Confidential reproductive health services for minors: the potential impact of mandated parental involvement for contraception

A Research Agenda for Emergency Medicine-based Adolescent Sexual and Reproductive Health

OBJECTIVE

The objective was to identify key questions for emergency medicine (EM)-based adolescent sexual and reproductive health and to develop an evidence-based research agenda.

METHODS

We recruited national content experts to serve as advisory group members and used a modified Delphi technique to develop consensus around actionable research questions related to EM-based adolescent reproductive and sexual health care. Author subgroups conducted literature reviews and developed the initial list of research questions, which were iteratively refined with advisory members. External stakeholders then independently rated each item for its importance in expanding the evidence base (1 = not important to 5 = very important) via electronic survey.

RESULTS

Our final list of 24 research questions included items that intersected all sexual and reproductive health topics as well as questions specific to human immunodeficiency virus/sexually transmitted infections (HIV/STIs), pregnancy prevention, confidentiality/consent, public health, and barriers and facilitators to care. External stakeholders rated items related to HIV/STI, cost-effectiveness, brief intervention for sexual risk reduction, and implementation and dissemination as most important.

CONCLUSIONS

We identified critical questions to inform EM-based adolescent sexual and reproductive health research. Because evidence-based care has potential to improve health outcomes while reducing costs associated with HIV/STI and unintended pregnancy, funders and researchers should consider increasing attention to these key questions.

Projecting the Unmet Need and Costs for Contraception Services After the Affordable Care Act

OBJECTIVES

We estimated the number of women of reproductive age in need who would gain coverage for contraceptive services after implementation of the Affordable Care Act, the extent to which there would remain a need for publicly funded programs that provide contraceptive services, and how that need would vary on the basis of state Medicaid expansion decisions.

METHODS

We used nationally representative American Community Survey data (2009), to estimate the insurance status for women in Massachusetts and derived the numbers of adult women at or below 250% of the federal poverty level and adolescents in need of confidential services. We extrapolated findings to simulate the impact of the Affordable Care Act nationally and by state, adjusting for current Medicaid expansion and state Medicaid Family Planning Expansion Programs.

RESULTS

The number of low-income women at risk for unintended pregnancy is expected to decrease from 5.2 million in 2009 to 2.5 million in 2016, based on states' current Medicaid expansion plans.

CONCLUSIONS

The Affordable Care Act increases women's insurance coverage and improves access to contraceptive services. However, for women who remain uninsured, publicly funded family planning programs may still be needed.

Determinants of and disparities in reproductive health service use among adolescent and young adult women in the United States, 2002-2008

OBJECTIVES

We investigated determinants of and disparities in reproductive health service use among young women in the United States from 2002 to 2008.

METHODS

Using data on 4421 US women aged 15 to 24 years from the National Survey of Family Growth (2002, n = 2157; 2006-2008, n = 2264), we employed descriptive and univariate statistics and multivariate regression models to examine service use across women's sociodemographic and reproductive characteristics and to investigate potential disparate changes in service use over time.

RESULTS

More than half the sample (59%) had used services in the past year. In regression models, predictors of service use included age, education, birthplace, insurance, religious participation, mother's education, childhood family situation, age at menarche, sexual intercourse experience, recent number of partners, and previous gynecological diagnosis. Although service use decreased by 8% overall from 2002 to 2006-2008 (P < .001), the magnitude of decline was similar across demographic and socioeconomic groups.

CONCLUSIONS

Inequalities in reproductive health service use exist among women in the United States, particularly among the youngest and socially disadvantaged women, which may translate to poor and disparate reproductive outcomes. Public health and policy strategies are needed to eliminate inequities in reproductive health service.

Discouraging trends in reproductive health service use among adolescent and young adult women in the USA, 2002-2008

BACKGROUND

To investigate reproductive health service use by young women in the USA between 2002 and 2008.

METHODS

Using data from two waves of The National Survey of Family Growth, we investigated reproductive health service utilization among women aged 15-24 years (2002 n=2157; 2006-2008 n=2264). Descriptive and univariate statistics and multivariate regression models were employed to describe types of reproductive health services used and compare service use across years. Analyses focused on questions regarding specific recent use of reproductive health services (within the previous 12 months).

RESULTS

Over half the pooled sample (n=4421) reported lifetime family planning clinic (58%) and recent reproductive health service (59%) use, including contraceptive (48%), gynecological exam (47%) and counseling (37%) services. Lifetime family planning service use declined by 15% from 2002 to 2008 (P<0.001) and recent reproductive health service use by 8% (P=0.01), including gynecological exam (8%, P= 0.03) and contraceptive (6%, P= 0.02) services. By 2006-2008, women were less likely to use reproductive health and contraceptive services than in 2002 [odds ratio (OR) 0.6, confidence interval (CI) 0.5, 0.8, P< 0.001 and OR 0.7, CI 0.6, 0.9, P= 0.005, respectively]. Trends were similar but smaller in magnitude among the sexually experienced women, with a 5% decline in both reproductive health (OR 0.7, CI 0.6, 1.0, P= 0.02) and contraceptive (OR 0.8, CI 0.6, 1.0, P= 0.03) service use.

CONCLUSIONS

Reproductive health service use among young women in the USA has declined over the past decade. Public health and policy strategies are needed to promote service use, ultimately to improve reproductive health outcomes.

Adolescents, contraception and confidentiality: a national survey of obstetrician--gynecologists

BACKGROUND

Given recent legislative efforts to require parental notification for the provision of reproductive health care to minors, we sought to assess how obstetrician-gynecologists (Ob/Gyns) respond to requests for confidential contraceptive services.

STUDY DESIGN

Mailed survey of 1800 US Ob/Gyns, utilizing a vignette where a 17-year-old college freshman requests birth control pills and does not want her parents to know. Criterion variables were the likelihood of encouraging her to abstain from sexual activity until she is older, persuading her to involve her parents in this decision and prescribing contraceptives without notifying her parents. Covariates included physicians' religious, demographic and clinical characteristics.

RESULTS

Response rate 66%. Most (94%) would provide contraceptives without notifying her parents. Half (47%) would encourage her to involve a parent, and half (54%) would advise abstinence until she is older. Physicians who frequently attend religious services were more likely to encourage her to involve her parents (OR 1.9), and to abstain from sex until she is older (OR 4.4) but equally likely to provide the contraceptives.

CONCLUSIONS

Most obstetrician-gynecologists will provide adolescents with contraceptives without notifying their parents.

A semi-qualitative study of attitudes to vaccinating adolescents against human papillomavirus without parental consent

Background

The first vaccine to prevent human papillomavirus (HPV) and cervical cancer has been licensed, and in future, vaccination may be routinely offered to 10–14 year old girls. HPV is a sexually transmitted virus and some parents may refuse consent for vaccination. Under-16s in the UK have a right to confidential sexual health care without parental consent. We investigated parents' views on making available HPV vaccination to adolescent minors at sexual health clinics without parental consent.

Methods

This was a semi-qualitative analysis of views of parents of 11–12 year old school children collected as part of a population-based survey of parental attitudes to HPV vaccination in Manchester. Parents were firstly asked if they agreed that a well-informed child should be able to request vaccination at a sexual health clinic without parental consent, and secondly, to provide a reason for this answer. Ethical perspectives on adolescent autonomy provided the framework for descriptive analysis.

Results

307 parents answered the question, and of these, 244 (80%) explained their views. Parents with views consistent with support for adolescent autonomy (n = 99) wanted to encourage responsible behaviour, protect children from ill-informed or bigoted parents, and respected confidentiality and individual rights. In contrast, 97 parents insisted on being involved in decision-making. They emphasised adult responsibility for a child's health and guidance, erosion of parental rights, and respect for cultural and moral values. Other parents (n = 48) wanted clearer legal definitions governing parental rights and responsibilities or hoped for joint decision-making. Parents resistant to adolescent autonomy would be less likely to consent to future HPV vaccination, (67%) than parents supporting this principle (89%; p < 0.001).

Conclusion

In the UK, the principle of adolescent autonomy is recognised and logically should include the right to HPV vaccination, but this may concern parents who would otherwise approve vaccination.