A Scoping Review of Barriers to Accessing Abortions among Adolescents in the United States

Abstract

Study objective:

Even before the Dobbs Supreme Court decision, minors experienced a wide variety of barriers to abortion care in the United States, including legal, financial, cultural, transportation, and misinformation barriers as well as pressure from parents and partners. This scoping review summarizes the literature on barriers to abortion among minors in the United States prior to the Dobbs decision.

Methods:

We conducted a database search to identify original research in the United States published between 2007 and 2022. We included quantitative and qualitative empirical articles and assessed their quality. We created categories for the barriers to abortion among minors identified in the articles. We screened 7584 records and included 70 articles in the scoping review. We charted study aims, study designs, data sources, analytic samples, and results.

Results:

The articles explored factors related to abortion access and identified several categories of barriers to abortion among minors. These included legal barriers (41 articles found them to be a barrier), financial barriers (14 articles), cultural barriers (13 articles), transportation barriers (12 articles), pressure from parents (11 articles), misinformation (8 articles), and pressure from a partner (8 articles). Legal barriers, including laws that require minors to inform or get permission from an adult guardian, were the most commonly identified barrier.

Conclusion:

These findings suggest that minors need policy and interpersonal support to overcome general and age-specific barriers to abortion care. Future research should examine if and how barriers for minors have intensified post-Dobbs, informing targeted policy responses.

Introduction

About one in ten abortions in the United States (U.S.) are obtained by adolescents (age £19), who have the highest ratio of abortions to live births of any age group^1,2 Yet adolescents, particularly minors (age <18), face unique barriers to abortion care – including fewer financial resources,^3–5 parental involvement laws,^6,7 obstacles to transportation,⁸ and limited information on abortion access.⁹ However, abortion research often overlooks minors.¹⁰ Most existing research on abortion either excludes or aggregates minors with older participants, making it difficult to understand minors’ experiences.

The U.S. has undergone significant changes in the abortion landscape since the 1973 Supreme Court decision in Roe v. Wade.¹¹ A key turning point was the Gonzales v. Carhart Supreme Court decision in 2007, which upheld a ban on intact dilation and extraction, allowing state legislatures to enact additional abortion restrictions.¹² In 2022, the U.S. Supreme Court decision in Dobbs v. Jackson Women’s Health Organization (Dobbs) ruling marked another legal turning point by eliminating the federal constitutional right to abortion.

While the Dobbs decision resulted in new abortion restrictions in many states,¹³ minors experienced disproportionate barriers to abortion even prior to Dobbs. Minors are affected both by general restrictive abortion laws and those specific to minors.¹⁰ Six years following the Roe decision, the Belloti v. Baird Supreme Court decision allowed states to require a pregnant, unmarried minor to obtain parental consent prior to obtaining an abortion.¹⁴ Currently, 38 states have parental involvement laws, requiring parental notification or parental consent.¹⁵ Now more than 7 million American adolescents girls ages 13 to 17 live in states with abortion bans, restrictive gestational limits or parental involvement requirements.¹⁶ However, most reviews of abortion barriers in the U.S. have not focused on minors,^17–19 while those focused on adolescents do not include U.S.-based studies.^9,20,21 Reviews about adolescent reproductive health in the U.S. have focused on contraception^20,22 and pregnancy prevention^23,24 rather than abortion. To address this gap, we conducted a scoping review to examine barriers to abortion care among minors in the U.S. before Dobbs.

Methods

Literature Search

Detailed search strategies are available in the Supplementary Materials Table 1. We searched the following databases on July 6, 2022: PubMed, Embase.com, CINAHL Plus with Full Text (EBSCOhost), ProQuest (APA PsycINFO, Sociological Abstracts, Public Affairs Information Service Index). We used Web of Science to search the Arts & Humanities, Emerging Sources, Social Sciences, and Science Citation Indexes. On July 7, 2022, we searched Nexis Uni for law review articles. After screening and review, we conducted backwards and forwards citation searches on our included articles by manually reviewing the reference lists and using Scopus to identify articles that cited our included articles. We developed our search strategies on the three domains of adolescents, abortions, and barriers, using a spreadsheet to facilitate database translation.²⁵ Publication was limited to 2007–2022 to reflect the legal landscape between the Gonzales and Dobbs Supreme Court decisions.

We imported search results from each database to EndNote 20 to identify and remove duplicates. We uploaded remaining records to Covidence²⁶ for screening. IRB approval is unnecessary for scoping reviews.

Inclusion and Exclusion Criteria

To be included, articles had to be original, empirical, peer-reviewed, written in English, published 2007–2022, report data from the U.S., include minors, and specifically examine factors related to accessing abortion. Because few articles presented stratified results for ages <18, we also included articles that aggregated minors with young adults through age 26. We excluded studies that included minors in the population of reproductive age women but did not report on the age group separately (e.g. an analysis combining women ages 15–49). We excluded reviews, non-empirical articles, including news and commentary, and conference abstracts.

Screening and Data Extraction

Two trained screeners blinded in Covidence evaluated each abstract for inclusion. Inter-rater reliability was established before beginning screening by independently categorizing a random sample of articles and discussing disagreements until consensus and reliability were established. Disagreements were resolved by a third reviewer. Similarly, two blinded researchers reviewed the full text of each article that passed abstract screening, with a third resolving conflicts. If excluded, the reason was specified.

The scoping review includes articles passing the full text review, from which data were extracted. Extractors trained to intra- and inter-rater reliability by meeting frequently at the beginning to ask clarifying questions and add instructions to the data extraction forms. As a check for inter-rater reliability, one researcher extracted data, and another researcher checked each article.

We extracted study descriptors, methods, participants, analysis and results from each included article. Study descriptors included: title, author, publication year, journal, and article type (quantitative or qualitative). Methods data included: data collection year(s), aim, design, and data source. Participant data included: inclusion criteria, exclusion criteria, minors/young adults sample size, sample demographics (race/ethnicity, sexual orientation, and gender identity), and location of study. Analysis and results included statistical information (quantitative) and/or synthesis methods (qualitative), factors examined, and barriers determined. We extracted all factors related to abortion access that were tested and then determined whether the results indicated a barrier. Access factors were categorized as barriers to abortion if significantly negatively associated with abortion as an outcome in quantitative studies or thematically emerged in qualitative studies. We extracted verbatim all barriers that were identified in the included manuscripts, then inductively grouped the barriers into thematic categories after all manuscripts were reviewed.

We additionally assessed the quality of each article using the Downes’ Appraisal tool for Cross-Sectional Studies (AXIS tool)²⁷ for quantitative articles, the summary framework developed by Walsh & Downe²⁸ for qualitative articles, and both for mixed-method articles.

Results

Database searches resulted in 12,851 records, with 5267 duplicate records. Of the 7584 unique records screened, 70 articles were included in the review (Figure 1; Table 1). Of the included articles, 49 (70%) examined legal factors related to minors’ abortion access. Other factors examined were transportation n=14(20%), financial n=15(21%), cultural n=13(19%), inter-personal parental influences n=11(16%), misinformation n=12(18%), and partner n=9(13%). These sum to greater than 100%, as some articles investigated multiple factors as barriers are often multi-faceted and interconnected.

Figure 1:

PRISMA Flow Diagram of database search identification, studies screened, and included articles

Table 1:

Characteristics of Articles Included in the Scoping Review (N=70)

Author, Year (Reference number)	Study’s Main Aim	State(s)	Policies	Method: Study Design, Data Source(s)	Analytic Sample	Access Factors Examined Among Minors
Adamcyzk, 200873	Illustrate the ways religiosity and denominational affiliation influence the probability that a young woman will have an abortion	All states		Longitudinal, Add Health	N=4,564 Grades: 7–12 Female participants	Religiositya
Adamcyzk, 200852	Examine individual, contextual, and structural factors that could shape the abortion decisions of women who conceive before marriage	All states	MWP SFAM TRAP	Longitudinal, Add Health	N=1,497 Ages: 12–26 First-time pregnant people	No clinic in countya; Informed consenta; Mandatory waiting perioda; No public funding at state levela; Conservative Protestant denominationa; Religiosity at the county level
Adamcyzk, 200978	Test whether individual and school religiosity influence abortion behavior among women who become pregnant while unmarried	All states		Longitudinal, Add Health	N=1,502 Ages: 14–26 First-time pregnant people	Conservative Protestant ideologya
Altindag, 201751	Describe demographic characteristics and abortion timing of minors in Arkansas who obtained an abortion through a judicial bypass, and to contrast the frequency of judicial bypass in other US states	AR; AK; AL; GA; ID; KS; OK; SC; SD; TX; WI	JB	Cross-sectional, AR Department of Health	N=2,624 Ages: 12–17 Abortion seekers	Judicial bypass of parental consent or notificationa; Parental involvement lawsa
Altshuler, 201572	Explore the use of social media for recruitment of US adolescents and young adults and to describe how they learn and feel about abortion	All states		Cross-sectional, U.S. Census; NSFG	N=856 Ages: 13–18 Adolescent participants	Attitudesa; Previous sexual experiencesa; Abortion information sourcesa
Anand, 202086	Determine college health centers’ referral patterns for students seeking induced abortion	PA		Cross-sectional, Simulated patient	N=115 Bachelor’s degree-granting institutions	Inadequate abortion referrala
Carr, 201798	Analyze the causal effects of state-level sex education policies from 2000–2011 on various teen sexual health outcomes	CO; ME; MI; WA; WI	SE	Longitudinal, CDC; Guttmacher Institute state policy briefs	N=5 states’ policies	State-level abstinence education
Chevrette, 201550	Assess whether US state-level policies regarding abortion and sexual education are associated with different teen birth and teen abortion rates	All states	MWP PI SE SFAM TRAP	Cross-sectional, U.S. Census; CDC; Guttmacher Institute state policy briefs	Birth rates and abortion rates Ages: 15–19 All births and abortions in 2008	Republican dominancea; More than 50% Christian adherentsa; Access to public or private insurance prohibited for abortionsa; Percentage Black teens; Abstinence education; Mandatory sex education; Contraception; Parent consent
Clark, 202165	Explore the impact of restrictive abortion policies in the state of Georgia on the lives of people seeking abortion and how they would manage unwanted pregnancies	GA		Cross-sectional; mixed methods, Survey; Medical charts	N=33 Ages: <20 Abortion seekers	Abortion illegalitya; Ability and willingness to travel out of statea
Cockrill, 201377	Create a measure of abortion stigma and analyze social and demographic characteristics associated with abortion	CA; CO; FL; MI; NJ; TN		Cross-sectional; mixed methods, Planned Parenthood health centers; interviews	N=35 Ages: 15–18 Family planning clinic patients	Catholic and Protestant religiositya; Community condemnation; Isolation; Self-judgment
Coleman-Minahan, 201948	Explore adolescents’ experiences with the judicial bypass process	TX	JB PI	Qualitative, Interviews	N=20 Ages: 16–19 Abortion seekers	Judicial bypassa; Parental consent lawsa
Coleman-Minahan, 202049	Explore why they chose to get an abortion, who they involved in their decision and what their experiences of social support were	TX	JB PI	Qualitative, Jane’s Due Process client records	N=20 Ages: 16–19 Abortion seekers	Material support such as transportation for the judicial bypassa; Pressure from partnera
Coleman-Minahan, 202147	Explore what’s at stake for multiple actors within a shared social space and how interactions between those actors reproduce stigma	TX	JB	Qualitative, Interviews	N=19 Ages: <18 Abortion seekers N=19 attorneys participating in judicial bypass cases	Judicial bypass proceduresa
Coles, 201287	Understand if providers caring for adolescents have the knowledge to counsel accurately on medication abortion	All states		Cross-sectional, Questionnaire	N=430 clinical providers, Members of Society for Adolescent Health and Medicine	Provider knowledge and self-assessment of knowledgea
Colman, 200845	Evaluate the presence of misclassification bias in the estimated effect of parental involvement laws on minors’ reproductive outcomes	TX	PI	Cross-sectional, TX vital records	All births and abortions to 17- and 18-year-olds in Texas 1998 – 2001	Parental involvement lawsa
Colman, 200946	Evaluate the association between Texas’s parental notification law and the occurrence of second-trimester abortions among minors who have responded to the law by delaying abortion until age 18	TX	PI	Cross-sectional, TX vital records	N=29,284 Ages: 15–19 Abortions	Parental involvement lawsa
Colman, 201164	Test whether mandated information and waiting periods affect the demand for abortion	TX	GAB MWP	Cross-sectional, TX vital records; vital records from nearby states of abortions to TX residents.	N=78,001 Ages: <20 Abortions	Law that all abortions at or after 16 weeks’ gestation be performed in an ambulatory surgical centera; Mandatory information session; 24-hour waiting period; Parental consent
Crock, 200779	Examine abortion decision-making attitudes of adolescents attending Roman Catholic schools	KS		Cross-sectional, The Abortion Attitude Scale survey	N=350 Ages: 12–18 School-based participants	Religiositya
Deeb-Sossa, 201463	Explore the obstacles Mexican immigrant women and teens living in North Carolina face in seeking abortions and the ways in which the barriers experienced by these women are the product of intersecting forms of oppression	NC		Qualitative, Interviews	N=1 Age: 17 Age: 17 Abortion patient	Judges’ interrogation during the judicial bypass processa
Dodge, 201244	Determine the accuracy of information regarding state-level abortion laws and policies received by a simulated patient from front-line staff at facilities providing abortion services	11 states, not named	JB MWP PI	Cross-sectional, Phone calls	N=138 Phone calls, simulated abortion seekers N=46 Abortion facilities	Provider misinformation about the availability of judicial bypassa; Provider information about laws regarding spouse and parent involvement, and mandatory waiting periods.
Ely, 201771	Explore and describe those that received support from abortion funds as part of the National Network of Abortion Funds	All states		Cross-sectional, National Network of Abortion Funds	N=639 Ages: 11–19 Abortion patients	Costa - to young people, African American people, single people, those seeking abortion in the second trimester
Ely, 20183	Determine whether or not the experiences of adolescent and adult abortion patients who received financial assistance to help pay for an abortion differed	All states		Cross-sectional, National Network of Abortion Funds	N=481 Ages: <18 Abortion patients	Obtaining adequate fundsa; Procedural costsa; Travel and transportationa
Forsstrom, 202162	Estimate a structural model that nests four channels through which abortion costs impact partnership and fertility	All states	PI SFAM	Longitudinal, National Longitudinal Survey of Youth 1997	N=3,289 Ages: 12–18 Adolescent participants	Parental consent lawsa
Foster, 201276	Understand whether certain women are at risk of low confidence in their abortion decision	One state, not named		Cross-sectional, Self-report	N=475 Ages: 10–17 Abortion seekers	Belief in a higher power having spiritual concerns about abortiona; Lack of social support; Lacking decision confidence
Foster, 201361	Identify who would be affected by abortion bans after 20 weeks gestation	All states		Longitudinal; mixed methods, Turnaway study	N=77 Ages: 15–19 Abortion patients	Unemploymenta; Ages 15–19a; Discovery of pregnancy at 12 weeks compared to 5 weeksa; Travel time to clinica; Marital status; Race; Chronic health conditions; Heavy drinking; Drug use; Depression; Insurance status
Friedman, 201543	Describe characteristics of teenagers seeking judicial bypass for abortion	OH	JB PI TRAP	Cross-sectional, Juvenile court psychiatric clinic surveys	N=55 Ages: <18 Abortion seekers	Judicial bypassa; Concerns of violence or being excluded from the familya; Social support
Fuentes, 201925	Describe the distance US abortion patients traveled for abortion services	All states	MWP PI	Cross-sectional, Guttmacher Institute Abortion Patient Survey	N=32,071 Ages: <18 Abortion patients	Living in an area of less than 50,000 peoplea; Mandatory waiting periodsa; Two-visit lawsa
Fulcher, 202299	Evaluate the impact of the COVID-19 pandemic on abortion care utilization and disparities in utilization by patient age	MA		Cross-sectional, Planned Parenthood medical records	N=411 Ages: <18 Abortions	COVID-19 policy changes
Gilbert, 202142	Determine financial cost of compliance with judicial bypass processes	MA	JB PI	Cross-sectional, Planned Parenthood medical records	N=469 Ages: <18 Abortions	Judicial bypass as a function of parental involvement lawsa; Low socioeconomic statusa
Gonzalez, 202260	Analyze the relationship between abortions and economic fluctuation at the U.S. state level for the 1995–2016 period	All states [excluding CA; NH; WY]	MWP PI SFAM TRAP	Longitudinal, U.S. Census; U.S. Bureau of Labor Statistics; CDC; Guttmacher Institute Abortion Provider Census	N=905 state-years	Unemployment ratea; Medicaid abortion funding restriction
Gonzalez, 202041	Identify factors related to abortion timing via a state-specific analysis	All states	PI SFAM	Cross-sectional, U.S. Census; U.S. Bureau of Labor Statistics; CDC; American Hospital Association	N=921 state-years	Medicaid funding restrictionsa; Parental involvement laws
Gould, 201340	Investigate individual- and facility-level factors that influenced women’s reports of receiving abortion counseling and the helpfulness of counseling	All states	MWP TRAP	Cross-sectional, Turnaway Study; Guttmacher Institute state policy briefs	N=107 Ages: 15–19 Abortion seekers	Legal mandates regulating abortion counselinga; Receiving abortion counseling
Hasselbacher, 201483	Explore factors that influenced whether minors involved or excluded a parent when seeking an abortion	IL	PI	Qualitative, Interviews	N=30 Ages: 14–17 Abortion seekers	Having to tell a parent about the abortiona
Janiak, 201480	Enumerate barriers to care described by women seeking abortion in the latter half of the second trimester	MA	GAB	Cross-sectional, MA referral and case management program for abortion care	N=26 Ages: <18 Abortion seekers	Fear of telling parentsa
Janiak, 201939	Describe individual-level delay in obtaining abortion associated with use of the Massachusetts judicial bypass system	MA	JB PI	Cross-sectional, Planned Parenthood clinics; MA vital records	N=2,026 Ages: <18 Abortions	Massachusetts’ parental consent lawa
Jerman, 201884	Examine the motivations and circumstances of individuals seeking information about self-abortion on the internet	All states		Cross-sectional, Survey	N=474 Ages: <18 Self-managed abortion information seekers	Knowledge and informationa
Johns, 201769	Examine distance traveled to obtain abortion care in California by several demographic and abortion-related factors	CA	SFAM	Cross-sectional, CA Medicaid (Medi-Cal) claims	N=1154 Ages: <18 Abortion patients	Minors traveled longer distances to obtain an abortion covered by Medicaida
Jones, 201188	Examine perceptions of male knowledge and support for the abortion according to three relationship characteristics: Union status, length of relationship, and exposure to intimate partner violence	All states		Cross-sectional, Guttmacher Institute Abortion Patient Survey	N=627 Ages: <17 Abortion patient	Whether women perceived men to know about the abortion and whether they perceived them to be supportivea
Jones, 201368	Estimate how far women traveled to get to the facility where they obtained their abortion	All states	MWP	Cross-sectional, Guttmacher Institute Abortion Patient Survey	N=558 Ages: <18 Abortion patients	Longer distance to nearest clinica; Younger age
Joyce, 2010100	Evaluate the influence of the 2005 change in Arkansas’ parental abortion involvement law	AR	JB PI	Cross-sectional, CDC; AR Department of Health	N=972 Ages: <18 Abortion patients	Policy change from parental notification to parental consent
Joyce, 202038	Analyze of the effect of parental involvement laws on the incidence of abortions to minors	AZ GA MD MN MS NE NC PA SC TN TX VA	PI	Longitudinal, State vital records; Guttmacher Institute Abortion Provider Census	N=12 states	Parental involvement laws before the mid-1990s and in some statesa; Parental involvement laws after the mid-1990s and in some states
Kavanagh, 201237	Explore minor’s opinions of parental involvement laws	IL	PI	Qualitative, Interviews	N=30 Ages: 12–17 Abortion seekers	Parental involvement lawsa
Kelly, 2007101	Analyze the effects of state policies enacted in the wake of welfare reform on reproductive behaviors.	All states	PI SFAM TRAP	Longitudinal, CDC; Guttmacher Institute Abortion Provider Census; NARAL	N= 50 states and Washington D.C.	Measures of abortion restriction; Child support; Other economic factors related to welfare reform; political climate
MacAfee, 201536	Assess the association of the 2012 New Hampshire parental notification law with patterns of abortion in northern New England minors	MA ME NH VT	PI	Cross-sectional, Planned Parenthood of Northern New England medical records	N=373 Ages: <18 Abortion patients	New Hampshire Parental Notification Lawa
Madkour, 201382	Examine the influence of pre-pregnancy parental support and control on adolescent girls’ pregnancy resolution decisions	All states		Longitudinal, Add Health	N=1,107 Ages: <20 First time pregnant people	Parents with less than a Bachelor’s degreea; Parental controla; Pre-pregnancy parental support
Mann, 201575	Examine how Latina/o teenage parents living in California narrate their experiences with unintended pregnancy resolution	CA		Qualitative, Semi-structured interviews	N=24 Ages: 14–18 Teen parents	Pressure from partnera; Pressure from parentsa; Cultural normsa
Medoff, 200759	Estimate the effects of various restrictive abortion laws on the demand for abortion	All states	MWP PI SFAM	Longitudinal, U.S. Census; Guttmacher Institute Abortion Provider Census	N=150 observations using abortion rate per 1,000 pregnancy	Abortion pricea; Parental notification lawa; Parental consent lawa; Evangelical religiositya; Female income; Labor force participation; Single; Education; State Medicaid funding of abortions; Mandatory waiting period; Mandatory waiting period of border states
Medoff, 200958	Investigate whether four biased abortion falsehoods have an impact on the demand for abortions in the year 2000	All states	PI SFAM	Cross-sectional, U.S. Census; state vital records; Guttmacher Institute Abortion Provider Census	N=50 states and Washington D.C.	Abortion pricea; No Medicaid fundinga; Parental involvementa; Marrieda; Abortion misinformation about: mental health problems, breast cancer, infertility and fetal pain; Income; Labor force participation; Education; Evangelical religiosity
Myers, 202035	Document dramatic increases in the distances minors must travel if they wish to obtain an abortion without involving a parent or judge	All states PI		Longitudinal, U.S. Census; CDC; state vital records; Guttmacher Institute Abortion Provider Census	N=50 states and Washington D.C.	Parental involvement lawsa; Distance to avoid parental involvement lawsa
New, 200726	Analyze the effect of pro-life legislation on the incidence of abortion among minors	All states	GAB PAB PI SFAM TRAP	Longitudinal, U.S. Census; CDC; NARAL; Bureau of Economic Analysis	N=566 Ages: 13–17 Abortions	Parental involvement lawsa; Public funding restrictionsa; Informed consent lawsa; Partial birth abortion bans
New, 201457	Reassess earlier paper to measure the impact of a range of antiabortion laws	37 states	MWP PI SFAM TRAP	Longitudinal, CDC; State vital records; Guttmacher Institute Abortion Provider Census; National Right to Life Committee	N=37 states	Public funding restrictionsa; Parental involvement lawsa; Informed consent lawsa
O’Donnell, 201867	Analyze rural women’s experiences related to pregnancy decision-making and pathways to abortion services in Central Appalachia	KY; TN; VA		Qualitative, Interviews	N=8 Ages: 16–20 Adolescents with an unwanted pregnancy	Isolation from social support (family, friends, and healthcare providers) a; Absence of abortion narrative in communitya; Social support (family/friends); Observation of another person’s abortion experience
Quast, 2017102	Examine the relationship between the abortion rate and the proximity of abortion facilities	TX		Cross-sectional, TX vital records	N=4873 Ages: 10–19 Abortions	Distance to nearest abortion clinic
Ralph, 201434	Examine differences in abortion characteristics, including parental and partner involvement, between minors and adults	CA	PI	Cross-sectional, Medical records and surveys from abortion clinic	N=476 Ages: <18 Abortion patients	Lack of parental supporta; Cultural beliefs surrounding abortion/religious beliefsa; lack of male partner’s supporta; Race/ethnicity; Mental health history; Abortion history
Ralph, 201832	Examine the impact of a parental notification requirement on the frequency, timing, and out-of-state travel of minors seeking abortion	IL	PI	Cross-sectional, Medical records and surveys from abortion clinic	N=538 Ages: <18 Abortion patients	Parental notification lawa
Ralph, 202133	Describe minors’ demographic characteristics, reasons for seeking judicial bypass, individuals involved in decision-making, and distances traveled and time elapsed to attend the court hearing	IL	JB	Cross-sectional, Illinois Judicial Bypass Coordination Project	N=128 Ages: <18 Abortion seekers	Judicial bypass: time and travela
Ramesh, 201631	Describe the impact of the Illinois Parental Notification of Abortion Act on minors presenting for first-trimester abortion	IL	PI	Cross-sectional, Medical records	N=631 Ages: <18 Abortion patients	Parental notification law
Riley, 201556	Assess physicians’ knowledge of these laws, attitudes around the provision of confidential care to minors, and barriers to providing confidential care	MI	PI TRAP	Cross-sectional, Survey	N=259 Physicians (Fam Med, Med-Peds, OBGYN, and Peds)	Insurance issuesa; Parental concerns and relationships with the familya; Issues with the electronic medical recorda
Roberts, 201470	Describe payment for abortion care before new restrictions among a sample of women receiving first and second trimester abortions	All states		Longitudinal, Turnaway Study	N=108 Ages: 15–19 Abortion seekers	Self-reported cost of raising money for abortiona
Sanders, 201630	Assess the impact of Utah’s 2012 law that increased mandatory abortion waiting period from 24 to 72 hours	UT	MWP	Longitudinal, Medical records; Interviews	N=221 Ages: <18 Abortion patients	72-Hour Waiting Perioda
Sisco, 201481	Identify correlates of parent-daughter communication about abortion among non-pregnant adolescents	IL		Cross-sectional; mixed methods, Surveys; Focus groups	N=265 survey N=23 focus group Ages: <18 Non-pregnant adolescents	Parental supporta
Stevenson, 202029	Estimate the percentage of Texas judicial bypass petitions for abortion denied annually from 2001 to 2018	TX	JB	Longitudinal, Jane’s Due Process records; Texas Office of Court Administration	N=2761 minors seeking judicial bypass	Stricter judicial bypassa
Strayhorn, 200974	Compile publicly accessible data on birth rates, conservative religious beliefs, income, and abortion rates in the US	46 states exclude -ing DC CA FL LA NH		Cross-sectional, CDC; Pew Survey; Guttmacher Institute Abortion Provider Census	N=35,957 Ages: 15–19 Non-pregnant survey respondents	Religiositya
Sutton, 201966	Examine rural–suburban–urban disparities in intendedness and resolution of first pregnancies among adolescents	All states		Cross-sectional, NSFG	N=5233 Ages: 15–19 First-time pregnant adolescents	Living in a rural areaa; Living in an urban area
Upadhyay, 201428	Examine the factors influencing delay in seeking abortion and the outcomes for women denied abortion care because of gestational age limits at abortion facilities	All states	GAB	Longitudinal, Turnaway Study; Guttmacher Institute Abortion Provider Census	N=173 Ages: <18 Abortion seekers	Gestational age limitsa
White, 201754	Examine distance traveled and the number of days between their in-person consultation and abortion procedure visits	AL	MWP	Cross-sectional, Billing data	N=121 Ages: <18 Abortion patients	Waiting period requirementsa; Distance to nearest clinic
White, 201927	Assess whether indicators of limited access to services explained changes in second-trimester abortion after implementation of a restrictive abortion law in Texas	TX	PAB	Longitudinal, ACS; TX vital records; Mystery client calls to abortion facilities	N=1,902 Ages: <18 Abortions	TX HB2: Facility closurea; longer waits for care / later abortion carea; Increased travela
White, 202255	Explore procedures for documenting parental involvement, minors’ and parents’ reactions to requirements, and challenges with implementation and compliance	3 Southeastern states	PI	Qualitative, Interviews	N=34 Staff members at abortion facilities	Parental involvement requirementsa
Wills, 201453	Investigate the effect of parental notification and consent laws on teen births and abortions in Texas	TX	PI TRAP	Longitudinal, TX vital records	N= not given due to data privacy Ages: 13–21 Aggregated abortion and birth rates	Parental notification, for 16- to 17-year-oldsa; Parental consent, for 13- to 15-year-olds
Woodhams, 201689	Describe African American teenaged males’ attitudes and perspectives on abortion	IL		Cross-sectional, African American Adolescent Male Perceived Responsibility for Pregnancy Prevention Study	N=338 Ages: 14–19 Male adolescents	Pressure from partnera

Table notes:

^aFound to be a significant barrier to abortion access

Abbreviations for policies:

GAB: Gestational age bans; IC: Informed consent; JB: Judicial bypass; MWP: Mandatory waiting periods; PAB: Partial abortion ban; PI: Parental involvement; SE: Sex education; SFAM: State funded abortion under Medicaid; TRAP: Targeted regulation of abortion providers

Abbreviations for data sources:

ACS: American Community Survey

Add Health: National Longitudinal Study of Adolescent to Adult Health

CDC: United States Centers for Disease Control and Prevention

NARAL: Reproductive Freedom for All (formerly National Abortion Rights Action League)

NSFG: National Survey of Family Growth

Legal Barriers

Forty-one articles identified legal barriers to abortion access.^29–69 Among these, twenty articles identified parental involvement laws, which require parental consent to and/or notification of abortion as barriers to abortion access.^{29,30,36,38–43,46,49,50,52,57,59–63,66} There is evidence that minors who are unable or unwilling to involve their parent in their abortion care may experience delays or inability to access care.^43,57 In one study, this was a salient issue for minors who became pregnant at age 17 and chose to postpone abortion care until they turned 18 to avoid parental involvement laws, rather than disclose their pregnancy to a parent.⁵⁰ Several articles found a significant association between parental involvement laws and lower abortion rates among minors, including those in eight states^{42,36,40,49,57} and nationally.^30,62

Ten articles identified judicial bypass, under which minors can seek a judge’s waiver to parental involvement, as a barrier to abortion.^{37,39,46,47,51–53,59,67} While judicial bypass seeks to alleviate the barrier of parental involvement, it is associated with delays in care resulting from the legal process.^37,43 One attorney described judges’ behaviors in judicial bypass as unlike other legal procedures, with a “…separate set of non-rules for abortion cases and they will look for any excuse to deny, and any reason they can come up with.”⁵¹ Staff at abortion facilities noted that it was especially difficult for minors with non-traditional family structures to meet states’ requirements proving an adult’s parental relationship.⁵⁹

Four articles identified waiting period laws, which mandate a delay between the intake appointment and the abortion procedure, as barriers to minors’ access to abortion.^29,34,56,58 While these laws apply to all abortion seekers, they deter minors who may already experience delays in accessing care due to obstacles in getting to multiple appointments. For instance, one study of Alabama’s 24-hour waiting period law found that minors had significantly greater odds of not returning to their second appointment compared to those aged 18–24.⁵⁸ Additionally, an increase in Utah’s waiting period from 24 to 72hours was associated with a greater reduction in abortions to minors compared to other age groups, indicating waiting period laws may pose a larger barrier for minors.³⁴

Transportation Barriers

Twelve articles identified transportation as a barrier to minors’ abortion access.^{3,29,37,39,53,56,65,69–73} Nationally, the average “avoidance distance” – the distance a minor would have to travel to obtain an abortion without involvement from a parent or a judge – increased from 58 to 454 miles from 1992 to 2016, with larger avoidance distances associated with elevated birth rates, especially among those in the poorest quartile counties.³⁹ Parental notification laws are associated with increased travel: 11% of minors residing in states with parental notification laws traveled over 100 miles for abortion care compared to 2% in states without such laws.²⁹ Among those who accessed financial aid from an abortion fund, minors were expected a greater travel distance for abortion than adults.³

In addition to the potential need for minors to travel further than adults for abortion care, minors may have limited access to transportation options. For instance, unmarried pregnant women aged 12–26 were more likely to obtain an abortion if there was an abortion clinic in their county.⁵⁶ This is a particularly important factor among minors residing in rural areas,^29,70,71 since abortion providers often cluster in urban areas.⁷³ Among those living in rural areas and seeking abortions, minors had lower odds of traveling longer distances to obtain care than those aged 20–24.⁷² One nationally-representative study found that individuals aged 15–19 experiencing unintended pregnancy in rural areas had higher likelihood of live birth and lower likelihood of abortion, compared to those in urban areas.⁷⁰

Financial Barriers

Fourteen articles identified financial barriers to minors’ access to abortion,^{3,45,46,53,54,59,60,62–65,73–75} including the direct cost of care, lack of health insurance, and restrictions on health insurance covering abortion. A nationally-representative study of patients seeking financial assistance for abortion found that procedure costs were highest in the youngest age groups, totaling $3,892 on average for those aged 11–13, $1,788 more than for those aged 22–29.⁷⁵ In addition, a Massachusetts study found that judicial bypass processes were associated with $120 increased out-of-pocket costs.⁴⁶ This amounted to 20% of a Medicaid-eligible household’s maximum monthly income, which is notable given that 74% of minors in this study were insured by Medicaid.⁴⁶

Lack of health insurance resulted in a financial barrier to abortion among minors,^54,60,62 in addition to explicit restrictions on insurance abortion coverage. For example, among individuals aged 15–19, the abortion rate was 13.8 per thousand births among those living in states that prohibited insurance from covering abortions, compared to 18.8 in states without such restrictions.⁵⁴

Cultural Barriers

Thirteen articles identified cultural barriers to abortion among minors^{38,53,54,57,70,76–83} including internalized stigma, often stemming from religious beliefs. For example, a qualitative study of judicial bypass seekers found the majority of participants experienced or anticipated stigma from their communities regarding obtaining an abortion.⁵³ Another qualitative study of unintentionally pregnant Latina youth aged 14–18 found that “the majority of participants viewed making a choice other than continuing the pregnancy and parenting the child as selfish, irresponsible and, in some cases, immoral.”⁷⁹ Analysis of abortion seekers indicated that 36% of religiously identified individuals expressed spiritual concerns over obtaining an abortion.⁸⁰ Another study of abortion seekers concluded that, “Protestant women were more worried about judgment and were more isolated than nonreligious women, while Catholic women were more likely to be isolated from social support and more likely to perceive their community as hostile to abortion.”⁸¹ On a macro level, increased state-level religiosity was strongly correlated with increased adolescent birth rates.⁷⁸

Pressure from Parents

Eleven articles identified endured or anticipated pressure from parents as a barrier to abortion among minors.^{38,47,53,71,81,84–87} Some minors who disclosed their pregnancies to their parents reported receiving pressure from them either to have an abortion or parent their baby.⁷⁹ While minors often involve parents in their abortion decision,⁸⁵ many do not if they think their parents might react violently,⁴⁷ evict them, or restrict their ability to obtain an abortion.⁸⁷ Among those seeking second-trimester abortions, 27% of minors delayed care in fear of telling their parents.⁸⁴ Younger minors are more likely than older minors to tell their parents about their decision to seek an abortion, and mothers are more likely to be told and be supportive than fathers.³⁸ Minors are also more likely than adults to obtain an abortion because someone, most often their mother, wants them to.³⁸

Misinformation

Eight articles identified barriers to abortion experienced by minors because of misinformation, ^{48,54,60,71,76,88–91} including confusion about legality of abortion and medical providers giving incorrect or limited information.⁶² A survey of those who googled “self-abortion” found that 25% of respondents did not know if abortion was legal in their state and 7% believed it was not, despite being legal in all states at the time.⁸⁸ While knowledge of legality did not vary by age, one study indicated that minors were less likely than adults to know if there was an abortion provider within 50 miles of their residence.⁸⁸

Further, medical providers who share inaccurate abortion-related information also serve as a barrier. One study found that when individuals posing as minors seeking an abortion referral called student health centers in Pennsylvania, 33% of calls produced a referral to a non-abortion provider, 22% did not provide any referral, and 21% of staff incorrectly said that a minor could receive an abortion without parental consent in Pennsylvania.⁸⁹ In 11 states with parental involvement laws, a “mystery shopper” study found that 40% of abortion facility staff failed to inform a simulated minor of their right to a judicial bypass.⁴⁸ This misinformation extends to knowledge about abortion procedures among providers – almost 25% of U.S. adolescent healthcare providers incorrectly reported that medication abortion was unsafe and 32% misidentified the maximum gestational age for administration.⁹¹

Pressure from a Partner

Eight articles identified pressure from a partner as a potential barrier to abortion care for minors.^{38,53,65,71,79,81,92,93} Adolescents seeking abortions were significantly less likely than those aged 20–24 to perceive male partner support for an abortion.⁹² Two qualitative articles of pregnant adolescents found that partners frequently took a directive role in their decision, with some strongly discouraging abortion.^53,79 Further, a qualitative study of abortion seekers at or beyond 20 weeks’ gestation found that for 20% of participants, conflict with their male partner over the decision to have an abortion delayed their ability to seek care.⁶⁵ Among minors who told their partner about their desire for an abortion, 85% of partners were supportive; those with a supportive partner were more likely to have confidence in their decision.³⁸

Quality Assessment

Supplementary Table 2 summarizes the quality assessment results for quantitative and mixed-method articles (N=61). Nearly every article met the quality assessment threshold for clear aims/objectives, appropriate and sufficiently described study design, clearly defined reference population, appropriate measurement of risk factors and outcome variables, internally consistent results, results presented for all analyses in methods, results justified conclusions, and ethical approval or consent attained. However, almost half (48%) did not address and categorize non-responders.

Supplementary Table 3 summarizes the quality assessment results for qualitative and mixed-method articles (N=13). These articles generally met criteria for scope and purpose, design, sampling strategy, analysis, interpretation and ethics. However, the majority (77%) did not demonstrate researcher reflexivity, the concept that research is not an unbiased endeavor because the researcher’s perspective affects a project. There was not a clear audit trail given for 31% of qualitative and mixed-method articles.

Discussion

Our scoping review of the existing research examining barriers to abortion care among minors in the U.S. found evidence that minors face many and varied barriers to accessing abortion across multiple aspects of the social determinants of health. Nonetheless, minors have been overlooked in efforts to promote sexual and reproductive health equity,¹⁰ with recent calls to focus more on their needs.^94,95

We identified seven major categories of barriers: legal, transportation, financial, cultural, pressure from parents, misinformation, and pressure from a partner. More than half of the articles we reviewed found that anti-abortion laws targeting minors posed significant barriers to abortion. These laws led minors to seek abortions later in pregnancy, which increased cost and decreased availability of services. Of particular concern was the finding that minors feared telling parents about their pregnancy for their safety and well-being, which highlights the potential negative impacts of parental involvement laws beyond reducing access to care.

Non-age-specific abortion restrictions, such as gestational limits or waiting periods, may nevertheless have an outsized effect on minors.¹⁶ For example, younger people typically learn they are pregnant further into gestation,⁹⁶ and thus may be more likely to be impacted by abortion bans with gestational limits. Both state laws and clinic policies could increase the distance a minor must travel for abortion care, increasing cost and exacerbating transportation barriers.³⁹ Waiting periods requiring multiple appointments similarly increase cost and transportation barriers. These barriers are particularly high for minors, who have limited opportunity to earn income to pay for the abortion care or travel required for care, and may not have a credit card, severely limiting options for transportation.

While policies were the most common barrier to abortion care identified, other barriers for minors were identified across multiple influences, including parents, partners, and providers. Each of these individuals operates within a context shaped by abortion laws, cultural values, and the information environment. Information is critical in the adolescent population because they have less experience than adults navigating the healthcare system and may be vulnerable to disinformation and misinformation.⁹⁷

New policies have emerged post-Dobbs designed to limit minors’ access to abortion care. For example, so-called “abortion trafficking” laws target and criminalize adults who transport or assist a minor seeking abortion care.⁹⁸ More research is needed as the impacts of these laws begin to unfold. Finally, a reproductive justice approach means striving for people to have the support they need to parent, not parent, give birth, or not give birth. Although the focus of this review is on barriers that minors experience in obtaining an abortion, it is also important in future work to consider barriers minors may experience carrying a wanted pregnancy to term.³⁸

Methodological Challenges

Abortion research has methodological challenges,⁹⁹ especially when studying minors.¹⁰⁰ In this review we have specifically noted the practices of excluding minors from studies and/or failing to stratify results for minors separately. In addition, a systematic review of sampling strategies for research on abortion barriers concluded that the literature is too reliant on recruiting at abortion clinics, missing people that sought or wanted abortions but did not obtain them.¹⁹ One exception is the Turnaway Study,¹⁰¹ which prospectively observed two groups of people who were very similar except for one thing – some were able to obtain an abortion and some were ‘turned away’. However, this study included few minors.

There are also known gaps and data quality issues with state and national abortion surveillance, including states that do not collect this data, known underreporting in other states, and inconsistency in the measurement of age.^10,102 Notably, California does not have any statewide abortion surveillance⁶⁴ and most studies of California analyze Medicaid data, which are often suppressed for minors.⁷³ In the absence of high-quality state or national public health surveillance data, studies often relied on individual clinics or health systems data that may not include minors.³⁴

About half of the articles in this review did not attempt to categorize non-responders in their data, which could lead to biased results. Improving data collection to include minors could result in a more comprehensive understanding of abortion access and utilization. These compounded methodological challenges – from sampling limitations to the general exclusion of minors from many studies – restrict the ability to identify, monitor, and address the needs of minors in accessing abortion.

Limitations

The scoping review method has inherent limitations. Risk of bias was not assessed in the included studies. Additionally, the synthesis presented here is descriptive and cannot be used to draw definitive conclusions, such as which barriers have the greatest impact or effect on health and other outcomes. Our review reflects topics most often studied, not necessarily the frequency or magnitude minors are impacted by barriers. Another limitation is that this review does not include articles published after 2022, excluding barriers post-Dobbs.

Conclusion and Implications

The main finding from this scoping review is that anti-abortion laws have the intended effect of preventing minors from obtaining abortions. Minors encounter a wide variety of barriers when seeking an abortion. Future research on abortion barriers should include more minors and present their results separately from adults to continue to characterize the experiences of minors – who experience general barriers and minor-specific barriers. Additional research is needed to elucidate subgroups of minors most likely to encounter each barrier type and to understand the post-Dobbs landscape. Such research should then be translated to policymakers, abortion funds, clinicians, and others involved in minors’ abortion seeking to help reduce barriers that minors face seeking desired health care.