Monitoring the missing half: why reporting adolescent births is insufficient

Lack of national abortion data impedes development of sexual and reproductive health care policies and programs for young Australians

Recent data show a steady decrease in adolescent births to a historic low of 10 births per 1000 15–19‐year‐olds.1 Notwithstanding that some adolescent pregnancies are planned or wanted, these data are surely positive, as pregnant adolescents are vulnerable to numerous adversities and delaying pregnancy is healthier for mothers and children.2 However, birth rates reflect access to comprehensive sexuality education, reliable contraception and safe abortion. Specifically, as lower birth rates may reflect higher abortion rates, a complete national picture is required. More broadly, pregnancy and its outcomes reflect various inequities that continue to affect adolescents and their offspring across their lives. Greater understanding of adolescent pregnancy outcomes, including abortion, would help shape a suite of interventions for vulnerable adolescents, including interventions that facilitate access to quality schooling and alleviate poverty.

Yet national abortion data are unavailable in Australia. In New Zealand, 36% of pregnancies among 15–19‐year‐olds end in abortion,3 consistent with data from South Australia and Western Australia, the only two Australian states that publish abortion data. Medical abortion, a better option for uncomplicated pregnancies, has come to represent the majority of induced abortions in most European countries, presumably because of women's preference and ease of access.4 The absence of medical abortion data precludes confirmation of this shift in Australia, let alone understanding access by age. Further, while abortion is generally legal here, access varies widely (Box).

The recent controversy regarding My Health Record underscores concerns around potential abuses of routinely collected health data, and the ethical necessity of robust security. Abortion data are especially sensitive, with potential stigma and legal consequences attached to patients and providers. However, SA and WA have been uneventfully collecting and publishing anonymised data since 1970 and 1998, respectively. The Centers for Disease Control and Prevention (CDC) have reported United States abortion data since 1969. The CDC reasons for routine data collection equally apply in Australia: to “identify characteristics of women who are at high risk of unintended pregnancy; evaluate the effectiveness of programs for reducing teen pregnancies and unintended pregnancies among women of all ages; calculate pregnancy rates, on the basis of the number of pregnancies ending in abortion, in conjunction with birth data and pregnancy loss estimates; monitor changes in clinical practice patterns”.5

Childbirth may result in considerable stigma, depending on a woman's circumstances, but mandatory birth certificates collect extensive personally identifiable information about mother and child. We routinely collect data on stigmatising conditions when there is benefit to individuals or the community; information regarding potentially sensitive diagnoses (eg, cancer, infectious illnesses), surgical procedures and medications is gathered in various jurisdictions for reasons of public health or safety, and to understand trends.

Variation in legality and access

Adolescents are cost‐sensitive. However, outside the Northern Territory and SA, abortions are provided almost exclusively by private clinics, and cost tends to be highest where access is least. Surgical abortion is generally available only in metropolitan areas. Mifepristone–misoprostol can be prescribed by obstetricians and gynaecologists and, after online training, certified physicians including general practitioners. Medical abortion is available in all states and territories and accessible by telehealth with postal delivery of medications, except in SA and the Australian Capital Territory. In practice, this is limited by the expectation that women stay within a 2‐hour drive of 24‐hour emergency care until the abortion is complete. In most jurisdictions, consent to abortion for minors is consistent with consent for other medical procedures (ie, Gillick competent mature minors may consent), except in WA where those aged under 16 years must apply to the Children's Court to waive parental notification.6

What is known in Australia

In Australia, existing data cannot be used to inform reliable national abortion estimates. Surgical interventions for abortion are included in Medicare Benefits Schedule data, but as coding excludes indication, abortion procedures are indistinguishable from other gynaecological conditions (eg, dilatation and curettage for menorrhagia). Public hospital procedures are not processed with Medicare codes, further limiting the utility of Medicare Benefits Schedule data. As the only indication for mifepristone–misoprostol is abortion, medical abortion rates could be estimated using Pharmaceutical Benefits Scheme or manufacturer data, but none have been published and these data alone may give an incomplete picture. Thus, mandatory notification is the only reliable means to monitor abortion.

Current understanding of adolescent pregnancy is drawn from national birth statistics and the complete data (births, pregnancy losses and terminations) gathered from SA and WA, where notification and data compilation are legally mandated (the 2017 NT legislation decriminalising abortion also mandates notification and data collection but reports are yet to be published). National birth data show a steady decrease in births to 15–19‐year‐olds over the past two decades. While also true for Indigenous Australians, the birth rate among Indigenous 15–19‐year‐olds is around five times higher than that of non‐Indigenous Australians.1 In SA, among 15–19‐year‐olds, abortions fell from 24.5/1000 in 2002 to 8.3/1000 in 2016, reflecting a decrease in pregnancies to 17.6/1000, the lowest rate since 19707 (pregnancies among those aged under 15 years are uncommon and are included in numerators for 15–19‐year‐olds). Forty‐seven per cent of pregnancies in 15–19‐year‐olds and 77% of those in under‐15‐year‐olds ended in abortion.7 The pattern in WA is similar.8 Among 15–19‐year‐olds, pregnancy, abortion and birth rates have been in decline since 2006, with respective lows of 21.6, 9.1 and 12.4/1000 in 2015. The proportion of pregnancies ending in abortion was highest in 15–19‐year‐olds (42.3%). Those in this age group living outside metropolitan areas had substantially higher pregnancy rates (39.9/1000 v 22.3/1000), but comparable rates of abortion (12.3/1000 v 11.3/1000). Although the proportion of pregnancies which were terminated was generally lower for Indigenous than non‐Indigenous women (11.2% v 19.9%), Indigenous adolescents were much less likely to end their pregnancies than their non‐Indigenous counterparts (11.7% v 52.2%).8 These state data reveal substantial variability by age, remoteness and Indigenous status in the proportion of teenage pregnancies which end in abortion, affirming that birth data alone provide an incomplete picture of adolescent pregnancy.

Although many other countries have also experienced recent declines, adolescent pregnancy rates vary widely, ranging from 8/1000 in Switzerland and 14/1000 in the Netherlands, to 57/1000 in the US and 51/1000 in New Zealand.3 The proportion ending in abortion in these countries is similarly variable: 59%, 50%, 26% and 36%, respectively. International comparisons highlight that many different factors contribute to lower rates of adolescent pregnancy and abortion, including access to quality comprehensive sexuality education, access to quality primary health care and subsidised contraception, access to legal abortion without parental consent, and cultural acceptance.9

Data can help assess preventive actions

In the United Kingdom, the collection of complete pregnancy outcome data allows calculation of teenage pregnancy rates used to assess prevention programs and contextualise changes in birth and abortion rates locally, regionally and nationally.10 This comprehensive approach permitted monitoring of the Teenage Pregnancy Strategy (1999–2010), and facilitated regional adjustment at a mid‐course review in 2005.11 The strategy was a complex, whole‐of‐government, multicomponent intervention to prevent adolescent pregnancy and support young parents. A core feature was access to quality comprehensive sexuality education in schools and broad access media campaigns. Between 1999 and 2013, pregnancy in under‐18‐year‐olds halved from 47/1000 to 23/1000. An evaluation using routinely collected area level data and national survey data measured the strategy's impact on participation in education, work and training, and cost benefits.10 These data made a strong case that the fall in teenage pregnancies was attributable to the strategy, and that its greatest impact was in areas of highest disadvantage where pregnancy rates were highest. Importantly, teenage conceptions decreased during the strategy — births and abortions fell steeply from 2006.

With earlier onset of puberty, technological changes (eg, online pornography) and dynamic behavioural norms, comprehensive sexuality education needs to start in primary school, and like other education must be tailored to age and development. This includes addressing challenges disproportionately experienced by LGBTQI youth, including discrimination, interpersonal violence and mental health disorders, which increase unplanned pregnancy risk. As recognised by the CDC and the Teenage Pregnancy Strategy, complete pregnancy outcome data are required for objective evaluation and continued improvement of comprehensive sexuality education.

With broad access to comprehensive sexuality education and reliable contraception, safe abortion should be accessible, legally available and uncommonly required. Given highly variable access to abortion, reliable data collection is required in all states and territories, with national data integration and analysis. The unheralded but longstanding success of SA and WA in monitoring medical and surgical abortion provides models for a national public health surveillance system. More consistent laws would promote equity of access to medical and surgical abortion and telehealth consultations. Publicly funded abortion clinics are needed in all states and territories, with a feasible plan for access for people living in remote areas, including adolescents. Notwithstanding the recent same‐sex marriage decision, the defunding of various sexuality education programs suggests we live in an era of growing sexual conservatism. In this context, it is important to remember that access to sexual and reproductive health services for the young constitutes part of their right to health as well as being their human right. Health professionals are uniquely positioned to advocate for these measures.