Abortion legislation.

‘Restrictive abortion legislation’ created greater challenges for adolescents to access services whilst trying to maintain confidentiality from their family. Fuentes et al. reported women’s experiences accessing abortion in Texas after the 2013 House Bill 2 (HB2) was passed. A Bill which further restricted abortion service provision resulting in the closures of abortion facilities [27]. Adolescents described trying to work out how to keep their pregnancy and subsequent abortion a secret from their parents [27]. Adolescents stated that legislative changes affected their ability to secure an abortion privately as availability of services had reduced. As a result adolescents had to seek assistance from their parents to access a clinic [27]. In 2016 HB2 was overturned by the US Supreme Court [60, 61].

Under the ‘Clinic-based gestational age limits’ theme, in a five-year longitudinal study 35% of adolescents 15 to 17 were turned away from services as they were over the clinic’s gestational limit. Clinic gestational age limits varied between clinics and were not stated in the paper. This is a larger proportion than the 24% of 18 to 24-year olds and 20% of 25-34-year olds who were turned away [44].

Under the sub-theme ‘Adolescent specific legislation’ key data related to ‘Parental notification law’ and ‘Judicial bypass’. In the US, parental notification and consent legislation varies from state to state [62]. Individual states require consent from at least one, sometimes both parents, others require only parental notification about the abortion procedure [62]. Two quantitative studies from the US investigated the effects of the introduction of parental notification laws on the ability of minors to obtain an abortion in New Hampshire [28] and Illinois [30]. Both studies found a decrease in adolescents seeking abortions following legislative change at 12 months [30] and two years [28].

Provider and frontline abortion clinic staff knowledge of adolescent-specific abortion legislation was high, greater than 90% of front-line staff interviewed [37] and greater than 50% of physicians interviewed [38]. Riley at al. found that physicians with adolescent children were supportive of the parental notification laws [31].

One study compared adolescent abortion across four different countries. It reported in two of the countries a different approach to the involvement of parents in adolescent abortion service seeking [54]. Swedish and Dutch health professionals supported adolescents to engage in discussions with their parents about their unintended pregnancy [54]. In Sweden, providers cannot legally talk to parents without adolescent consent [54].

Judicial bypass refers to an American bureaucratic process allowing adolescents to obtain an abortion without having to notify or receive parental consent by way of a judge granting permission. This was the focus of three quantitative studies [28, 37, 57] and two qualitative case studies [34, 48]. Judicial bypass is a costly and bureaucratic process [63]. The process involves judges questioning adolescents to determine if they are ‘mature’ enough to undergo an abortion. If their responses are deemed rational and intelligent, a judge may permit the adolescent to have an abortion [63]. If not, the adolescent has to carry the pregnancy to term [63]. Three studies identified ways in which adolescents received information about how to obtain a judicial bypass [28, 37, 57]. Adolescents did not receive correct information about their legal options. For example, one participant was incorrectly informed that abortions for adolescents under the age of 18 were not allowed in her state and another participant was not provided accurate information about the judicial bypass court process [57]. Participants in three studies state judicial bypass and parental notifications laws do not serve adolescents, instead address the beliefs of adults that adolescents lack rational and responsible decision-making capabilities [34, 48, 53]. Jacqueline, a participant from Coleman-Minahan et al. who was denied a judicial bypass, stated to her court-appointed guardian-ad-litem and the judge during her hearing,

You guys keep telling me I’m not mature enough to make this decision and I don’t know what I’m getting myself into, yet…if I’m not mature enough to make a decision like this how am I mature enough to even have a baby and to go through the emotional and physical changes of having a kid? [34]

However, in Deeb-Sossa et al., Estefania, an adolescent seeking an abortion, revealed how she was provided appropriate information and support about how to access abortion without her father having to be notified [48]. In Coleman-Minahan et al. the majority of adolescents stated that their attorneys and staff from the non-profit they had accessed provided them the most and at times only source of support. Jasmin, one participant, explained that her attorney “cared more than just about the procedure. She actually asked me about my future and what I wanted to do…” [34]. In the studies by Coleman-Minahan et al., Deeb-Sossa et al. and Ehrlich et al. adolescents described their experiences of being extensively questioned by judges and health professionals about their maturity and reasons for an abortion [34, 48, 57]. Adolescents expressed apprehension about travelling to court and the need for support in the court room [57]. Melissa, one of several participants, discussed being nervous, anxious about talking to the judge and fearful that she would not be granted a judicial bypass [57]. Coleman-Minahan et al. found in their study that adolescent’s experience of obtaining a judicial bypass were unpredictable, humiliating, caused emotional distress and for some was a traumatic experience [34].

Confidentiality.

Maintaining one’s confidentiality was an important aspect of abortion care. Concern around confidentiality was reported in three studies [46, 48, 57]. Ethnographic research with an adolescent, Estefania, found a desire for privacy when seeking abortion care was essential for her. Adolescents cited several reasons not to disclose their desire for an abortion to their parents. These reasons included: a belief that their parents would be upset, fear of adverse reactions, anticipated harm to their relationship with their parents, concern for their parent’s health, and a belief that they would be pressured to continue the pregnancy [46]. Adolescents expected difficult family relations, desired autonomy, and feared that news of their pregnancy and/or abortion would be shared with others [57].

Comprehensive care.

‘Comprehensive care’ is a necessary component of abortion care. It encompasses the range of services and resources provided pre- and post-procedure. Ensuring individuals are provided and have access to all necessary information and care required [64]. The findings from six studies described ‘components of care’ which surround the actual abortion procedure, and included pre- and post-counselling, support and provision of contraception if desired. Three studies examined decision-making and the need for pregnancy options counselling [47, 53, 54] and three examined contraceptive counselling and follow-up with women at the point of care [35, 36, 55]. Experts interviewed in Welsh et al. stated that “counselling was a crucial element of a clinic visit involving a teen’s request for pregnancy termination” [54]. However, in other studies, adolescents reported that counselling was not necessary as they had already made their decision to have an abortion [47, 53]. For example in Brown’s 2013 study, that explored whether or not young British women would accept pregnancy options counselling, participants generally declined. Counselling was not necessary because they had already decided not to continue with the pregnancy [47].

Two studies explored the provision of contraception at the time of abortion as an aspect of comprehensive care. In Aiken et al. adolescent participants were significantly more likely (P< 0.001) than adults to obtain contraception from the non-profit abortion provider and choose an intrauterine contraceptive or implant [35]. In contrast adolescents in Israel, 67.6% were not provided a prescription for contraception peri-abortion [36].

Abortion procedure.

Three studies focused on the experience and acceptability of the abortion procedure itself as part of ‘components of abortion care’. Phelps et al. studied the experiences of adolescents who had undergone complete, uncomplicated medical abortions [41]. The acceptability of the procedure appeared to increase over time [41]. Fielding et al. explored adolescents’ experience of medical abortion and their choices [49]. A 19-year-old participant stated that she chose medical over surgical abortion because it seemed to be less mentally distressing [49]. Another adolescent stated, “cramping was the worst part” [49] but was “relieved that it is over with” [49]. In contrast, in Halldén et al. adolescents found surgical more convenient and less confronting [51].

Delays in access.

Studies found and examined delays that adolescents experienced at various points along their abortion care trajectory. These delays were either self-created (e.g., failing to recognise the unwanted pregnancy) or externally created (e.g., need for parental consent and judicial bypass). Studies also examined the effects that these delays experienced by adolescents had on their access to abortion care. The first sub-theme was ‘Individual delays in access’. In three studies, adolescents experienced a longer delay than adults in identifying that they were pregnant [21, 53, 58]. In Finer et al. <18-year olds took a week longer than all other age groups to suspect pregnancy [58]. Reasons for not suspecting pregnancy was examined in Mantovani et al. with asylum seekers in the UK under state care. Adolescents believed their symptoms were due to stress and changes in their environment [53].

The second sub-theme was ‘System-level delays’. In a New Zealand study, the age of woman had a statistically significant individual effect on the delay to abortion access. The average days between first visit with a referral doctor and the abortion for 20-year-olds and younger was 26.1 days. This delay gradually decreased as age increased [43]. The study by Finer et al. in the US found that on average ≤17-year-olds took more than 70 days from last menstrual period to the abortion. This was at least 10 days or more than adults [58].

Two studies from the US examined the effects of delays on adolescents access to abortion care. The studies found adolescents were more likely than older women to have an abortion later than 12 weeks of gestation [20, 45]. Eighteen to 19-year olds were significantly (P = 0.03) more likely than 20–24 year olds to have an abortion > 12 weeks [20], whilst 13 to 19 year olds were more likely (P = 0.04) than older woman (>19 years) [45].

Information about abortion procedures.

Four studies examined information adolescents received concerning how to access abortion care, and the abortion procedure [33, 48, 49, 54]. Adolescent’s encountered abortion misinformation and inaccuracies in common social beliefs about the abortion procedure. This lead adolescents to avoid surgical abortion methods [49] and sought accurate information for themselves [33, 46]. In the Netherlands, information on how to access abortion care is provided to adolescents in school [54].

Decision-making process.

Adolescents sought to make appropriate decisions for themselves. Adolescent’s decision-making was the beginning of their trajectory and access to the health system. In six studies, adolescents’ reasons for seeking an abortion were explored. These included their age, male partners/ boyfriends leaving, disruption of future life goals (education and career), current life circumstances, their inability to take care of and provide for the child, their relationship with their parents, pressure from parents or partner, and issues related to pregnancy, abortion, or adoption [29, 46, 47, 52, 57, 59]. Adolescents stated: “…couldn't raise a child nor give it up for adoption” [57], “…pregnancy a mistake/accident” [57], “…I have a big future. He has a big future. It’s not something we want right now. It was a huge mistake” [36], “…abortion the best solution", "couldn't go through with adoption” [57], and “because I felt that it’s unfair on the child if I bring it up now” [52].

Four studies examined those with whom adolescents talk about making a decision. Adolescents appear to discuss their decision-making with influential adults (such as a clergyman, pastor, teachers, doctors, social workers) [53, 57], their mother/parents [42, 57], boyfriend or male partner [42, 53, 57], friends, or other family members. Some adolescents reported they did not talk to anyone as they had made the decision for themselves [47, 58] and realised the decision was their own [46]. One participant stated, “Yeah, but I didn’t take it because I knew straight away as soon as I found out. I already knew that I didn’t want it. (R3, aged 17)” [47].

Several factors were found to influence abortion decision-making, including expectations of negativity from adults around them [52, 53, 57], adolescents’ own cultural and/or religious beliefs [53], parent(s)’ reaction to their pregnancy [42, 51, 53, 57], and boyfriend/male partner leaving [53, 56]. Partner support was found to indicate less involvement of the mothers of adolescents [42]. Other factors influencing decision-making included male partner’s attitudes towards the pregnancy and/or abortion [42, 54], inability to financially support the child [46, 47, 51], and the effect on their future life plans [46, 51, 58]. For 24% of 15-to 19-year-olds in Chibber et al., their partner was the reason they sought an abortion [56].

Clinic operation and environment.

Two sub-themes emerged under this theme. Under ‘Effects of protesters’, a study in the US found protesters appear to emotionally affect and upset adolescents [39].

The second sub-theme was ‘Telemedicine’. Telemedicine is an option for adolescents who are unable to travel long distances or cover the costs opted for when available [50]. Adolescent participants were comfortable with the idea as one 19-year-old stated “Our generation, we’ve always done video chat and everything so it’s not awkward or anything…To me it kind of felt like the same thing [as an in-person visit with the doctor] just because I’ve grown up using computers” [50]. Another adolescent felt telemedicine assisted her in accessing and talking to a doctor [50].

Structural barriers.

Adolescents experience heightened ‘structural barriers’ along their care-seeking pathway accessing an abortion. These barriers were beyond the adolescents control and appear to be exacerbated by their age and context. They were part of the external context and environment, e.g., geography, transportation and payment. Adolescents faced transportation and financial challenges in accessing abortion [26, 40, 45, 46]. In the US, experts questioned in Welsh et al. stated that geographical location is a barrier for adolescents in accessing abortions, especially as rural areas lack abortion providers [54]. White et al. examined the association between travel distance and returning for the abortion procedure and found no association. However, of 18.8% of women who did not return for an abortion, 34.7% were <18 [32]. In Grindlay et al. study of telemedicine in the US, a 19-year-old participant discussed the difficulty of getting time off work and how the long-distance she would need to travel would compound the situation [50].

An 18-year-old participant in Fuentes et al. stated she lived more than a three-hour drive from the closest abortion clinic and was unsure if she would be able to cover the costs of travel or the abortion procedure [27]. Data from the US and Australia indicate adolescents had difficulties with transportation, experiencing delays, and difficulty paying [21, 26, 37, 40, 45, 46]. In Ely et al. adolescents experienced significantly higher (P<0.001) procedural costs and greater distances to travel than adult women in the US [26]. Experts from four high-income countries interviewed as part of the Welsh et al. reported in Sweden, the cost of an abortion is less than the contraceptive pill, while in the Netherlands, it is free [54].