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Contraception Editorial October 2010

Parental Involvement Laws and Parent–Daughter Communication: Policy Without Proof

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Robert D. Webster, Amy N. Neustadt, Amy K. Whitaker, Melissa L. Gilliam

The number of states with parental involvement (PI) laws in effect has more than tripled over the past 20 years. Currently, 34 states enforce a PI law.1 Parental involvement law is an umbrella term for both parental consent and parental notification laws. Parental consent laws require one or both parents of a minor to give permission, in most cases written, prior to their daughter obtaining an abortion. Parental notification laws require one or both parents to be informed prior to their daughter obtaining an abortion. One of the main debates centers on the benefit or harm of PI laws to parent–daughter communication. Those who support PI laws argue that such laws benefit the daughter by promoting communication about the abortion decision, thereby helping the minor make better decisions about pregnancy resolution.2, 3 This argument is in line with public support for PI laws. National polls consistently find that approximately three quarters of those surveyed support PI laws.4, 5 In contrast, those who question these laws argue that legally mandated communication may harm the daughter by worsening the overall parent–daughter relationship, delaying access to medical care or putting her at risk for violence or abuse. Twenty of the leading medical and health care organizations, including the American Medical Association, the American Academy of Pediatrics, the Society for Adolescent Medicine, the American College of Obstetricians and Gynecologists, and the American Public Health Association, have policies explicitly supporting parental involvement in adolescent health care, but not at the expense of a minor's right to confidential care when considering an abortion.6, 7, 8, 9, 10, 11, 12, 13 Concerns about the effect of PI laws on communication reflect larger questions of whether these laws benefit or harm adolescents.

This editorial is timely as yet another state faces potential enforcement of a PI law. After a 15-year injunction, Illinois is nearing a crucial court decision on enforcement of its 1995 Parental Notice of Abortion Act.14 Illinois is currently the only Midwestern state without a PI law in effect. Enforcement of a law in Illinois will likely have effects beyond its borders.

We conducted a review of the literature to determine if there is evidence that legally mandated communication in the form of PI laws benefit or harm parent–daughter communication. Our review identified two main research areas on parent–daughter communication: (1) the frequency in which a minor informs a parent of her decision in states with and without PI laws; (2) the reasons for not telling and the consequences of telling a parent. Here, we review and assess the strengths and weaknesses of the extant literature making recommendations to clinicians, researchers, and advocates regarding areas for future research and policymaking.

1. Research on the effect of PI laws on parent–daughter communication 

Our review of the literature yielded nine studies examining rates of parent–daughter communication about abortion. Only two studies compare communication in states with PI laws in effect to states without PI laws in effect. In the smaller of the two studies, which was conducted in 1984, Blum et al. 15 found that almost two thirds of sampled minors in Minnesota (with a parental notification law) and Wisconsin (without a PI law) informed at least one parent of their plan to have an abortion (65.1% and 62.1%, respectively). In the second study, Torres et al.16 collected data in 1979 and 1980 from a nationally representative sample of 1170 minors, of whom 218 were subject to PI laws and 952 were not. Forty-five percent of subjects from states with PI laws versus 37% of subjects from states without PI laws informed their parents about their abortion.

Seven other studies examined rates of parent–daughter communication about the minor's pregnancy and her intention to terminate her pregnancy but only included samples of minors from states without PI laws in effect.17, 18, 19, 20, 21, 22, 23 Across these seven studies, 34–91% of minors told parents about their pregnancy termination plan. Four of the seven studies reported that more than half told their parents.17, 19, 21, 23 In the most widely cited of these seven studies, Henshaw and Kost20 examined parent–daughter communication using data collected in 1991 from a nationally representative sample of 1519 minors who underwent abortion and lived in states without PI laws. The authors found that less than half (45%) of all respondents told at least one parent about their pregnancy and abortion, although a majority (61%) of parents ultimately knew through other sources. The nine studies yielded from our review provide important information on the quantity of parent–daughter communication about abortion; however, five of these studies are at least 25 years old.15, 16, 17, 18, 19 The behaviors and practices of young people have most likely changed significantly since these studies were conducted.

2. Research on the anticipated or actual consequences of notifying or requesting consent 

Interestingly, neither of the two studies comparing communication in states with and without PI laws in effect assessed the consequences of a minor involving her parent15, 16, and only one reported why minors did not involve a parent.15 Blum et al.15 found that the major reason minors subject to the law did not notify a parent was that they anticipated family conflict. Similarly, in a study of Massachusetts minors who chose not to inform a parent, despite living in a state with a parental consent law in effect, almost one quarter (22.4%) feared that they would face family conflict, physical harm, or other abuse if they told a parent about the pregnancy.24 Other studies of minors in states without PI laws in effect report fear of physical punishment as the major reason for not involving a parent.18, 20 Henshaw and Kost's study20 of minors not subject to PI laws suggested that mandated communication could be harmful to youth. In this study, 3% of minors whose parents discovered their pregnancy without being told by the minor reported physical violence or being beaten after the parents became aware of the pregnancy versus 1% of minors who voluntarily told a parent.

3. Research on parent–daughter communication prior to pregnancy 

While research on the effect of PI laws on parent–daughter communication is limited, data suggest that good family functioning and communication prior to pregnancy reduce the need for mandated communication. In a study of 284 African-American adolescents who visited two Baltimore clinics for pregnancy testing, Zabin et al.19 found that adolescents were more likely to confide in a parent before the clinic visit if they felt it was easy to talk to their mother about sex or received most of their information about having a baby from their parents. In a study of 439 abortion patients ages 12 to 21 years in metropolitan Atlanta, Griffen-Carlson and Mackin21 found that youth who told their parents about the pregnancy were significantly more likely to describe their family communication as open and report being comfortable when speaking with a parent about sex. The two national studies also found that open communication about sex and contraception prior to pregnancy was associated with a minor telling a parent about her pregnancy.16, 20 Blum et al.25 found that minors subject to a parental notification law were more likely to notify their parents of the pregnancy instead of using the judicial bypass option if they perceived maternal support.

These studies about communication prior to pregnancy are consistent with what we know about benefits of general parent–daughter communication outside of pregnancy. In general, open communication leads to less sexual risk-taking and improved contraceptive and condom use and, therefore, reduces rates of sexually transmitted infections (STIs) and unintended pregnancy.26, 27, 28, 29, 30, 31 Additionally, ongoing parental communication about sex, sexuality, and development prior to pregnancy results in open and closer relationships between parents and their children.32, 33 However, studies have reported that many adolescents have limited communication with their parents about sexual health topics.34, 35 Moreover, when parents do discuss sexual health topics with their adolescents, the range of topics can be very narrow with a focus on “safe” topics such as biological changes and limited discussion of contraception, pregnancy, and psychological aspects of sexual activity.33, 36 Similarly, many parents lack the skills and knowledge to communicate effectively with their young daughters about these issues.34, 37, 38, 39 Thus, parental communication about sex and pregnancy is critical long before the pregnancy occurs. Parents need resources, education, and support to prepare for these discussions.

4. Policy despite limited data 

The existing literature on the effect of PI laws on parent–daughter communication has several limitations. We found no studies examining communication about minors' pregnancy and abortion plans in a state before and after a law went into effect including a control population, which may reduce bias in considering this question. Other researchers have provided recommendations for how rigorous studies might be conducted.40 In addition, we found no recent published studies, within the past 15 years, specifically addressing this question. Our review found mixed results in the two studies examining rates of parent–daughter communication in states with PI laws compared to states without PI laws. In addition, we found no evidence that higher rates of parent–daughter communication about abortion improve family relationships or adolescent decision making about abortion. Therefore, it is difficult to draw conclusions about the effect of these laws on the quantity and quality of parent–daughter communication. The existing literature contains some evidence suggesting that forced parent–daughter communication around abortion could be harmful or perceived as harmful for some youth.

5. Policy recommendations 

Evidence is critical for making accurate and effective policy recommendations. Current research is insufficient to conclude whether PI laws benefit parent–daughter communication and relationships, and therefore, existing policies and laws are not evidence-based and should reflect this fact. While adolescents should be encouraged to involve their parents in their reproductive health care, in the absence of rigorous studies demonstrating that PI laws provide tangible benefit to the adolescent, her right to confidential care should remain intact. In addition, with good evidence to support the benefits of increased pre-pregnancy communication, it is critical to implement and support evidence-based policies that foster healthy parent–daughter communication about sexual decision making. Such communication leads to less sexual risk-taking and improved contraception use, thereby reducing rates of STIs and teenage pregnancy and promoting parent–daughter communication should pregnancy occur.

Robert D. Webster
Section of Family Planning and Contraceptive Research Department of Obstetrics and Gynecology The University of Chicago Chicago, IL

Amy N. Neustadt
Section of Family Planning and Contraceptive Research
Department of Obstetrics and Gynecology
The University of Chicago
Chicago, IL

Amy K. Whitaker
Section of Family Planning and Contraceptive Research
Department of Obstetrics and Gynecology
The University of Chicago
Association of Reproductive Health Professionals
Chicago, IL

Melissa L. Gilliam
Section of Family Planning and Contraceptive Research
Department of Obstetrics and Gynecology
The University of Chicago
Association of Reproductive Health Professionals
Chicago, IL

References

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Used with permission from Elsevier, Inc.