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Recent years have seen new challenges to laws protecting minors’ confidential access to reproductive health services. Little research has explored parental views on the issue.
To examine parents’ views about laws requiring parental notification (PNLs) when minor children seek to obtain prescription contraceptives, the exceptions parents would endorse, and the consequences they would expect.
Fifteen-minute telephone surveys conducted in 2002.
Minnesota and Wisconsin.
Population-based sample of 1069 parents of adolescents aged 13 to 17 years with a working telephone number. An additional 1095 eligible parents declined and 360 were not available to participate.
Main Outcome Measures
Views about PNLs (“Do you think a law requiring notification of parents when a teen requests birth control from a clinic is a good idea, a bad idea, or neither a good nor a bad idea?”).
Of the eligible parents, 42.4% completed the survey. More than half (55.1%) of participants thought PNLs were a good idea. However, 96.1% of parents expected at least 1 negative consequence and 47.6% expected 5 or more negative consequences to result with the enactment of PNLs. For exceptions to PNLs, 85.5% of parents endorsed at least 1, and 29.7% endorsed 5 to 6. Each additional anticipated positive consequence of enacting PNLs was significantly associated with more than twice the odds of favoring PNLs (odds ratio [OR], 2.28), and each additional negative consequence was associated with lower odds of supporting PNLs (OR, 0.87). Likewise, each additional exception endorsed was associated with lower odds of supporting PNLs (OR, 0.71).
Many parents hold complex views on the need for confidentiality and the appropriate involvement of parents in adolescent health care services. Educating parents about the potential negative consequences of parental notification could change their support of PNLs.
Although policies vary widely from state to state, a variety of laws and statutes allow adolescents to obtain certain health care services on a confidential basis.1-4 However, recent years have seen increasing challenges to minor consent laws, particularly in the domain of reproductive health care.1 Since 2000, more than a dozen states have considered repealing or modifying laws that allow minors to consent to reproductive or other health care or have considered restricting access to confidential care for minors.
Health care providers (physicians, nurses, etc) and professional organizations have been clear in their support for confidential health care for minors seeking reproductive services. According to the American Medical Association,
Uncertainty about whether health services will be confidential is perceived by both physicians and adolescents as a factor that may lead some adolescents to suppress relevant information or delay or avoid medical visits. Lack of candor makes it harder for the physician to identify and provide appropriate treatment for the adolescent’s medical problems. The delay or failure to seek necessary care may result in more serious short- or long-term complications.5
Although they consistently encourage young people to involve their parents in health care decision making, numerous health care professional organizations conclude that “the potential health risks to adolescents if they are unable to obtain reproductive health services are so compelling that legal barriers and deference to parental involvement should not stand in the way of needed health care for patients who request confidentiality.”6,7
Research regarding adolescents’ health care attitudes, use of clinics, and parental involvement has long shown that young people may be reluctant to seek needed care if their parents must be notified.8-11 In a recent study of adolescent girls using reproductive health services, Reddy and colleagues12 found that 59% of these girls reported that they would stop using sexual health care services, delay testing or treatment for sexually transmitted infections, or discontinue use of specific sexual health care services if their parents were informed when they seek prescription birth control. Taken together, the body of research with adolescents suggests that withholding assurances of confidentiality in reproductive health care for minors poses threats to individual and public health.
Although parents are the third group affected by laws governing health care disclosure regarding adolescents, very few studies have explored parents’ views on these medicolegal issues. One published study by Cutler and colleagues13 found that Minnesota parents were not knowledgeable about state laws concerning adolescent medical care. In their study, no clear majority of parents favored or opposed laws ensuring minors’ access to confidential reproductive services. A more complete assessment of parents’ views on laws related to minors’ access to contraceptive services can make important contributions to public discourse. Ultimately, such discourse can exert a strong influence in policy decisions affecting the health of young people.
The present study builds on previous work by delving more deeply into parental notification laws (PNLs) to obtain a clearer picture of parents’ views on this health care issue. We looked specifically at parents’ views on PNLs (which have been proposed as legislation) that would require health care providers to notify parents, in writing, when their adolescent seeks to obtain prescription birth control methods (a service that is currently provided confidentially, ie, without a parental notification requirement). Furthermore, we examined parents’ beliefs regarding the expected consequences and exceptions to such laws, and the relationship of such beliefs to parents’ global views on PNLs. Thus, findings from this study can inform public discourse on adolescent health services policies and shape public education efforts regarding health care services that are responsive to adolescent health needs.
Study design and sample
Data for this study come from a telephone survey conducted with a sample of parents of adolescents aged 13 to 17 years living in Minnesota and Wisconsin, from March 6 through June 29, 2002. Telephone lists were purchased from Genesys Sampling Systems with the goals of (1) maximizing the proportion of calls reaching parents of adolescents aged 13 to 17 years and (2) achieving a sample representative of race and population density distributions within each state. Trained interviewers at the University of Wisconsin–Milwaukee Institute for Social Policy Research conducted the surveys using a computer program from Computer Aided Technology, Inc (Buffalo Grove, Ill).
Of the 5349 telephone calls made, 2524 reached eligible contacts. Eligible persons were Minnesota or Wisconsin parents with at least 1 adolescent child aged 13 to 17 years living in the home and who were physically able to complete the interview and spoke English. A total of 1069 parents (500 in Minnesota and 569 in Wisconsin) completed the 15-minute survey, representing 42.4% of the eligible sample. This response rate is similar to those of other recent large telephone surveys conducted with purchased lists.14
Instrument and measures
Study investigators developed the telephone survey instrument through a systematic review of items that have been used in various state and national surveys of young people and parents. Information on the psychometric properties of key survey measures have been published previously.13,15-19 Pilot testing with 26 eligible Wisconsin parents (who were not included in the final sample) allowed investigators to make minor changes in question wording, order, and survey length to minimize respondent burden and maximize question clarity. Completion of the telephone interview implied consent to participate, and the institutional review boards of the University of Minnesota, Minneapolis, and University of Wisconsin–Milwaukee approved all study protocols.
The telephone survey included 3 items assessing the study outcome, parents’ views on PNLs. These items were asked at different points during the interview and included the following: “In most states, a person aged 17 or younger can obtain contraceptives or birth control from health care clinics without parent consent. In your opinion, is this a good idea, a bad idea, or neither a good nor a bad idea [question A]?” “A parent notification law might be like this: When a minor teen requests birth control from a clinic, the clinic would need to send a certified letter to the teen’s parents. The clinic would wait for proof that the letter arrived, plus wait 5 more days before providing birth control to the teen. Do you think sending a letter like this is a good idea, a bad idea, or neither a good nor a bad idea [question B]?” and “Thinking about this idea overall, do you think a law requiring notification of parents when a teen requests birth control from a clinic is a good idea, a bad idea, or neither a good nor a bad idea [question C]?”
The study’s key independent variables were measured with a survey item assessing perceived consequences of PNLs and an item assessing exceptions to PNLs, as shown in Table 1. To control for reinforcing or saliency effect artifacts, the computer from Computer Aided Technology, Inc was programmed to randomize the order in which PNL exceptions and consequences were presented during the interview. The numbers of positive and negative consequences expected and the number of exceptions endorsed were summed separately to create 3 continuous measures. In addition, we assessed several demographic and personal characteristics, including sex, age group, race, religion, educational attainment, income level, and political orientation of the respondent/parent, and sex of the adolescent (Table 2).
Sampling weights adjusted the proportion of Wisconsin participants from different racial backgrounds to reflect the proportion of white and nonwhite participants in Wisconsin according to 2000 Census Bureau reports. The Minnesota sample was proportional to the state on this characteristic, so it was not weighted.
We reported the proportion of parents giving each response for the 3 PNL items, each perceived consequence, and each possible exception. With logistic regression, we examined associations between parents’ views on PNLs and the 3 PNL-related beliefs (number of exceptions, perceived positive consequences, and perceived negative consequences), as well as 8 demographic and personal characteristics. The final sample for each analysis included only respondents who reported that the current practice or the proposed law was a good or a bad idea. Initially, we examined bivariate relationships between parents’ views on PNLs and each independent variable as described in this paragraph. For multivariate models, we entered all 3 key independent variables (number of exceptions and perceived positive and perceived negative consequences) and all demographic and personal characteristics simultaneously. The patterns of relationships with independent variables were markedly similar for the 3 PNL items (questions A, B, and C). For clarity of presentation, and because question C was presented during the interview as the summary question that addressed overall parental attitudes toward PNLs, we only report results of bivariate and multivariate analyses completed with question C.
Characteristics of the sample
Most respondents were white (88.5%), female (67.8%), and aged 40 to 49 years (65.8%). Approximately half (47.2%) were self-identified as Protestant, and an additional 38.9% as Catholic. Approximately one quarter of respondents (26.1%) had completed high school as their highest educational level, and 71.7% had pursued some type of post–high school education. More than one third (35.7%) of parents surveyed had a bachelor’s degree (24.2%) or a graduate/professional degree (11.5%). Almost half (47.9%) of household annual incomes were in the ranges of $41 000 to $60 000 or $61 000 to $80 000. One third (32.2%) of parents considered themselves somewhat politically conservative, and an additional 38.0% assessed their political orientation as middle-of-the-road. Approximately half (53.5%) of the sample had a male qualifying child.
PARENTS’ VIEWS ON PNLs
The Figure shows parents’ responses to the 3 PNL measures. Almost half of parents (49.1%) viewed a minor’s right to obtain contraceptives without parental permission as a good idea (question A); 42.1% thought sending written notice to parents before dispensing prescribed contraceptives was a good idea (question B); and 55.1% thought that overall, a PNL was a good idea (question C).
Parents’ views on 3 items concerning parental notification laws. Questions are described in the “Instrument and Measures” subsection of the “Methods” section.
Some combinations of responses to questions A, B, and C highlight the complexity of views on this topic. For example, of those parents who viewed a minor’s right to receive contraceptive services without parental consent as a good idea (question A), only 42.3% were also opposed to PNLs (questions B and C); 21.6% thought that minors’ right to services without parental consent and PNLs were a good idea. Of parents who opposed minors’ consent to contraceptive services (question A), approximately two thirds (64.4%) described PNLs as a good idea. However, 13.4% of these parents reported PNLs as “a bad idea” for 1 or both of the other survey items. Among parents who said that minors’ access without parental consent (question A) was not a good or a bad idea, 40.8% thought PNLs were a good idea and 7.8% thought PNLs were a bad idea, as reported in questions B and C.
Most parents anticipated some consequences if PNLs were enacted (Table 3). A slight majority of parents (53.4%) expected at least 1 positive consequence, primarily that teenagers would think more before having sex (42.2%) or would be more apt to talk with their parents (33.1%). Only 9.5% expected 3 or 4 positive consequences. Few parents (15.4%) believed teenagers would have less sex if PNLs were enacted, and even fewer believed PNLs would cause teenagers to stop having sex (3.6%). Conversely, almost all parents (96.1%) expected at least 1 negative consequence, and nearly half (47.6%) expected 5 or more negative consequences from enactment of PNLs. Three quarters (75.5%) of parents thought PNLs would result in teenagers using birth control methods that did not require a clinic visit (such as condoms and foam), and two thirds (67.3%) expected teenagers would have more unprotected sex if PNLs were enacted. Most parents also anticipated more teen pregnancies (58.5%) and sexually transmitted infections (58.2%) if PNLs were enacted.
Table 3 also illustrates exceptions to PNLs that were supported by parents. Most parents (85.5%) endorsed at least 1 exception to PNLs, and close to one third (29.7%) endorsed 5 or 6 exceptions. The most commonly endorsed exceptions included cases in which an adolescent was abused or involved in incest (67.6%). Most parents also favored waiving parental notification if an adolescent was at risk of harm from the parent (56.7%) or had a poor parental relationship (51.3%).
ASSOCIATIONS BETWEEN EXCEPTIONS AND CONSEQUENCES AND PARENTS’ VIEWS ON PNLs
Using odds ratios (ORs) derived from logistic regression analysis, Table 4 shows the odds of supporting PNLs in relation to the number of positive and negative consequences expected, the number of exceptions endorsed, and parents’ demographic and personal characteristics. Significant bivariate relationships between PNL views and PNL-related beliefs were in the expected directions. Each additional perceived positive consequence of enacting PNLs was associated with more than twice the odds of supporting PNLs (OR, 2.41). Each additional negative consequence was associated with lower odds of supporting PNLs (OR, 0.79). Likewise, each additional exception endorsed was associated with lower odds of supporting PNLs (OR, 0.67). Mothers (vs fathers), parents with more liberal political orientations, parents with more education, and parents with higher incomes were less likely to favor PNLs.
In the multivariate logistic regression in which all variables in Table 4 were entered simultaneously, associations between views on PNLs and the numbers of perceived positive consequences (OR, 2.28), perceived negative consequences (OR, 0.87), and number of exceptions endorsed (OR, 0.71) were attenuated slightly but remained statistically significant after controlling for social and personal characteristics. Of demographic factors included in the multivariate model, only political orientation remained significantly associated with PNL views, such that more liberal parents tended to be less in favor of PNLs (OR, 0.63).
These results paint a complicated picture of parental views on the rights of minors to consent for contraceptives and PNLs. Approximately half of parents endorse a minor’s right to receive confidential reproductive health care services without parental notification and, likewise, to give their own consent for prescription contraceptives. Approximately half believe that, overall, PNLs are a good idea. However, these are not necessarily opposite halves of the sample. Many parents reported a combination of responses (good idea, bad idea, or neither) that were to some extent inconsistent across the 3 key questions, ie, 22% of parents who supported minor consent also supported PNLs, and 13% of parents who did not support minor consent also did not support PNLs. Such combinations of responses may, in fact, reflect parents’ multifaceted views about the need for confidentiality on the one hand and their own desire to be involved on the other. For example, although parents might want their teenager to have access to contraceptives unencumbered by the need to obtain assurance of parental notification, they also might favor policies that they believe would facilitate communication with their adolescent, such as PNLs. Alternately, different wordings in each question (eg, use of the word law in 2 of 3 items) may also mean that items were tapping into slightly different constructs. Parents may, for example, have reported a combination of what they would like to have vis-à-vis adolescent health care and what they think the laws need to be. These different constructs may account for the complex findings in this study.
Our multivariate findings suggest that parents’ views in support of PNLs are associated with perceiving more positive consequences and fewer negative consequences and endorsing fewer exceptions to such laws. Parents’ views on issues related to their teenagers’ access to reproductive health care services may reflect reason, research-based evidence, media sound bites, personal or sociocultural values, personal experience with the health care system, characteristics of parent-child relationships, and experiences as parents, to name a few sources of influence. Although parents may intellectually recognize the need for adolescents to have access to confidential care, support for PNLs may arise from other factors such as fear of unknown others making decisions about their children’s health, the desire to monitor their children’s activities, and global beliefs about the appropriate role of parents.
Findings related to the anticipated consequences of PNLs concur with previous research with adolescent girls. Most parents who completed this survey, like the girls in the study by Reddy and colleagues,12 anticipated declines or delays in clinic visits, along with increases in unprotected intercourse and use of nonprescription birth control methods, should clinics be required to notify parents before providing contraceptive services. Few parents in the present study (3.6%) expected teenagers would stop having intercourse, just as only 1% of the adolescent girls studied by Reddy and colleagues expected that they would choose abstinence in response to laws restricting confidential services. If these expectations predict actual behavior, increases in pregnancies and sexually transmitted infections might be unanticipated outcomes of enacting legislation that would impede or restrict access to and use of reproductive health care services among young people. These potential individual and public health consequences of foregone services should be emphasized in discussions about PNLs with parents and policy makers.
Despite the widely expected negative consequences, many parents still support laws limiting minors’ confidential access to reproductive health care by notifying parents. Such parent views are in sharp contrast to young people’s preferences.8-12 They are also at odds with policy statements of numerous professional organizations regarding the best practices for protecting the health of young people.5-7,20-22
This study has several limitations. First, the sample was drawn from 2 neighboring states, and more than half of eligible parents chose not to participate in this study. Thus, the sample may not be representative of all parents of teenagers. Although the response rate in the present study is not unusual for contemporary telephone surveys, nonparticipants may systematically differ from participants on some characteristic related to the study objectives and the key variables addressed herein. For example, this sample includes a larger percentage of Catholics (39%) than found in recent previous statewide estimates of religious affiliation for Minnesota (25%) and Wisconsin (28%).23 This may influence the generalizability of the study’s findings. Second, although many influences expected to be relevant to parental views on PNLs were assessed in this study, others were not. Unmeasured considerations, such as placing questions in a particular health care context (eg, confidential care provided by a known and trusted health care professional vs an unknown provider) and assessment of additional information about parents’ situations (eg, previous experience with confidential adolescent health care issues, or feelings about their own teenager’s needs for confidential services) may explain the combination of views expressed by many parents. The selection of particular items at the expense of others is a shortcoming common to all survey research; future studies should consider additional psychosocial, familial, or cultural factors that might reveal reasons for supporting or opposing minor consent laws or PNLs. Qualitative approaches might also further elucidate parents’ views on these issues.
This study also has several strengths. To our knowledge, this study is one of the first to survey directly a large sample of parents of teenagers on these issues. Views of health care providers and youth are already represented in position statements and extant research literature. Adding the views of parents as a third party directly affected by PNLs makes an important contribution to the larger discussion on minors’ confidential health care and PNLs. Second, this study used a population-sampling frame rather than a convenience sample and includes data from racial and ethnic minority parents representative of the racial/ethnic mix of Minnesota and Wisconsin. These sample characteristics increase the extent to which findings may reflect views of the larger population of parents of adolescents aged 13 to 17 years within these 2 states. Finally, survey items have been previously validated, which reduces measurement error as a source of bias in study findings.
In this study, parents who expected few positive outcomes and multiple negative outcomes of PNLs were more likely to support minors’ confidential access to prescription contraception and oppose PNLs. In keeping with position papers and statements of professional organizations, health care providers may wish to educate parents about the likelihood of adverse consequences (eg, increased rates of teen pregnancy and sexually transmitted infections) and the improbability of positive consequences (eg, youth choosing abstinence). This may be a worthwhile strategy for increasing parents’ awareness of potential outcomes associated with narrowing adolescents’ access to confidential reproductive health services.
Correspondence: Marla Eisenberg, ScD, MPH, Division of General Pediatrics and Adolescent Health, Department of Pediatrics, University of Minnesota, 200 Oak Street, SE, Suite 260, Minneapolis, MN 55455 (email@example.com).
Accepted for Publication: August 12, 2004.
Funding/Support: This study was supported in part by grant U48/CCU513331 from the Centers for Disease Control and Prevention, Atlanta, Ga (Prevention Research Center [Dr Resnick]); project T30 MC 00021-11 0 from the Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human Resources, Rockville, Md (Center for Adolescent Nursing [Dr Bearinger]); and grant FPTPA50031 from Title X Office of Family Planning, Department of Health and Human Services, Public Health Service, Rockville (Region V/Title X Family Planning Training Program [Ms Swain]).
Acknowledgment: We thank Abigail English, JD, for helpful feedback on this manuscript and information regarding state legislation.
Eisenberg ME, Swain C, Bearinger LH, Sieving RE, Resnick MD. Parental Notification Laws for Minors’ Access to Contraception: What Do Parents Say? Arch Pediatr Adolesc Med. 2005;159(2):120–125. doi:10.1001/archpedi.159.2.120
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