Abortions in minors account for 4–7% of the abortions in the United States.1,2 Although this rate has declined over the past few decades, it remains unclear if this decrease is related to the overall decrease in teen pregnancy, legislation restricting access to abortion, increased abstinence or contraceptive use, or a combination of influences.3
Legislators looking to curb abortion rates in minors have enacted parental involvement laws, which require parental notification, consent, or both before a minor obtains an abortion. Although many states have enacted such laws, studies of these laws have demonstrated conflicting results. A meta-analysis from 2009 found the only consistent outcome was an increase in the number of minors crossing state lines for abortions.4 In 2012, New Hampshire became the 37th state to enact a parental involvement law, which requires either a parent be present at the time of the abortion or notified 48 hours in advance. Alternatively, minors may seek a judicial bypass option to avoid parental involvement.
The primary objective of this study was to determine whether the parental notification law resulted in a change in the number of minors seeking abortions at Planned Parenthood clinics in New Hampshire, Vermont, and Maine. We hypothesized that New Hampshire minors would be less likely to seek abortions in New Hampshire and more likely to cross state lines. Secondary objectives included evaluating changes in the age and gestational age of minors seeking abortions and assessing rates of parental involvement among northern New England minors seeking abortions.
MATERIALS AND METHODS
We performed a retrospective chart review on all women younger than 18 years of age who had a medical or surgical abortion at any of the Planned Parenthood of Northern New England clinic sites from January 1, 2011, through December 31, 2012. The Planned Parenthood of Northern New England system includes clinics in Maine, New Hampshire, and Vermont and provides abortion services for nearly all (more than 99%) patients in Vermont and approximately half (45%) of those in New Hampshire and Maine.1,5 The remaining abortion services in Maine and New Hampshire are provided by freestanding private clinics.
New Hampshire is an ideal geographic location to study the specific effects of a parental notification law on minors seeking abortion because it is surrounded by only three states—two without parental involvement laws (Vermont and Maine) and one with a more restrictive parental consent law (Massachusetts) (Fig. 1).
We collected information regarding the patient's age (years), gestational age (completed weeks) at the time of abortion, state of residence, and state where the abortion service was provided. Study participants were identified from a prospectively collected database of all abortion patients, and personal information was redacted before data use for research purposes. Information on parental involvement was self-reported and confirmed by clinic staff. If a parent was not aware or present at the time of the abortion, judicial bypass was confirmed if required, and patients reported whether another adult was aware or present. We excluded participants who had less than 4 or more than 16 completed weeks of gestation and participants for whom an address was not provided or known. The 16-week gestational age limit was used because that was the limit for abortion services at all clinics in the study at the beginning of 2011.
Statistical analysis was performed using OpenEpi 36 and VassarStats7 using standard t test, χ2, Fisher exact tests, or Wilcoxon rank-sum tests where appropriate. We did not have an a priori sample size calculation, because all cases from the Planned Parenthood clinics were collected during the study period. A post hoc power analysis demonstrated that we had 80% power to detect a 36% decrease in the number of abortions in minors in New Hampshire. The study protocol received exempt certification from the University of Vermont institutional review board because study personnel accessed only deidentified data for study use.
A total of 385 abortions among minors occurred during the study period, 12 of which were excluded based on gestational age (two participants less than 5 weeks of gestation, two participants more than 16 weeks of gestation) or incomplete or unavailable address information (eight participants). The remaining 373 cases were included in our analysis. Abortions in minors decreased in all three states from 2011 to 2012 with a total decrease of 25% (95% confidence interval [CI] 19.99–32.10) despite stable numbers of procedures in adult patients over the same time (Tables 1 and 2). There was a 47% (95% CI 37.03–57.88) decrease in abortions performed in New Hampshire that was largely attributable (62% [28/45]) to a significant decrease in the number of Massachusetts minors crossing state lines. In comparison, 24.4% (11/45) of the decrease in the number of abortions was attributable to New Hampshire minors and 15.6% (7/45) to Vermont minors. Abortions among minors who resided in New Hampshire decreased by 19.3% (95% CI 10.05–31.91) during the study period, a rate comparable to that seen in Vermont (17.8%, 95% CI 9.84–28.53; P=.707) and Maine (16.7%, 95% CI 7.92–29.29; P=.585) (Table 2).
Evaluation of the demographic variables revealed no difference in the age or gestational age by state of service or year of procedure, and the average gestational age for abortion was between 8 and 9 weeks in the study population (Table 3). There was no change in the number of second-trimester procedures based on state of service during the study period.
After enactment of the law, parental involvement increased in New Hampshire from 54% to 92% (51/94, 95% CI 44.21–63.96 to 46/50, 95% CI 80.65–97.36; P<.001), as shown in Table 4. Despite increased parental involvement in New Hampshire, the rate of overall adult (parent or other adult) involvement remained unchanged from 2011 to 2012 (95%, 95% CI 87.85–98.01 to 94%, 95% CI 83.16–98.56; P>.999). Four minors (8%) in the study population used the judicial bypass option in 2012, and clinic compliance with the law was strict. The rates of parental and adult involvement in Vermont and Maine, states unaffected by the law, averaged 75% and 22%, respectively, such that only 2% of minors did not involve some adult in their decision. There was no change in parental or adult involvement rates in these states.
Contrary to our hypothesis, the number of minors crossing state lines for abortions at Planned Parenthood clinics in northern New England decreased among the study population from 21.5% to 8.2% (46/214, 95% CI 16.5–27.5 in 2011 to 13/159, 95% CI 4.732–13.59 in 2012; P<.001). We observed no change in the number of New Hampshire minors crossing state lines from 7% in 2011 to 8% in 2012 (4/57, 95% CI 2.28–17.18 to 4/46, 95% CI 2.90–20.86; P>.999) among Planned Parenthood of Northern New England clinics. Closer examination of minors who crossed state lines found that there was no difference in rates of parental involvement for minors residing in New Hampshire, Maine, or Vermont. This is in stark contrast to Massachusetts minors, where the number of minors decreased from 29 to 2 and parental involvement increased from 21% to 100% (6/23, 95% CI 9.49–38.75 to 2/2, 95% CI 29.03–100; P<.013) during the study period among Planned Parenthood clinics.
Enactment of the New Hampshire parental notification law correlated with a decrease in the number of minors seeking abortions in the state, a finding that was largely but not completely attributable to a decrease in the number of Massachusetts minors crossing state lines. We observed no effect on the age or gestational age at the time of presentation and very few minors were observed traveling to Vermont or Maine Planned Parenthood clinics to avoid parental involvement. We observed high baseline rates of parental or adult involvement and parental involvement increased in New Hampshire after enactment of the law.
Although we observed no difference in the percentage of minors in New Hampshire who involved a parent or other adult in their care, there was a significant shift to increased parental involvement rather than another adult. Our study revealed high rates (54–77%) of parental involvement in minors' decisions to have an abortion compared with previous studies that found parental involvement in states without laws to be 61–64%.8,9 In addition, most minors who did not involve their parent informed another adult instead. In fact, only 2.7% of the study population (including states without a parental involvement law) involved no adult at all, indicating that almost all northern New England minors engage an adult in the decision to have an abortion.
Study strengths include its geographic location and ability to easily capture minors crossing state lines for abortion services within a confined area. The use of a control group before the enactment of the law removes the bias associated with using an older age group and allows for a direct comparison among similar populations. This study also provides focused data on abortions among minors in New Hampshire, one of the few states in the nation that does not require reporting of abortion statistics. This study was limited by a number of factors, including the small sample size and the lack of data from non-Planned Parenthood abortion providers. This study also only provides evaluation of the immediate effect of the law and does not predict any long-term consequences of the legislation.
Although we did observe a decrease in the number of minors having abortions, teenage birth rates in New Hampshire during this time showed a reciprocal trend, increasing from 5.4 in 2011 to 6.2 in 2012 per 1,000 among 15–17 year olds.10,11 Teenage births are a relatively rare event in New Hampshire and this difference is not statistically significant; however, it does mark a shift in the overall trend that previously had been continual decline in the teenage birth rate. This is in stark contrast to the trend of decreasing teenage birth rates both regionally and nationally. In comparison among the states of northern New England, there was an overall decrease in teenage birth rates from 2011 to 2012: Massachusetts 7.9 to 6.8 per 1,000, Maine 9.3 to 7.2 per 1,000, and Vermont 8.2 to 7.4 per 1,000.3 Although our study does not imply causality, it suggests that legislation may be limiting teen access to abortion in New Hampshire. Further trends in both the teenage birth and abortion rates in New Hampshire will be revealing.
This study adds to the growing body of literature studying the effect of legislation limiting access to abortion services among minors. Our study is similar to previous studies that demonstrated a decrease in the number of abortions and a decrease in minors coming into the state for abortion services from more restrictive states.12–14 We did not find evidence of minors leaving the state after enactment of the law, which has previously been shown,12 but that could be related to the higher baseline rates of parental and adult involvement.
In summary, we found that there was a decrease in the number of minors seeking abortions in New Hampshire, which was largely attributed to a decrease in Massachusetts minors crossing state lines. Furthermore, there were high rates of parental and adult involvement across the region. In New Hampshire, the rate of parental involvement increased as a result of the law, but there was no change in the rates of overall adult involvement. Use of the judicial bypass option was an uncommon event as was New Hampshire minors crossing state lines to avoid parental involvement. Ongoing evaluation of these trends is needed to monitor the effects of this legislation over time.
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