Abortion is a very common, safe medical procedure that nearly one in four women (23.7%) in the United States will experience in their lifetime. Between 2008 and 2014, the national abortion rate declined 25%, with the largest decrease (46%) reported among adolescents ages 15 to 19, in large part because of improvements in contraceptive use.

Although the lifetime incidence of abortion has declined, rates continue to vary widely by race and ethnicity because of structural factors, including racism, discrimination, and lack of access to family planning services. Researchers at the Guttmacher Institute found that black women were overrepresented among abortion patients with the highest abortion rate (27.1 per 1,000). Access to abortion services also varies greatly depending on a woman’s health insurance coverage, geographic location, and age.1

When accessing reproductive health services, particularly abortion, young people face additional barriers, such as cost, stigma, confidentiality, and privacy concerns. Although research supports adolescents’ cognitive ability and autonomy to choose abortion, state-level abortion restrictions present an undue burden for those defined as minors (younger than 18 years of age). Most states require parental notification, parental consent, or both, which has been shown to contribute to adolescents delaying or foregoing healthcare altogether.

Even when a young person has health insurance that includes abortion coverage, billing practices often do not ensure privacy or confidentiality, resulting in sensitive services being revealed to parents or guardians. The Society for Adolescent Health and Medicine and the American Academy of Pediatrics support protections of confidentiality for adolescents and young adults in healthcare billing and insurance claims processes as essential to providing necessary quality healthcare.2

Teens Face Barriers in Care

Given these notable barriers, in 2018 researchers assessed differences between adolescents and adults seeking abortion funds. The term abortion fund “refers to a collection of organizations that provide financial assistance and advocacy, with the goal of removing barriers to abortion for those who find it economically inaccessible.”3 Researchers analyzed case data for 3,288 abortion fund recipients from 2010 to 2015. Of the recipients, 481 were adolescents (17 years or younger) and 2,807 were between 18-49 years of age.2

Results of this study reiterate that health policy in the United States disproportionately burdens adolescents compared to adults and that young people receiving abortion funds experience greater personal hardships than adult patients. Two additional significant findings showed that adolescents were more likely to seek abortion because of lack of contraception and that a greater proportion of recipients aged 17 years or younger identified as black.2

Although overall rates of pregnancy and birth among U.S. adolescents declined between 2007-2014, three in four adolescent pregnancies still are reported as unintended, which suggests a need to explore how providers can support improved contraceptive use. In a recent study, investigators found that increases in using one or more contraceptive methods (78-88%), dual methods (24-33%), long-acting reversible contraception (LARC; 1-7%), and withdrawal (15-26%) were the primary reasons for the declines. Although these findings are optimistic, we also must examine what access to contraception looks like for adolescents, especially those of color, if we seek to improve them.4

Even when financial barriers are removed, numerous other factors affect a young person’s ability, motivation, and willingness to use contraception. Economic disadvantage, neighborhood characteristics, and lack of education all are structural barriers that contribute to the disparities in contraceptive use and abortion rates.5 Equally important, the United States has a troubled history of reproductive abuses against women of color, involving forced sterilization, coercive family planning policies, race-based discrimination, and anti-choice messaging associating abortion with a racist conspiracy.

One national representative survey showed that 42% of blacks and 51% of hispanics believed that the government promotes contraception to limit minorities, compared to only 25% of whites, contributing to skepticism about the motivation of family planning providers.6 This deep-seated mistrust of the medical system should help inform providers’ contraceptive counseling practices, particularly when discussing LARCs with young women of color, to promote reproductive justice for all adolescents. The term reproductive justice, coined by women of color, acknowledges the relation between social justice and reproductive rights and addresses intersecting oppressions regarding access.7

Both findings further demonstrate the issue of constrained access to reproductive health services, particularly abortion, in the United States for adolescents and people of color resulting from systemic and structural factors that include racism and discrimination. Health professionals have a responsibility to recognize how these systems affect young people of color and acknowledge how these underlying factors inform provider biases.

The Society for Adolescent Health and Medicine released a position paper in 2018 that addresses the harmful effects of racism on nondominant racial-ethnic youth and youth-serving providers.8 The paper proposes many recommendations and strategies as a call to action for organizational change, which include:

  • Engaging in advocacy efforts that support adolescent patients and reject harmful policies that pose additional barriers for young people and people of color. (Review the Physicians for Reproductive Health’s advocacy training resources at https://bit.ly/2OYvR5z.)
  • Understanding adolescents as autonomous individuals and providing youth-friendly services in your practice that address their specific needs. (Visit the Physicians for Reproductive Health’s Adolescent Reproductive and Sexual Health Education Program module on “Abortion and the Adolescent Patient” at https://bit.ly/2AbkW0a.)

When we, as front-line staff, counselors, advocates, and providers, educate and inform ourselves about adolescents’ specific and local rights and resources to help them navigate the process of accessing an abortion, this speaks volumes to young people and is a distinct form of advocacy.

REFERENCES

  1. Jones RK, Jerman J. Population group abortion rates and lifetime incidence of abortion: United States, 2008-2014. Am J Public Health 2017;107:1904-1909.
  2. Ely GE, Hales TW, Jackson DL, et al. Access to choice: Examining differences between adolescent and adult abortion fund service recipients. Health Soc Care Community 2018;26:695-704.
  3. National Network of Abortion Funds. Available at: https://bit.ly/2IVwCXI. Accessed Oct. 19, 2018.
  4. Lindberg LD, Santelli JS, Desai S. Changing patterns of contraceptive use and the decline in rates of pregnancy and birth among U.S. adolescents, 2007-2014. J Adolesc Health 2018;63:253-256.
  5. Hock-Long L, Herceg-Baron R, Cassidy AM, Whittaker PG. Access to adolescent reproductive health services: Financial and structural barriers to care. Perspect Sex Reprod Health 2003;35:144-147.
  6. Dehlendorf C, Harris LH, Weitz TA. Disparities in abortion rates: A public health approach. Am J Public Health 2013;103:1772-1779.
  7. SisterSong Women of Color Reproductive Justice Collective. Reproductive justice. Available at: https://bit.ly/2NH5Vac. Accessed Oct. 19, 2018.
  8. Racism and its harmful effects on nondominant racial-ethnic youth and youth-serving providers: A call to action for organizational change. J Adolesc Health 2018;63:257-261.