It is increasingly common for pregnant young women under 18 to have an abortion. However, there is considerable geographical variation across Great Britain in the proportion of under-18 conceptions ending in abortion. This study, by the Centre for Sexual Health Research at the University of Southampton, addressed the reasons for this variation through examining the factors that shape young women's decisions about their pregnancies. The research found that:

• A national figure of 44 per cent of conceptions among women aged 15 to 17 being terminated masks considerable disparity between local authorities - varying between 18 per cent in one area and 76 per cent in another.
• More deprived areas have both higher rates of conception under 18 and lower proportions of such conceptions ending in abortion.
• Young women's decisions tended to depend on the economic and social context of their lives, rather than abstract moral views. Those young women who perceived their lives as insecure were more likely to view motherhood as something that might 'change their life' in a positive way. Those who were certain that their future life would develop through education and employment were more likely to opt for abortion.
• There was a strong correlation between the proportion of under-18 pregnancies ending in abortion and the proportion of adult pregnancies ending in abortion. This suggests that local familial and/or cultural processes also have an important impact.
• There were also associations (regardless of deprivation levels) between high proportions of abortions and more extensive local family planning provision, higher proportions of female GPs and greater independent sector abortion provision.

Background
Abortion in Britain is legal under the terms of the 1967 Abortion Act. One clause of the Act states that an abortion can be performed up to 24 weeks of pregnancy if continuation constitutes a greater threat to the physical or mental health of the pregnant woman than does termination, and most abortions are performed for this reason.

Women seeking abortion normally go through three stages: the referral stage (when they request that a doctor refer them to an abortion provider), the consultation (where they discuss their request and other relevant issues with an abortion provider) and the procedure itself.

Geographical variation
Between 1999 and 2001, 44 per cent of conceptions among women aged 15 to 17 were terminated. However, this overall figure masked considerable disparity between local authorities - varying between 18 per cent in one area and 76 per cent in another.

Factors influencing variations
Statistical analysis, as well as interviews, showed that young women generally made decisions about whether to continue with or terminate their pregnancy before visiting a health professional. Their decisions appeared to be influenced mainly by socio-economic circumstances, family and community views and, possibly, by the availability of family planning and abortion services. The correlation between abortion proportions for all women and those for under-18s indicates that similar processes are shaping the decisions of different age groups.

Social deprivation
The association between social deprivation and teenage conception and motherhood has long been recognised. This study confirmed that more deprived areas have both higher conception rates and a lower proportion of under-18 pregnancies ending in abortion.

Such areas may therefore have relatively high numbers of abortions, but a lower percentage of conceptions ending in abortion than more affluent areas. This clearly has implications for service capacity. The association between social deprivation and abortion proportions is stronger amongst 16- to 17-year-olds than it is for those aged under 16.

Attitudes to abortion and motherhood
Interviews with young women who had experienced an unplanned pregnancy looked at their attitudes to abortion and motherhood. Those whose background and experience led to a strong belief that their future life would centrally include activities such as higher education and career (who were emphatically 'not motherhood yet') were clear and decisive in their choice of abortion. Those who opted for abortion tended to have high expectations of life in the present, and clear pathways marked out for the immediate future.

"There was no question of me keeping it because I knew I was going to go to university ... I'd had a good education and I had a career path to go down, it was all laid out for me."

By contrast, many of those who continued their pregnancies could perceive motherhood in a relatively more positive light, since it did not appear to interfere with plans for the immediate future. Continuing a pregnancy, even if it was unintended, could appear to make possible a positive direction in life, the opportunity to take personal responsibility and, in some cases, a close personal relationship with a partner, parent and/or child.

"It has been the best thing that's ever happened to me ... if I hadn't had the baby I'm sure I would've been in jail."

Most of the mothers interviewed for this study did not clearly associate motherhood with lack or loss. While some did associate motherhood with 'missing out', their feelings of excitement about pregnancy compensated for this. Some viewed motherhood as rewarding, associating it with responsibility, and as a spur to achievement. These young women did often strongly eschew abortion, not because of a general belief that abortion is always 'wrong' so much as because of the way that pregnancy and motherhood appears to them.

Many young women had relatively few dilemmas about deciding what to do about an unplanned pregnancy. They tended to have strong feelings themselves about what should happen.

A large minority, however, found making a decision more difficult. Of these young women, those who opted for abortion viewed it as the 'right thing to do' and the 'responsible choice'. They explained their decision through reference to their future plans, their lack of financial independence, and the absence of stable relationships that might surround them as a mother.

The influence of partners, friends, family and community
Few young women reported that they had actually thought in great detail about pregnancy, abortion or motherhood prior to conceiving. Women - including those who continued with a pregnancy - were shocked and horrified to find themselves pregnant. Some had clear prior views for or against abortion (even though, when finding themselves pregnant, they may not have acted consistently with these), but many thought about it for the first time only when faced with this crisis in their lives. Even those with clear views were frequently at a loss to describe where these views had come from.

Most young women perceived the outcome of pregnancy to be their decision. Many of those who went on to have the baby could countenance motherhood without having a clearly stable relationship with the father, although they viewed the father's involvement as desirable. Many of those who terminated pregnancies with 'mixed feelings' about doing so felt more strongly that they could only continue with the pregnancy in the context of greater relationship stability.

"He would have left me straightaway ... It got to the extent where it wasn't his baby any more, it was mine."

Young women's perceptions of the place of motherhood in their lives appeared to be shaped by community and family views and experience. These included the extent to which having children relatively early was accepted and seen as normal, the importance placed on goals that are not compatible with early motherhood, and differing perceptions of the difficulties and demands that parenthood carries with it.

Those young women who had abortions mostly indicated that their parents viewed abortion in a pragmatic way, and saw young motherhood, certainly for their daughter, to be a more negative outcome than abortion.

"It was very easy, because I didn't want it ... I could tell my mum wanted me to have a termination."

By contrast, parents of those who continued their pregnancy were more likely to be reported as having negative views on abortion. Where young women proceeded with pregnancies, family members - especially female family members - played an important role, as they sometimes stepped in and took on much of the responsibility for childrearing. Young women who readily chose abortion indicated that their friends would do the same, while those who viewed abortion as 'wrong' and continued their pregnancies highlighted how relatives and neighbours thought the same.

"My mum will never have an abortion and she hasn't made up my mind for me, but she was always that way."

Stigma about abortion made considering, and choosing, this option difficult. Almost all young women who chose abortion - even where they were immediately very sure it was the right choice - found it stigmatising. Young women often thought they should keep an abortion secret from parents. Young women who had had an abortion were pleasantly surprised when they found health professionals who treated them with sympathy and without judgement.

Abortion services
Clinicians rarely had a direct influence on decisions about whether to end or continue with a pregnancy. Most young women decided what they wanted to do before they booked an appointment with a referring doctor.

However, statistical analyses show that abortion proportions are related, independently of deprivation levels, to service provision in three ways: family planning clinic provision; the proportion of female GPs; and the availability of independent sector provision of abortion. It may be that independent sector clinics have been sited in areas that already have a higher proportion of abortions, and that cultural and/or socio-economic factors have an independent association with the proportion of female GPs.

Young women seem more likely to regard family planning services, rather than GP services, as somewhere to go for abortion referral, possibly for reasons of anonymity or because of perceptions of the relevance and expertise of the service.

A strong moral opposition to abortion on the part of professionals does not emerge as a clear barrier to access to abortion. Some young women did find doctors' attitudes problematic and upsetting when referring doctors made their disapproval of teenage pregnancy and/or abortion apparent, tried to pass young women on to another professional as fast as possible, or were unhelpful regarding to access to abortion after the first trimester.

NHS-funded abortion services are almost always available where young women request abortion. However, in some instances, local services are struggling to meet demand and, in a small number of cases, waiting times are longer than the Government recommended three weeks. From survey results and interviews, it was found that some clinicians appear to dislike abortion after the first trimester; fewer NHS clinics offer this service than an early abortion service with consequently greater distance for women to travel to access independent providers.

Young women who had used independent providers reported more positive experiences than those who had used the NHS. Young women with positive experiences of abortion care emphasised the availability of services, and the extent to which health professionals respected their right to choose, provided them with information, and were non-judgemental.

"She had a chat with me, told me what the procedures were and gave me all these leaflets ... She says, 'at any time you can pull out, we won't be mad with you' ... It didn't seem like a hospital, that was the best thing about it. They were just talking to you about any old thing, trying to take your mind off it."

Those with negative experiences highlighted the reverse side of the same issues, as well as reporting sometimes feeling 'over counselled' and negative experiences of dating scans.

"They were all right ... but when I went for the scan the woman went, 'oh there's definitely a heartbeat there', and I was like, 'I don't want to know that ... how dare you say that to me.' "

Conclusion
Young women's pregnancy decisions involve a series of choices. But while women can and do make such choices, there are many elements that contribute to the final outcome. The researchers conclude that policy needs to take account of following:

• Young women's decisions about pregnancy are shaped by social circumstance and personal relationships.
   
• Many young women get satisfaction from motherhood, and need medical services that accept their choice.
   
• Young women's expectations about what can be achieved through education and success in the world of work affect their decision-making.
   
• Building on developments in abortion provision, quality and care and making it clear that abortion is an aspect of reproductive health care and family planning could make abortion less stigmatised. Greater discussion in school-based sex and relationships education, or the wider availability of literature that spells out the options, might also help in this.
   
• Access to family planning and sexual health services, and the availability of independent sector abortion provision, directly affect abortion proportions.
   
• Abortion services vary in quality and are particularly uneven in dealing with abortion in the second trimester. Not all young women currently get sympathetic and caring treatment at consultation and procedure that fully takes into account their needs.

About the project
The aim of this study was to investigate the relationship between abortion proportions and broader social factors amongst women aged 17 years and under. The research ranged from the macro-level, involving national data on geographical patterning, to the micro-level, involving intensive interviews with young women (103 in total, with an even split between those who had continued with and those who had ended their pregnancies) and with older people in selected communities with relatively high rates. Three main themes were covered - the availability of abortion services and experiences of services generally, perceptions of abortion, and influences on decision-making.

How to get further information
The main report, A matter of choice? Explaining national variations in teenage abortion and motherhood, by Ellie Lee, Steve Clements, Roger Ingham and Nicole Stone, is published by the Joseph Rowntree Foundation (ISBN 1 85935 181 6, price £14.95).

The technical report is available from Nicole Stone, Centre for Sexual Health Research, University of Southampton, Highfield, Southampton, SO17 1BJ, UK, Tel: 02380 597770, e-mail: cshr@socsci.soton.ac.uk or from http://www.socstats.soton.ac.uk/cshr.

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Click on the 'report .pdf' icon in the left margin to download a pdf of the full report free of charge. (File size is 0.54MB).