Elevating the Needs of Minor Adolescents in a Landscape of Reduced Abortion Access in the United States

Abstract

Abortion is a safe and essential component of comprehensive sexual and reproductive health (SRH) care. Following the United States Supreme Court ruling in June 2022 that struck down Roe v. Wade, the movement to restrict abortion access in many states will severely limit reproductive freedom for pregnancy-capable people [[1]Dobbs v. Jackson Women's health organization, 597. Supreme Court of the United States, 2022Google Scholar]. Individuals and communities, particularly those marginalized because of race/ethnicity, gender identity, income inequality, immigration status, and/or age, face barriers to reproductive health equity, and these policy changes exacerbate an already unjust reproductive health care landscape [[2]Bryson A.E. Hassan A. Goldberg J. et al.Call to action: Healthcare Providers must Speak up for adolescent abortion access.J Adolesc Health. 2022; 70: 189-191Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar]. This article highlights abortion access barriers specific to minor adolescents (those aged <18 years) and proposes strategic responses adolescent healthcare communities can enact. The Society for Adolescent Health and Medicine and six other organizations stated opposition to restrictions on the reproductive rights and care of adolescents and young adults, including access to abortion [[3]SAHM NewsStatement on Dobbs v. Jackson. Society for Adolescent Health and Medicine.https://www.adolescenthealth.org/SAHM-News/Consensus-Statement_DobbsDate: 2022Date accessed: August 29, 2022Google Scholar,[4]SAHM NewsSAHM/NASPAG Statement on leaked draft SCOTUS opinion regarding Mississippi v. Jackson Women’s Health. Society for Adolescent Health and Medicine.https://www.adolescenthealth.org/SAHM-News/SAHM-NASPAG-Statement-on-leaked-draft-SCOTUS-o-(2).aspxDate: 2022Date accessed: August 29, 2022Google Scholar]. These statements recognize abortion as a basic human right and fundamental to adolescent SRH. They call to normalize abortion as an essential component of comprehensive SRH care, educate policymakers on adolescent developmental capacity to make safe and informed reproductive health decisions, and advocate for improved access to adolescent contraception, sexual health education, and structural initiatives to promote opportunity and health equity among marginalized adolescents. Those who provide health care for minor adolescents must understand the great impact restricted abortion access will have on minors and provide strategic responses. Although pregnancy and birth rates declined over the past 30 years, adolescents aged ≤19 years (the standard age range reported by the US Centers for Disease Control and Prevention) account for approximately 9% of individuals who obtain abortions. Although these numbers represent a minority of those seeking abortions, this translates into at least 50,000 adolescents aged ≤19 years needing abortion services annually, with some estimates being nearly double that [[5]Kortsmit K. Mandel M.G. Reeves J.A. et al.Abortion Surveillance - United States, 2019.MMWR Surveill Summ. 2021; 70: 1-29Crossref PubMed Google Scholar,[6]Jerman J. Jones R.K. Onda T. Characteristics of U.S. Abortion Patients in 2014 and changes since 2008, New York: Guttmacher Institute.https://www.guttmacher.org/report/characteristics-us-abortion-patients-2014Date: 2016Date accessed: August 29, 2022Google Scholar]. Adolescents have the highest abortion ratio of any age group (851 per 1,000 live births for those aged < 15 years and 332 per 1,000 live births for 15- to 19-year-olds compared with 260 per 1,000 live births for 20- to 24-year-olds). When adolescents do not have access to comprehensive reproductive care, unmet needs lead to negative health and social consequences that may persist across the life course. Minor adolescents face significant barriers to abortion care due to travel challenges, financial constraints, limited access to medication abortion, and parental notification and consent requirements limiting confidentiality [[2]Bryson A.E. Hassan A. Goldberg J. et al.Call to action: Healthcare Providers must Speak up for adolescent abortion access.J Adolesc Health. 2022; 70: 189-191Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar]. Although most adolescents have developmental capacity to make independent health care decisions [[7]Baltag V. Takeuchi Y. Guthold R. Ambresin A.E. Assessing and supporting adolescents' capacity for autonomous decision-making in health-care Settings: New Guidance from the World health organization.J Adolesc Health. 2022; 71: 10-13Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar], they may have less experience navigating reproductive health care decisions than older individuals, potentially needing tailored education and resources when seeking abortion. Without federal protections to abortion, state-specific restrictions will necessitate people in need of abortion to either travel to other states, self-manage in their own states, and face potential legal risks for doing so, or remain pregnant. Minors may face practical and legal barriers to travel for abortion access while maintaining confidentiality. Supportive adults who accompany minors across state lines may be unsure of their legal risk, which could further isolate minor adolescents from their support networks. This is particularly problematic, as adolescents are more likely to have later gestation abortions, and restrictions will cause further delays [[8]Upadhyay U.D. Weitz T.A. Jones R.K. et al.Denial of abortion because of provider gestational age limits in the United States.Am J Public Health. 2014; 104: 1687-1694Crossref PubMed Scopus (112) Google Scholar]. Although abortion is safer than childbirth, later gestation abortions entail more medical risks and are more difficult to obtain because of higher expenses and fewer experienced clinicians. Adolescents face greater costs of care [[9]Ely G.E. Hales T.W. Jackson D.L. et al.Access to choice: Examining differences between adolescent and adult abortion fund service recipients.Health Soc Care Community. 2018; 26: 695-704Crossref Scopus (6) Google Scholar,[10]Leyser-Whalen O. Torres L. Gonzales B. Revealing Economic and Racial Injustices: Demographics of abortion fund Callers on the U.S.-Mexico Border.Womens Reprod Health (Phila). 2021; 8: 188-202Crossref PubMed Scopus (0) Google Scholar], particularly if they lack confidential insurance coverage. Requirements for diagnostic tests such as ultrasound, abortion procedures, medications, missed school or employment, and other costs may be prohibitive. Many abortion telemedicine programs are restricted to those aged ≥18 years. Another barrier is online payment infrastructure, as minors are not allowed to use some of the common online payment services. Major medical organizations have historically opposed laws mandating parental involvement in minors' abortion decisions [[11]Burke P.J. Coles M.S. Di Meglio G. et al.Sexual and reproductive health care: A position paper of the Society for adolescent health and medicine.J Adolesc Health. 2014; 54: 491-496Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar]. Yet, 36 states currently require parental notification or consent before a minor can access abortion services [[12]Guttmacher InstituteParental involvement in minors’ abortion.https://www.guttmacher.org/print/state-policy/explore/parental-involvement-minors-abortionsDate: 2022Date accessed: August 9, 2022Google Scholar]. Adolescents' fear of disclosure around reproductive health care may delay their care [[2]Bryson A.E. Hassan A. Goldberg J. et al.Call to action: Healthcare Providers must Speak up for adolescent abortion access.J Adolesc Health. 2022; 70: 189-191Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar,[13]Davis A.R. Beasley A.D. Abortion in adolescents: Epidemiology, confidentiality, and methods.Curr Opin Obstet Gynecol. 2009; 21: 390-395Crossref PubMed Scopus (15) Google Scholar,[14]Braverman P.K. Adelman W.P. Alderman E.M. et al.The Adolescent’s right to confidential care when considering abortion.Pediatrics. 2017; 139Google Scholar]. Although most minor adolescents make decisions with support from a parent or other trusted adult [[15]Resnick M.D. Bearinger L.H. Stark P. Blum R.W. Patterns of consultation among adolescent minors obtaining an abortion.Am J Orthopsychiatry. 1994; 64: 310-316Crossref PubMed Scopus (28) Google Scholar], this support is not always available, and narrowly defined laws often ignore nonparent/guardian supportive adults. Minors may pursue judicial bypass to obtain an abortion without parental involvement, but this is a complex and time-consuming process. It is often psychologically traumatic for adolescents to disclose deeply personal information to strangers in court, and it relies on the decision of a judge who may lack expertise in medicine or adolescent development [[14]Braverman P.K. Adelman W.P. Alderman E.M. et al.The Adolescent’s right to confidential care when considering abortion.Pediatrics. 2017; 139Google Scholar,[16]Coleman-Minahan K. Stevenson A.J. Obront E. Hays S. Young Women's experiences obtaining judicial bypass for abortion in Texas.J Adolesc Health. 2019; 64: 20-25Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar]. In elevating the unique needs of youth, adolescent health professionals must apply principles of reproductive justice, the basic human right to maintain personal bodily autonomy, to have children, to not have children, and to parent one's children in safe and supportive communities [[17]SisterSong Women of Color reproductive justice Collective. Reproductive Justice.https://www.sistersong.net/reproductive-justiceDate: 2022Date accessed: August 29, 2022Google Scholar]. A recent commentary recommended a series of reproductive justice informed advocacy actions for adolescent health professionals in light of Texas Senate Bill 82. Changes to abortion access will unfold dynamically with state-specific variability. Partnering with local and national professional communities and advocacy groups will enable awareness and responsiveness to evolving reproductive health needs of adolescents. Table 1 provides specific strategies and resources.Table 1Barriers specific to minor adolescent abortion access with select approaches and resourcesBarrier specific to minor adolescentsExample approachResources and organizations (hyperlinks included)Need for youth-specific education and clinical support-Promote comprehensive sexual health education within and beyond schools-Create frequent opportunities to discuss healthy relationships, pregnancy intentions, contraception needs and preferences, and specifics of local abortion policy and access considerationsAdvocates for YouthAmaze.orgAmerican Academy of PediatricsARSHEP curriculumBright FuturesPlanned ParenthoodPower to DecideSIECUS: Sex Ed for Social ChangeTravel challenges-Be aware of support resources for legal counseling for adolescents and supportive adults seeking out-of-state care-Provide comprehensive information to youth while complying with local legal guidance for providers, minimizing additional barriers through overcompliance-Understand practical barriers and be flexible in scheduling whenever possibleAbortion finderCenter for Reproductive RightsNational Abortion FederationIf/When/HowPlan CRegulatory Assistance for Abortion ProvidersCost barriers and limited access to telehealth-Familiarize oneself and the youth in your care about costs and logistical considerations necessary to access abortion-Provide telehealth where legally availableCenter for Reproductive RightsNational Network of Abortion FundsReproductive Health Access ProjectParental consent and notification laws-Advocate to uphold or develop legislation to ensure minor consent and confidentiality to receive comprehensive reproductive health services-Work with legal experts to understand formal requirements and restrictions-Educate patients about specific details of local parental notification laws and all options available to patients-Support youth who wish to involve parents or other adults-Share resources for support through the judicial bypass process-Be mindful of the risks of accidental disclosure, especially from health systems and insurance plans that lack infrastructure to protect minor confidentialityGuttmacher InstituteRepro Legal HelpNational Abortion Federation HotlineNARAL Pro Choice America Open table in a new tab On the individual level, health care professionals, parents/guardians, and youth advocates can promote thoughtful, shared decision-making about reproductive health, including frequent opportunities to discuss healthy relationships, pregnancy intentions, contraceptive needs and preferences, and specific local abortion policies and access considerations with young people. On a community level, we can eliminate barriers to and promote comprehensive, accurate sexual health education and youth friendly SRH services. On a national level, we can advocate for health systems, researchers, funding agencies, and policy communities to examine specific impacts of restricted abortion access on youth and form strategic partnerships between clinicians, advocates, operational leaders, and policymakers who understand adolescent development and the health and social prerogative of protecting abortion access for all.