics, the "pregnant adolescent is required to divulge intimate details of her private life to dozens of strangers (clerks, bailiffs, court reporters, witnesses and others) to obtain a brief (ten-minute) hearing before a judge who has no firsthand knowledge of her case and typically no training in counseling adolescents or developmental issues." At the same time that judicial bypass laws make access to abortion more difficult, they do not appear to encourage more women to confer with their parents about their pregnancies. Abortion clinics and referral services in Massachusetts, Minnesota and Rhode Island reported that some 20-55% of their minor patients seek court permission rather than confide in their parents. Additionally, research indicates that the percentages of minors who inform parents about their intent to have an abortion are essentially the same in states with and without notification laws.13,14,15
1 Henshaw SK, Kost K. Parental involvement in minors’ abortion decisions. Fam Plann Perspect. 1992;24:196207, 213. 2 Zabin LS, Hirsch MB, Emerson MR, Raymond E. To whom do inner-city minors talk about their pregnancies? Adolescents communication with parents and parent surrogates. Fam Plann Perspect. 1992;24:148-154, 173. 3 State Policies in Brief: Parental Involvement in Minors’ Abortions. The Alan Guttmacher Institute, New York, NY. Accessed on July 7, 2005 at: http://www.guttmacher.org/statecenter/spibs/spib_PIMA.pdf 4 Cartoof V, Klerman J. Parental consent or abortion: the impact of the Massachusetts law. Am J Public Health. 1986;76:397-400. 5 Henshaw S. The impact of requirements for parental consent on minors’ abortions in Mississippi. Fam Plann Perspect. 1997;27:120-122. 6 Ellertson C. Mandatory Parental Involvement in Minors’ Abortions: Effects of the Laws in Minnesota, Missouri, and Indiana. Am J Public Health. 1997;87:1367-1374. 7 American Academy of Pediatrics, Committee on Adolescence. The Adolescent’s Right to Confidential Care When Considering Abortion. Pediatrics;1996:746-751. 8 Henshaw SK, Kost K. Parental involvement in minors’ abortion decisions. Fam Plann Perspect. 1992;24:196207, 213. 9 Donovan P. Judging teenagers: how minors fare when they seek court-authorized abortions. Fam Plann Perspect. 1983;15:259-267. 10 Donovan P. Judging teenagers: how minors fare when they seek court-authorized abortions. Fam Plann Perspect. 1983;15:259-267. 11 Crosby MC, English A. Mandatory parental involvement/judicial bypass laws: do they promote adolescents’ health? J Adolesc Health. 1991;2:143-147. 12 Ellertson C. Mandatory Parental Involvement in Minors’ Abortions: Effects of the Laws in Minnesota, Missouri, and Indiana. Am J Public Health. 1997;87:1367-1374. 13 American Academy of Pediatrics, Committee on Adolescence. The Adolescent’s Right to Confidential Care When Considering Abortion. Pediatrics;1996:746-751. 14 Donovan P. Judging teenagers: how minors fare when they seek court-authorized abortions. Fam Plann Perspect. 1983;15:259-267. 15 Blum RW, Resnick MD, Stark TA. The impact of parental notification law on adolescent abortion decision making. Am J Pub Health. 1987;77:619-620.
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