1.  INTRODUCTION AND SUMMARY

  1.1  I would like to focus this submission on the issue of parental notification for access to abortion for underage girls. The question is whether or not parental notification increases or decreases teenage pregnancy with all its adverse health outcomes. This is in response to paragraph 3 of the press notice of the Committee asking for "evidence of long-term or acute adverse health outcomes from abortion or from the restriction of access to abortion".

  1.2  Teenage pregnancy has been associated with a number of adverse health outcomes. For the child this includes increased risks of premature birth, low birth weight, an increased perinatal mortality, increased risk of sudden infant death syndrome and hospitalisation due to accidental injuries, an increased risk of experiencing abuse, poor housing, poor nutrition and later risk of school drop-out with subsequent risk of living in poverty. For the mother, adverse health outcomes include hypertension, anaemia, placental abruption, premature birth, depression, poor nutrition, poor housing, poverty and increased reliance on state welfare.[143]

  1.3  In an effort to reduce teenage pregnancies—it is widely known that the UK has the highest teenage pregnancy rate in Western Europe—the Department of Health issued a revised guidance[144] essentially requiring doctors in almost all circumstances to refer under-16-year-olds for abortions without parental consent, if certain criteria are met.

  1.4  Some would consider parental notification as a moderate restriction in access to abortion. This submission tries to answer the question: What is the evidence on the impact of a moderate limitation in access to abortion because of parental notification on:

(a) access to abortion/abortion rates; and

(b) on teenage pregnancy?

  1.5  The Department of Health seems convinced that easy access to abortion—in this context without parental involvement—can reduce teenage pregnancies. However, very recent scientific evidence does not support this assumption. Evidence from across the world and especially from the analysis of parental involvement laws in the US shows very clearly that parental involvement laws do not increase teenage pregnancies. Indeed, the introduction of parental notification reduces teenage abortion rates by 10-20%, while teenage pregnancy rates remains unchanged or even decrease slightly as a result of introducing parental involvement requirements.

  1.6  This is in keeping with the UK experience at the time of the Gillick ruling, which in 1985 restricted access to family planning services for under-16-year-olds in England (obviously a far greater restriction than just parental involvement). In 1985 and 1986, there was a halt in the year-on-year increase in underage pregnancies, but not in pregnancy rates for over-16-year-olds, who were not affected by this ruling and therefore could still attend family planning clinics. Scotland, which was not affected by this ruling, had an increase in pregnancy rates both in under and over-16-year-olds during this time.

  1.7  In view of these findings, there needs to be a reassessment of the UK policy of essentially unrestricted access for underage girls for abortions. The current policy aimed at reducing teenage pregnancies has clearly failed, and is not evidence-based.

2.  PARENTAL INVOLVEMENT IN ABORTION DECISIONS FOR UNDERAGE GIRLS. WHAT IS THE SITUATION IN OTHER COUNTRIES AND THE INTERNATIONAL EVIDENCE?

  2.1  A recent analysis of relevant studies on this issue is found in LEVINE, P, Sex and consequences. Abortion, public policy and the economics of fertility. Princeton University Press 2004. (It is important to point out that one of the commendations for this book comes from the chair of the International Planned Parenthood Council, Alexander Sanger. This publication therefore cannot be dismissed as "pro-life")

  2.2  The main approach used by Prof Levine, an economist, is that availability of abortion may be viewed in some ways a form of insurance. If an individual has car insurance and his or her car is stolen or has an accident, the insurance will help pay for it to be replaced or repaired. However, if the insurance provides complete protection, it may bring about behavioural changes for those who purchase it in that it may lead to riskier behaviour. Similarly, widespread and easy availability of abortion will have the opposite effect of what is intended: rather than decreasing teenage pregnancies it may actually have no effect or even increase teenage pregnancies due to increased risk-taking: If "things go wrong" and abortion is easily available, one can always have an abortion. He writes:

"... The availability of abortion shares some of the features of a standard economic treatment of insurance. The primary feature of abortion is that it provides protection from downside risk in the form of giving birth to a child that is unintended... If this form of insurance is available at very low cost, it may lead to changes in behaviour that increase the likelihood of it being needed." [In other words, it may increase sexual activity.] (Levine, ibid, p 3)

  2.3  Abortion availability can be considered as a form or insurance against an unwanted birth:

"When an abortion is very costly, a woman will choose to have an unwanted birth rather than have an abortion if she becomes pregnant. If its cost falls, the greater access [to abortion] will enable women to abort that pregnancy, protecting them from the downside risk of having a child that they do not want. But if its cost continues to fall further so that abortion is available at relatively little cost (in all dimensions—not just monetarily) then the primary impact will be on the likelihood of pregnancy. Couples will take fewer steps to avoid a pregnancy since these activities are costly as well, any may become more costly than an abortion". (ibid, p 186)

  2.4  This theoretical framework (abortion essentially being an "insurance") provides specific predictions of behavioural changes that would result in response to changes in abortion policy. If a very restrictive abortion policy is in place, relatively few women may choose to have an abortion. If abortion policies were made less restrictive, women may choose to abort a pregnancy rather than give birth to an unwanted child. As abortion becomes more readily available, couples may choose, essentially, to use abortion instead of contraception, leading to an increase in pregnancy rates. International data supports these assumptions.

2.5  Parental involvement laws in the US

2.5.1  Background

  2.5.1.1  Parental involvement laws can either require minors, typically under the age of 18, to obtain consent from their parent or guardian before an abortion can be performed, or they can require minors simply to notify their parent or guardian of their intention to have an abortion. At present, the majority of US states (33) have parental involvement laws in place, with these laws becoming more common over time (ibid. p17-18).

  2.5.1.2  It is interesting to point out that in the US, unlike the UK, over the past decades the teenage pregnancies have fallen significantly as the number of states enacting parental involvement laws has increased, as the following table shows:

  Obviously, the enactment of parental involvement laws is only one of several factors affecting teenage pregnancies, and association is not causation.

  2.5.1.3  US court rulings:

There have been a number of US court rulings in this area including two US Supreme Court rulings on this issue. Both held that parental involvement with judicial bypass is constitutional: (Ohio v Akron Centre for Reproductive Health 1990; Hodgson v. Minnesota 1990)

2.5.2  Data on the impact of parental involvement laws in the US

  2.5.2.1  Overall, there is evidence that parental involvement laws reduce abortion rates of minors by 10-20%. There is no evidence of a concomitant increase in the rate of underage births, and teenage pregnancies either were unchanged (according to the majority of studies), or even declined. (Levine, ibid p 120)

  2.5.2.2  Levine summarises the available studies on this subject and finds that all studies investigating the impact of parental involvement laws come to the above mentioned conclusion. (ibid p 116ff)

  2.5.2.3  Rogers et al 1991—Minnesota parental involvement laws led to reduction in underage abortion but there was no impact on birth rates.[146]

  Ohsfeld and Gohman 1994—examined state level data for 1984, 1985 and 1988. As a result of parental involvement laws, both abortion rates and pregnancy rates of 15 to 17-year-olds fell in relation to those of older women in response to parental involvement law.

  Joyce and Kaestner 1996—investigated the effects of parental involvement laws in Tennessee and South Carolina and found no effect of policy on abortion or births.

  Matthews et al 1997—investigated the impact of Medicaid funding restrictions and parental consent laws in 1978-88. These changes either reduced both abortion rate and birth rate or had no significant effect on either.

  Ellertson 1997—investigated the effect of parental involvement laws in three states compared with non-minors. Found that in-state abortion rates for minors fell, but that this may be attributable to increased travel out of state. No evidence of change in birth rate.[147]

  Levine 2003—used state-level data from 1985-96. Parental involvement laws reduced the likelihood of abortion for teens but not for older women, and had no effect on birth rates. Reduction in pregnancies resulted from increased use of contraception.

  2.5.2.4  Using Medicaid restrictions as the policy mechanism of interest, Levine et al[148] find that states restricting Medicaid funding for abortion during the years 1977-88 witnessed a decrease in their pregnancy rates on the order of 7.7%. This too implies that increasing abortion access increases the incidence of unprotected sex. Interestingly, Levine et al find that this effect seems to be driven mostly by behaviour among those in the 15-24 age range, implying that the behaviour of young people is the most sensitive to changes in abortion access.

  2.5.2.5  The overall impact of Medicaid funding restrictions for abortion was obviously a more drastic measure than "just" parental involvement. This leadsto an overall 3-5% reduction in abortion rate but there is no evidence of increase of birth rates, and some studies found that birth rates actually declined (ibid p 115ff). This further supports the hypothesis that abortion acts as an "insurance" for when things "go wrong" and that therefore, to reduce the access to abortion seems to have a somewhat beneficial effect on sexual behaviour, with less risk-taking.

  2.5.2.6  An overview over the published evidence is given by Paton.[149] This shows that essentially all studies, especially those of higher quality, revealed that as a result of parental notification requirements, teen abortion rates fall and teenage pregnancy rates either stay unchanged or fall. (See table)

2.5.3  Studies Evaluating the Impact of Parental Involvement for Abortion Services

  Note: "-ve" implies that parental involvement led to a reduction in rates.

Study	Context	Impact on teen abortion rates	Impact on teen birth rates	Impact on teen pregnancy rates
Stronger evidence
Haas-Wilson (1996)	Impact of laws on abortion rates amongst minors across States and over time	-ve & significant	n/a	n/a
Kane & Staiger (1996)	Impact of laws on teenage birth rates across States and over time	n/a	either no impact or -ve	n/a
Levine (2000; 2003; 2004)	Impact of laws on teenage abortion & birth rates across States & over time	-ve & significant	-ve but insignificant	-ve & significant
Moderate evidence
Cartoof & Klerman (1986)	Impact of Massachussets law on abortions rates amongst teenagers	no impact	n/a	n/a
Rogers et al (1995)	Impact of Minnesota law on abortion & birth rates to minors	-ve & significant	no impact	-ve & significant
Henshaw (1995)	Impact of Mississippi law on abortion rates to minors	-ve but insignificant	n/a	n/a
Ellertson (1997)	Impact of laws in three States on birth & abortion rates to minors relative to older teenagers	-ve or no change	no impact, -ve impact for some specifications	n/a
Joyce & Kaestner (1996)	Impact of laws in two States on abortion & birth rates relative to older teenagers	-ve & significant	+ve & significant
Joyce & Kaestner (2001)	Impact of laws in two States on abortion rates	no significant effect	n/a	n/a
Ohsfeldt & Gohmann (1994)	Impact of laws on abortion & pregnancy rates amongst minors across States & over time	-ve & significant	-ve & significant	-ve & significant
Altman-Palm & Tremblay (1998)	Effect of laws across States & over time on abortion & pregnancy rates amongst 15-17 year olds	-ve & significant	-ve & significant	-ve & significant
Gennetian (1999)	Impact of laws on unwanted births across States & over time measured by "supply" of children for adoption	n/a	-ve & significant	n/a
Wolfe et al (2001)	Impact of laws on probability of births across States over time	n/a	-ve but insignificant	n/a
Weaker evidence
Bitler & Zavodny (2001)	Impact of laws on abortion rates for all women across States & over time	-ve & significant	n/a	n/a
New (2004)	Impact of laws on abortion rates for all women across States & over time	-ve but insignificant	n/a	n/a
Matthews et al (1997)	Impact of laws on abortion rates for all women across States & over time	-ve & significant; -ve but insignificant in some	-ve & significant, +ve but insignificant in some	n/a
Blank et al (1996; 1994)	Impact laws on abortion rates for all women across States & over time	-ve or no change	n/a	n/a
Tomal (1999)	Cross-section impact laws on abortion & pregnancy rates amongst adolescents	-ve & significant	+ve & significant	n/a

2.6  International data on parental involvement

  2.6.1  As the UK has the highest teenage pregnancy rate in western Europe, it might be worth while analysing the international situation regarding provision of abortion services for underage girls. An analysis of international regulations regarding parental notification shows the following:

	Parental involvement	Remarks	Teenage Birth rate per 1,000 women aged 15-19[150]
Western Europe
Austria	No		12
Belgium	No		8
Denmark	Yes		7
Finland	No		7
France	Yes		9
Germany	No		11
Greece	Yes		10
Ireland	No	Abortion legal only to save mother's life	16
Italy	Yes		6
Netherlands	Yes		4
Norway	Yes		10
Portugal	n/a	Abortion very limited (rape, maternal health, foetal deformities)	17
Spain	n/a	Abortion very limited (rape, maternal health, foetal deformities)	6
Sweden	No		5
Switzerland	n/a	Abortion very limited (woman's life threatened)	5
UK	No		24
Eastern Europe
Albania	No		16
Bulgaria	No		41
Czech Republic	Yes		17
Hungary	Yes		21
Poland	Yes	Abortion very limited (rape, maternal health, foetal deformities)	16
Romania	No		37
Slovak Republic	Yes		24
Other countries
Canada	No		19
Japan	No		4

  2.6.2  The above table shows that there is a wide variety of scenarios: some Western European countries with a low teenage pregnancy rate—such as the Netherlands, Demark, France, Greece and Italy—require parental consent, whereas some other Western European countries with a low teenage pregnancy rate do not require parental consent, such as Belgium, Finland, Germany and Sweden. It might be worth while to comment specifically on two countries in this table: Germany and the Netherlands, countries that have fairly low teenage pregnancy rates and abortion rates.

  2.6.3  Germany has one of the lowest birth and abortion rates in Europe. Birth rates for 15 to 19-year-olds in Germany are 11/1,000 girls (compared to 24/1,000 in the UK),[151] with one of the lowest abortion rates, both for adults and, especially, for teenagers in Europe. Before an abortion takes place, there is mandatory counselling which is geared towards preserving the life of the foetus. There is also a mandatory waiting period before the abortion can take place. Health insurance may not cover the complete costs of abortion, leaving the woman to pay a proportion of the cost of the procedure. This is in effect a restriction on abortion access.

  2.6.4.  In the Netherlands, which has the lowest teenage pregnancy rate in Europe (birth rate of 4/1,000 girls aged 15-19; UK: 24/1,000) there is parental involvement before abortion can take place. The Netherlands has often been held up as an example on how to achieve good sexual health among adolescents.

  2.6.5  Summarising the international evidence, based mainly on the Eastern European experience but also on that of Western Europe and Canada, it becomes clear that to change from a liberal to a severely restricted abortion environment—for example as in Poland where abortion access was significantly restricted from 1993 onwards to cases of rape, foetal defects or to save the mother's life—leads to an increase in births, presumably due to an increase in unwanted births.

  2.6.6  More moderate restrictions do not appear to increase birth rates:

"Moderate restrictions on abortion within a legal abortion environment reduce pregnancies". (Levine, ibid. 156f)

I would argue that parental notification is such a "moderate restriction" within a legal environment. The international evidence therefore is that this leads either to no change or a reduction in teenage pregnancies.

2.7    The "Gillick experiment"

  2.7.1  UK data during the time of the "Gillick ruling" shows that restricting access to contraceptive services for under age girls did not lead to increased teenage pregnancies. The Department of Health guidance aims to reduce barriers for underage girls to access contraceptive services. The assumption is that increased access to family planning (or other sexual health) clinics will reduce unwanted pregnancies. There is overall very little evidence showing that access to family planning clinics reduces teenage pregnancy rates. There is, however, evidence from the UK to suggest that the opposite effect, ie an increase in unwanted pregnancies may occur with increased access to family planning clinics.

  2.7.2  A relevant "social experiment" has been the pattern of conception rates at the time of the Gillick ruling which restricted underage family planning in England and Wales, but not in Scotland. In 1984—the year before the Gillick Ruling—the conception rate in England and Wales was 1.37% higher than the previous year. In 1985, when restrictions were imposed on underage family planning, the conception rates for underage girls in England and Wales were unchanged, ie there was no increase. In the following year, when restrictions had been lifted, (but family planning attendances had not recovered to previous levels) conception rates rose by 0.01%. In contrast, conception rates in Scotland, which was not affected by the Gillick ruling, increased by 7.6% (1985) and 5.6% (1986), while conception rates of 16 to 19-year-olds increased by 3.3% and 1.3% respectively.[152]

  2.7.3  In conclusion, the 1985 Gillick ruling, which restricted access for under 16 year olds to family planning services in England and Wales, was associated with a halt in the year-on-year increase in underage pregnancies for two years. This contrasts with Scotland, where under 16-year-olds could attend family planning clinics. The underage pregnancy rate increased at the same time in Scotland. (Paton D. ibid.)

  2.7.4  Historically, a 1% increase in family planning attendances is associated with a short-term increase of 0.1% in the rate of underage conceptions. In the long term, the estimated impact is about twice this value. David Paton concludes:

"... I am unable to find any evidence that provision of family planning has reduced conception or abortion rates. Indeed, there is some evidence that family planning provision has been associated with an increase in conception rates for under-sixteens in the UK." (Paton D. ibid.)

3.  CONCLUSIONS

  3.1  The UK has the highest teenage pregnancy rate in Western Europe, six times the rate of the Netherlands, nearly five times the rate of Sweden, four times the rate of Spain or Italy and twice the rate of Germany. Despite a number of initiatives, the UK teenage pregnancy rate has remained essentially unchanged over the past three decades.

  3.2  Teenage pregnancies are associated with a number of serious adverse health effects both on the child and the mother. There is an urgent need to reduce teenage pregnancies.

  3.3  One strand of the UK teenage pregnancy strategy consists of confidential access to abortion for underage girls, presumably with the intent of reducing underage pregnancies.

  3.4  There is no evidence-base for this policy. Indeed, the best available evidence shows that parental notification in underage conceptions reduces underage abortions by 10-20%, while teenage pregnancy rates either are reduced by a few percent or—at worst—remain unchanged.

  3.5 The current teenage pregnancy strategy is not evidence-based and needs a significant change in view of scientific evidence.

  3.6 There is strong evidence to recommend parental consent for underage abortions.

September 2007

144   Press release and guidance on http://www.ffprhc.org.uk/admin/uploads/under16s.pdf; issued 30. July 2004. This guidance has been-unsuccessfully-challenged in the High Court by Sue Axon, a mother of five, in January 2006. Back

145   Child trend fact sheets -June 2007; on www.childtrends.org. Back

146   Rogers JL, Boruch RF, Stoms GB, DeMoya D. Impact of the Minnesota Parental Notification Law on abortion and birth. Am J Public Health. 1991 Mar;81(3):294-8. Back

147   Ellertson C. Mandatory parental involvement in minors' abortions: effects of the laws in Minnesota, Missouri, and Indiana. Am J Public Health. 1997 Aug;87(8):1367-74. Back

148   Phillip B. Levine, Amy B. Trainor, and David J. Zimmerman (1996), The Effect of Medicaid Abortion Funding Restrictions on Abortions, Pregnancies, and Births. Journal of Health Economics, 15: 555-578. Back

149   Paton D. Parental Consent and Teenage Pregnancy, February 2005. Back

150   Age Specific Fertility Rate (15-19 years) 2000-2005; http://www.childinfo.org/eddb/fertility/dbadol.htm Back

151   ibid. http://www.childinfo.org/eddb/fertility/dbadol.htm. Back

152   Paton D. The economics of family planning and underage conceptions. Journal of Health Economics 2002. 21: 27-45. Back