Brindis ParentalInvolvement Presentation 2006 09 1

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Parental Involvement in Adolescents’ Reproductive Healthcare: History, Research, & Policy Options:  Parental Involvement in Adolescents’ Reproductive Healthcare: History, Research, & Policy Options Claire Brindis, Dr.P.H. Professor, Department of Pediatrics Department of Obstetrics, Gynecology & Reproductive Sciences Bixby Center for Reproductive Health Research & Policy Institute for Health Policy Studies University of California, San Francisco September, 2006 In this presentation…:  In this presentation… What is the status of teen pregnancy, abortion, and childbearing in the United States? What relationship do healthcare professionals, policymakers, parents, and adolescents have regarding mandated parental involvement? What is the importance of parental involvement and confidentiality in the delivery of adolescent healthcare? What is the current status of legislation mandating parental involvement in adolescents’ abortion decisions in the US? Proposition 85 in California Do parental involvement laws have their intended impact? Parental involvement requirements pertaining to abortion:  Parental involvement requirements pertaining to abortion Parental Notification Parental consent Parent(s)/Legal Guardians must be notified, usually in writing, of a minors’ decision prior to provision of care Mandatory waiting period often accompanies notification requirement Minor retains decision-making capacity Judicial bypass option for confidential treatment Parent(s)/Legal Guardian(s) must give consent, usually written or in-person, prior to provision of care Parent/Legal Guardian(s) may refuse to provide consent such that minor can not receive care Minor retains ability to use judicial bypass Mandatory waiting period often accompanies consent requirement The frequency of adolescent pregnancies, births, and abortions:  The frequency of adolescent pregnancies, births, and abortions Adolescent pregnancy, birth, and abortion rates are currently at their lowest levels since the mid-1970’s. National Center for Health Statistics & The Alan Guttmacher Institute The frequency of adolescent pregnancies, births, and abortions has substantially decreased:  The frequency of adolescent pregnancies, births, and abortions has substantially decreased The Alan Guttmacher Institute, 2004; Sutton & Mathews, 2004 Declines in teen pregnancies, births, and abortions:  Declines in teen pregnancies, births, and abortions Between 1998 & 2002, the proportion of adolescent women aged 15-17 who have ever had sex declined from 37% to 30%. Between 1995 & 2002, the proportion of adolescent women aged 15-17 that used contraceptives at most recent intercourse increased from 71% to 83%. The proportion of sexually active teens who report having used the pill has increased from 52% to 61% between 1995 & 2002. Emergency contraception averts an estimated 4,000 unintended pregnancies to adolescents aged 17 and under each year. Delayed sexual activity Increased use of contraceptives Increased availability of effective contraceptive methods Abma et al, 2004; Jones et al, 2002 Despite tremendous progress, adolescents continue to experience a high incidence of unintended pregnancy, birth, and abortion:  The Alan Guttmacher Institute, 2004 US teen pregnancy, birth and abortion rates continue to be among the highest in the developed world Despite tremendous progress, adolescents continue to experience a high incidence of unintended pregnancy, birth, and abortion Confluence of Factors :  Confluence of Factors Adolescents:  The provision of confidential healthcare for adolescents has been promoted due to the recognition that some minors would not seek or would delay needed health care if they could not receive it confidentially. Adolescents Confidential healthcare & adolescents :  Confidential healthcare & adolescents In a recent national survey, 1/3 of students who did not seek needed healthcare reported that one of their reasons was “not wanting to tell their parents” (Klein et al, 1999). Assurances of confidentiality increase: the number of adolescents willing to disclose sensitive health information (from 39% to 47%) the commitment of adolescents to return for future healthcare visits (from 53% to 67%) (Ford et al, 1997). Privacy concerns can also deter adolescents from communicating openly with providers about certain health concerns (Ford et al, 1997). Confidential reproductive healthcare & adolescents :  Confidential reproductive healthcare & adolescents The proportion of adolescents who report that they would forgo care for certain types of concerns (including contraceptives, STIs, substance use, and mental health) is higher than those that would forgo general health care if confidentiality was not ensured (Marks et al, 1983). Nearly ½ of young, sexually active females visiting a family planning in Wisconsin reported that they would stop using all sexual health services if parental notification were required, however the vast majority indicated that they would not stop having sex (Reddy et al, 2002). One in 5 adolescents would stop using contraception or rely on an ineffective method (such as withdrawal) as one response to mandated parental notification for reproductive health care visits (Jones et al, 2005). Parents:  Parents Parental communication, connectivity, and engagement is very important in adolescent decision making Parent-child communication on issues of sex & sexuality :  Parent-child communication on issues of sex & sexuality Teens report that parents are the individuals that most influence their decisions about sex (National Campaign to Prevent Teen Pregnancy, 2004). Nearly 3/4 of adolescent women aged 15-17 reported having discussed sex or sexuality with at least one parent (Abma et al, 2004). 60% of adolescents reported that a parent or guardian was aware that they were accessing family planning services at the clinic (Jones et al., 2005b). The vast majority (79%) of teens in California indicated that their parents were aware of their sexual activities (CHIS, 2002). Nationally In California Parents:  Parents Slightly over half of parents (55%) support parental involvement laws, however they also expect that mandated involvement requirements will have at least one (98%) or more (48%) negative consequences (Eisenberg et al, 2005). In focus group research, parents indicated that their priority is that their teens be safe. “they want their daughters to get safe, professional medical care and counseling in a timely way, …even if their daughters feel that they can’t come to them”… “you can’t force every family to communicate” (Dial Group Research, 2005) Health Professionals:  Health professionals serve an important role in encouraging young people to communicate with their families Health Professionals Health professional :  Health professional A recent survey of Title X clinics demonstrated that clinics engage in a wide range of activities designed to promote parent-child communication, including: Counseling adolescents on the importance of talking to their parents (95%); Distributing pamphlets on strategies for communication (84%); Sponsoring social events (such as health fairs) for parents and adolescents (70%); and Promoting communication on posters and websites (54%) and as part of media campaigns (45%). Jones, 2006 Health Professionals:  Health Professionals Laws that seek to balance minors’ and parents’ rights often give discretion to physicians to determine when disclosure is warranted. With regards to reproductive healthcare, most professional medical organizations have issued policy statements expressing the importance of confidential care American Medical Association (AMA) American College of Obstetrics and Gynecology (ACOG) Society for Adolescent Medicine (SAM). Policymakers & Advocates:  Policymakers & Advocates Policy makers strive to recognize the public health implications of lack of confidentiality for adolescents and the impact of such requirements on not only the teen’s health and well-being, but on society as a whole. . Policymakers & Advocates:  Policymakers & Advocates 50 states allow minors to consent to STI & HIV testing. 21 states allow minors to consent to contraceptive services; over 20 states allow minors to consent to substance abuse/mental health services and related care. Title X funded family planning clinics Require delivery of confidential care when requested Require that physicians encourage parental involvement Jones & Boonstra, 2005 Parental Involvement Legislation in the U.S.:  Parental Involvement Legislation in the U.S. Parental involvement requirements were first passed in the mid 1970’s. Recently, there has been a surge in both the consideration and passage of parental involvement legislation. In the first 6 months of 2005, five states – Arkansas, Florida, Georgia, Oklahoma, and Texas – altered or adapted parental involvement in minors’ abortion requirements, more than had done so in the previous five years. Parental Involvement Legislation in the U.S. :  Parental Involvement Legislation in the U.S. The Alan Guttmacher Institute, 2006 Parental Involvement Legislation in the U.S.:  Parental Involvement Legislation in the U.S. Alternatives to parental involvement requirements 34 states include a judicial bypass option 6 states allow a grandparent or other adult relative to take the place of parent consent or notification 4 states allow specified health professionals to waive parental involvement requirements if a judge is unavailable Parental Involvement Legislation in the U.S. :  Parental Involvement Legislation in the U.S. 28 states permit exception to parental involvement requirements in cases of medical emergency 12 states permit exception to parental involvement requirements in cases of rape, incest, or assault Exceptions to parental involvement requirements The history of parental involvement legislation in California:  The history of parental involvement legislation in California Minors need written consent of one parent for abortion (unless they obtain court order authorizing abortion) Brought by American Academy of Pediatrics, California Medical Association, American College of Obstetricians & Gynecologists, and Planned Parenthood Claim that law violates Article I, Section 1 of California Constitution: “All people” possess certain fundamental rights, including “privacy” Law is never enforced because of court orders Trial San Francisco Superior Court, which rules law unconstitutional in 1992 Court of Appeal affirms 1994 California Supreme Court affirms 1997 1987 parental consent law Legal challenge The history of parental involvement legislation in California:  The history of parental involvement legislation in California Ballot initiative on the November 8th, 2005 special election ballot Parental notification Mandatory 48 hour waiting period Judicial bypass option/medical emergency provisions Reporting requirements for physicians & judges Civil penalties against physicians Definition of abortion in California Constitution changed to include “unborn child” Defeated 52% to 48% Proposition 73 Parental involvement legislation in California:  Parental involvement legislation in California Constitutional amendment to prohibit abortion for unemancipated minors until 48 hours after physician notifies minor’s parent or legal guardian, except in medical emergency or with parental waiver. Proposition 85 November 7th general election Parental involvement legislation in California:  Parental involvement legislation in California Parent/guardian must be notified: In person or via certified mail Physician cannot provide abortion care until 48 hours after parent received notification. Exceptions: Medical emergencies Waivers pre-approved by parent or guardian Judicial bypass (waiver approved by the Court) Minor must provide clear and convincing evidence that parental notification is not in her best interest or that she is mature enough to make the decision without parental involvement. Proposition 85 Parental involvement legislation in California:  Parental involvement legislation in California Creates new reporting requirements Health care providers must provide details on number of abortions performed and some minor demographic characteristics. Minors’ name not included, physician’s name included – although not “public record”. Authorizes monetary damages against physicians for violations. Proposition 85 Slide29:  Will this policy have its intended effect? Will there be an increase in parental communication and involvement in reproductive health decision-making? Will there be a decline in the frequency with which young women seek abortion care? Will parental involvement requirements change the age dynamics of relationships? Measuring the impact of parental involvement requirements:  Measuring the impact of parental involvement requirements Measuring out-of-state travel Accurate reporting of abortion statistics Overall declines in teen pregnancy Vast majority of recent studies are from the mid-1990’s, only one recent analysis Variations in study design Challenges in Analyzing Available Data The impact of parental involvement requirements:  The impact of parental involvement requirements Massachusetts After implementation of a parental consent requirement, half as many minors obtained an in-state abortion. Clinic personnel estimate that 75% of these young women had obtained parental consent, whereas 25% had obtained judicial bypass. An increase in out-of-state travel during this same time period accounted for 95% of the decline in the abortion rate. Over 1,800 minors traveled to 5 neighboring states to obtain out-of-state abortion care in the 20 months following the law’s implementation. 1 out of every 3 minors seeking abortion care traveled out of state for care after implementation of the state law. On the frequency of abortion and out-of-state travel Cartoof & Klerman, 1986 The impact of parental involvement requirements :  The impact of parental involvement requirements Missouri After implementation of a parental consent requirement, the in-state abortion rate declined by 20%. During this same time period, the odds of traveling out of state for abortion care increased by 50%. On the frequency of abortion and out-of-state travel Ellerston, 1997 On a related note: the impact of mandated parental notification for contraceptives:  On a related note: the impact of mandated parental notification for contraceptives Texas recently became one of 3 localities (in addition to Utah and McHenry county, Illinois) to mandate parental notification for the provision of prescription contraceptives. It has been estimated that the loss of confidentiality in family planning service provision in TX will result in an additional 8,000 pregnancies, 5,000 teen births, and 1,600 abortions to teens annually. The total projected cost of this loss of confidentiality is estimated at over $43 million (Franzini et al, 2004). Legislation that would mandate parental notification for provision of prescription contraceptives is currently under consideration nationally. “The Parents Right to Know Act” The impact of parental involvement requirements :  The impact of parental involvement requirements There is an increased risk of complications if an abortion is delayed into the 2nd trimester. Adolescents, on average, take 1 week longer to identify a pregnancy and 2 weeks longer to seek abortion care than adult women (Boonstra et al., 2006). In Mississippi, adolescents were 10-20% more likely to delay their abortion into the 2nd trimester after implementation of a parental consent requirement (Henshaw, 1995). Following implementation of Missouri’s parental involvement requirement, a steady but irregular increase in the percent of abortions to young women occurring after 12 weeks gestation was observed, from 17% (1980) to 26% (1992). What is the effect of these laws on the timing of adolescents’ abortions? The impact of parental involvement requirements:  The impact of parental involvement requirements An analysis of national data from 1974-1999 showed that states with parental involvement requirements have a higher share of post-first trimester abortions (Bitler & Zavodny, 2001). A 2006 study in the New England Journal of Medicine demonstrated that teens in Texas who were 17.5 or older when the state’s parental notification law took effect were significantly more likely to have a 2nd trimester abortion than younger teens (Joyce et al., 2006). What is the effect of these laws on the timing of adolescents’ abortions? The impact of parental involvement requirements:  The impact of parental involvement requirements A study in Pennsylvania found that 8 out of 60 judicial court districts provided complete information to young women inquiring about the judicial bypass option (Silverstein, 1999). A study of Alabama’s juvenile court system found the information received was inconsistent and oftentimes reflected the court employee’s personal opinion on abortion (Silverstein & Speitel, 2002). Is the judicial bypass option a viable choice? “Call information…just ask for an abortion clinic. If they say you need parental approval, then you’re going to have to have parental approval, because I don’t think a judge can order an abortion.” “You’ll have to go to Jefferson County to get that done. Our judge doesn’t do it; he doesn’t believe in it.” “Honey, I have no idea, I just have no idea. I feel like I don’t believe a judge or even a lawyer actually would do that….It would be best for you to talk to your parents.” Will this policy have its intended effect? :  Reduction in adolescent abortion rate. Increase in frequency of out-of-state travel for abortion. Increase in complications to accessing care: Delay Judicial bypass inconsistencies. Will this policy have its intended effect? Will there be a decline in the frequency with which young women seek abortion care? Parental involvement in minors abortion decisions:  Parental involvement in minors abortion decisions Will there be an increase in parental communication and involvement in reproductive health decision-making? Parental involvement in minors abortion decisions:  Parental involvement in minors abortion decisions Most parents (61%) are aware of their daughters’ decision to seek abortion care. Among younger adolescents, parental involvement is even higher Over 90% of 14 year olds & 75% of 15 year olds report the involvement of at least one parent. When one parent is involved, young women involve their mothers (59%) more frequently than their fathers (26%). Over 80% of adolescents report that they involved at least one adult (such as a parent, nurse, counselor, or clergy member) in their decision. How involved are parents in the absence of government mandates? Henshaw & Kost, 1992 The impact of parental involvement requirements:  The impact of parental involvement requirements A comparison of two states, with and without mandated notification requirements, demonstrated that parental involvement rates were similar regardless of the state law (Resnick & Blum, 1987). On parental involvement in abortion decision-making Parental involvement in minors’ abortion decisions :  Parental involvement in minors’ abortion decisions Why some teens do not involve their parents Henshaw, 1992 & Donovan, 1983. Over 30% of young women who chose not to involve their parents in their abortion decision cited: Fear of physical harm, Being kicked out of the house, or Other abuse as part of their decision not to involve their parents. A study of the judicial bypass procedure also revealed that many other women choose not to involve their parents because of an existing difficult family situation, including drug dependency, loss of jobs, health problems, and marital strain. Will this policy have its intended effect? :  Parental communication is high Mandated involvement requirements do not significantly increase the rate of parental involvement Will this policy have its intended effect? Increase in parental communication and involvement in reproductive health decision-making? The impact of parental involvement requirements:  The impact of parental involvement requirements On age differences between adolescent women and their sexual partners After implementation of a parental notification requirement in 2000, there was no significant change in the age distribution of fathers in Texas. Source: Special request of Texas Department of Health Services, birth rate data 1999-2002 Will this policy have its intended effect? :  Not directly studied, although evidence suggests no effect. Health care providers role as a mandated reporter ensures that they report coercive, abusive, or inappropriate relationships to proper authorities. Will this policy have its intended effect? Increased identification of abusive or coercive relationships? Existing Evidence Points to: :  Existing Evidence Points to: Patchwork of Laws: Existing parental notification and consent laws vary across the country, resulting in a variety of outcomes that have deep repercussions for adolescents’ lives. Even without mandates, California’s teen pregnancy, births, and abortions have significantly been reduced. Many of the laws have negative impacts--delays in seeking abortion care, judicial bypass, travel out of state. Medical care providers have an important role to play in encouraging parent and adolescent communication, without creating barriers for adolescents when they do not have the option to speak with their families. References:  References Abma JC, Martinez GM, Mosher WD, Dawson BS. Teenagers in the United States: Sexual activity, contraceptive use, and childbearing, 2002. Vital Health Statistics; Vol 23 no 24. National Center for Health Statistics, 2004. Bitler M, Zavodny M. The effect of abortion restrictions on the timing of abortions. J Health Econ. 2001. 20:1011-1032. Blum R. Resnick M, Stark T. The Impact of a Parental Notification Law on Adolescent Abortion Decision Making. Am J Public Health. 1987; 77:619-620. Boonstra H et al. Abortion in Women’s Lives. New York: Guttmacher Institute, 2006. Cartoof V, Klerman L. Parental Consent for Abortion: Impact of the Massachusetts Law. Am J Public Health 1986; 76:397-400. Dial Group Research, Focus Group on Parents’ Beliefs Regarding California’s Prop 73 Proposition. Unpublished Report, Sacramento, Ca. 2005 Donovan, P. Judging teenagers: how minors fare when they seek court-authorized abortions. Family Planning Perspectives 1983; 15(6): 259. Ehrlich S. Grounded in the reality of their lives: Listening to teens who make the abortion decision without involving their parents. Berkeley Womens Law Journal 2003. 18: 61-180. Eisenberg M, Swain C, Bearinger L, Sieving R, Resnick M. Parental Notification Laws for Minors’ Access to Contraception: What Do Parents Say? Arch Pediartr Adolesc Med. 2005; 159:120-125. Ellerston C. Mandatory Parental Involvement in Minors’ Abortions: Effects of Laws in Minnesota, Missouri, and Indiana. Am J Public Health. 1997; 87:1367-1374. Ford C, Millstein S, Halpern-Felsher B, Irwin C. Influence of physician confidentiality assurances on adolescents’ willingness to disclose information and seek future health care. JAMA. 1997; 278:1029-1034. Franzini L, Marks E, Cromwell P, Risser J, McGill L, Markham C, Selwyn B, Shapiro C. Projected Economic Consequences Due to Health Consequences of Teenagers’ Loss of Confidentiality in Obtaining Reproductive Health Care Services in Texas. Arch Pediatr Adolesc Med. 2004; 158: 1140-1146. Henshaw S, Finer L. Abortion Incidence and Services in the United States in 2000. Perspectives on Sexual and Reproductive Health 2003: 35(1): 6-15. Henshaw S, Kost K. Parental Involvement in a Minors’ Abortion Decision. Family Planning Perspectives. 1992; 24(5). Henshaw S. The Impact of Requirements for Parental Consent on Minors’ Abortions in Mississippi. Family Planning Perspectives, 27: 120-122, 1995. Jones, R. Do US family planning clinics encourage parent-child communication. Findings from an exploratory study. Perspectives on Sexual and Reproductive Health 2006; 38(3): 155-161. References, cont. :  References, cont. Jones R, Boonstra H. Confidential reproductive health care for adolescents. Curr Opin Obstet Gynecol 2005: 17:456-460. Jones R, Darroch J, Henshaw S. Contraceptive Use Among U.S. Women Having Abortions in 2000-2001. Perspectives on Sexual and Reproductive Health 2002: 34(6): 294-303. Jones R, Purcell A, Singh S, Finer L. Adolescents’ reports of parental knowledge of adolescents’ use of sexual health services and their reactions to mandated notification for prescription contraception. 2005; 293: 340-348. Jones R, Singh S, Purcell A. Parent-child relations among minor females attending U.S. family planning clinics. Perspectives on Sexual and Reproductive Health 2005; 37(4): 192-201. Joyce T, Kaestner N, Colman S. Changes in abortions and births and the Texas parental notification law. NEJM 2006; 354: 1031-8. Klein J, Wilson K, McNulty M, Kapphahn C, Collins K. Access to medical care for adolescents: results from the 1997 Commonwealth Fund Survey of the Health of Adolescents Girls. J Adol Health. 1999; 25:120-130. Marks A, Malizio J Hoch J, Brody R, Fisher M. Assessment of health needs and willingness to utilize health care resources of adolescents in a suburban population. J Pediatr . 1983; 102:456-460. Reddy D, Fleming R, Swain C. Effect of Mandatory Parental Notification on Adolescent Girls’ Use of Sexual Health Services. JAMA. 2002; 288:710-714. Silverstein H, Speitel L. “Honey, I have no idea”: Court readiness to handle petitions to waive parental consent for abortion. 88 Iowa L. Rev, 75 Sutton P, Mathews TJ. Trends in Characteristics of Births by State: United States, 1990, 1995, and 2000-2002. National Vital Statistics Reports: Vol 52 no 19. Hyattsville, Maryland: National Center for Health Statistics, 2004. The Alan Guttmacher Institute. U.S. Teen Pregnancy Statistics: Overall trends, Trends by Race and Ethnicity And State-by-State Information. New York, NY: The Alan Guttmacher Institute; 2004. The Alan Guttmacher Institute. Parental Involvement in Minors’ Abortions, State Policies in Brief, August 15, 2005 [online]. Available at: http://www.agi-usa.org. Accessed August 20, 2005. The National Campaign to Prevent Teen Pregnancy. Parents and Teen Pregnancy: What Surveys Show [online] 2004. Available at http://www.teenpregnancy.org. Accessed September 7, 2005. UCLA Center for Health Policy Research. California Health Interview Survey [online] 2001. Available at: http://www.chis.ucla.edu/. Accessed August 7, 2005. Contact information & additional resources:  Contact information & additional resources Claire Brindis Claire.Brindis@ucsf.edu Copies of the Adolescents and Parental Notification for Abortion: What can California Learn from the Experience of Other States? brief and this PowerPoint presentation are available at: http://crhrp.ucsf.edu Special thanks to: Maggie Crosby, JD Lauren Ralph, MPH

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