Scott, Rachel (2017) Understanding differences in conception and abortion rates among under 20s in Britain and France: Examining the role of disadvantage. PhD thesis, London School of Hygiene & Tropical Medicine. DOI: https://doi.org/10.17037/PUBS.03482688 Downloaded from: http://researchonline.lshtm.ac.uk/3482688/ DOI: 10.17037/PUBS.03482688 Usage Guidelines Please refer to usage guidelines at http://researchonline.lshtm.ac.uk/policies.html or alterna- tively contact [email protected]. Available under license: http://creativecommons.org/licenses/by-nc-nd/2.5/ Understanding differences in conception and abortion rates among under 20s in Britain and France: Examining the role of disadvantage RACHEL H.V. SCOTT Thesis submitted in accordance with the requirements for the degree of Doctor of Philosophy of the University of London December 2016 Department of Population Health Faculty of Epidemiology and Population Health LONDON SCHOOL OF HYGIENE & TROPICAL MEDICINE UNIVERSITY OF LONDON Funded by the Economic and Social Research Council Research group affiliation(s): Population Studies Group, London School of Hygiene and Tropical Medicine CESP INSERM U. 1018 Equipe ‘Genre, Santé, Sexualité’ 1 STATEMENT OF OWN WORK I, Rachel H.V. Scott, confirm the work presented in this thesis is my own. Where information has been derived from other sources, I confirm that this has been indicated in the thesis. Signed: ………… Date: …16.12.2016………………… 2 ABSTRACT Context Conception and abortion rates among women aged under-20 in Britain are high compared to those of other European countries. Conception and abortion rates among women aged under-20 are lower in France. In both countries, women from disadvantaged backgrounds are more likely to report a conception before age 20, and less likely to terminate the pregnancy with abortion if they do. A significant body of research has explored conception and abortion among young people in Britain, but fewer studies have capitalised on the potential of cross- national research to increase our understanding of the British situation. The aim of this research is to examine how proximal and contextual factors, particularly disadvantage, shape conception and abortion rates among under-20s by comparing two countries, Britain and France. Methods Routinely-collected data on births and abortions are used to describe rates, trends, and area-level variation in conception and abortion rates within and between the two countries, and associations between disadvantage and conception and abortion at area-level. Nationally- representative survey data from both countries are used to examine differences between the two countries in behaviours and outcomes at each stage in the pathway to abortion (sexual activity, contraceptive use, pregnancy and recourse to abortion), and the associations with socioeconomic characteristics at each stage. Results The proportion of young women sexually active is greater in Britain but differences between the two countries in contraceptive use are smaller. There are differences in the timing and circumstances of first sex between Britain and France. Associations between socioeconomic characteristics and each stage in the pathway to abortion in individual level analyses are similar in Britain and France. The correlation between disadvantage and conception and recourse to abortion is stronger in Britain. Discussion The findings indicate that differences in conception rates between Britain and France are driven proximately by differences in the proportion of young women that is sexually active, and, to a lesser extent, differences in contraceptive use. Motivations to avoid pregnancy may play a key role in shaping behaviours at each stage of the pathway to abortion. A cross-national comparison has enabled the role of country-level social context to be explicitly examined. These empirical findings lend weight to arguments that differences in behaviour are shaped by nation- specific compositional and contextual factors including the level of social inequality and proportion of the population that is disadvantaged, the timing and pace of the transition to adulthood, prevailing norms relating to gender and young people’s sexuality and capacity for parenthood, and the opportunities that are available to, and perceived to be accessible by, young people. 3 ACKNOWLEDGEMENTS I am grateful to my supervisors, Emma Slaymaker, Kaye Wellings and Nathalie Bajos, for their ideas, advice, critique and support during my PhD. I was lucky to have Cath Mercer and Alison Hadley on my advisory committee, who were on hand with helpful statistical and policy advice, respectively. I would also like to thank Laura Lindberg and Ann Moore for generously hosting me at the Guttmacher Institute, which was a great pleasure and where I learned a huge amount during a few short months. I am particularly grateful to Laura for her interest in and enthusiasm for my work and for providing a fresh pair of eyes on my research. Sue Mann and Sara Randall may not know it, but have been mentors who were important in getting me to where I am now. Many thanks go to Mary Grinsted at the Department of Health for advising me on the process of obtaining abortions data. This research wouldn’t have been possible without funding from the Economic and Social Research Council. It has been a pleasure to share the past four years with fantastic and supportive colleagues and friends. Thank you to Clara Calvert, Francesca Cavallaro, Mel Palmer, Susie Schaffnit and Cat Towriss for always being ready for a cocktail when it was going particularly well or particularly badly. And thank you to (in order of appearance) Marina Daniele, Anu Jain, Andreia Leite, Lukasz Aleksandrowich, Andrew Kennedy and Maria Peppa for continuing the LG21 support network. My PhD half-brothers and sisters in Paris provided not only friendship but a giant fluffy unicorn, and special thanks go to Cécile Ventola, who shares my love for PhDs across borders. Huge thanks go to David Law, for his unending support in the form of words of encouragement, company, and (especially during the last leg) actual hot dinners. Also, for putting up with me. Zara Brawley was the perfect Paris wing-woman, which was where this PhD really started. Hannah Rees has a knack for always telling me what I need to hear and for putting together the perfect care package. Tom Roberts was always on hand for much needed distraction and entertainment. Lastly, lots of love goes out to my family. To my mum, for always making me feel like I could do it; to my dad, for the GIS expertise, the patience and the proofreading; and to Hegs, for having as much admiration for my tables as I do for hers. To Judith, for the many glasses (OK, bottles) of wine over the last ten years that we have been both been studying or working in London. To Gran and Punky, for their continued interest in and support for my studies. And finally to Oma, for being an inspirational woman and for being so excited when I first started discovering anthropology and demography at university. 4 CONTENTS STATEMENT OF OWN WORK ............................................................................................... 2 ABSTRACT ........................................................................................................................... 3 ACKNOWLEDGEMENTS ........................................................................................................ 4 CONTENTS .......................................................................................................................... 5 LIST OF TABLES .................................................................................................................... 8 LIST OF FIGURES .................................................................................................................. 9 LIST OF APPENDIX TABLES ................................................................................................. 10 LIST OF APPENDIX FIGURES ............................................................................................... 11 1 INTRODUCTORY COMMENTS ................................................................................. 13 2 INTRODUCTION ..................................................................................................... 16 SPECIFIC AIMS AND RESEARCH QUESTIONS ........................................................................... 23 STRUCTURE OF THIS THESIS .................................................................................................... 25 3 BACKGROUND ...................................................................................................... 27 3.1 RATES AND TRENDS IN CONCEPTIONS AND ABORTIONS IN BRITAIN AND FRANCE . 27 3.2 PREVIOUS RESEARCH CONSIDERING CONCEPTION, PARENTHOOD AND ABORTION AMONG UNDER 20S IN BRITAIN AND FRANCE .......................................................... 28 3.3 CONSIDERING ABORTION AS A PROCESS .................................................................. 35 3.4 DIFFERENCES BETWEEN BRITAIN AND FRANCE IN SEXUAL ACTIVITY, CONTRACEPTIVE USE, PREGNANCY AND PROPENSITY TO HAVE AN ABORTION .................................. 36 3.5 ASSOCIATION BETWEEN SOCIOECONOMIC CHARACTERISTICS AND EACH STAGE IN THE PATHWAY TO ABORTION IN BRITAIN AND FRANCE ........................................... 37 3.6 SOCIAL AND STRUCTURAL DETERMINANTS OF HEALTH ........................................... 42 3.7 CONCEPTUAL FRAMEWORK ...................................................................................... 46 3.8 COUNTRY LEVEL DIFFERENCES BETWEEN BRITAIN AND FRANCE ............................. 49 4 METHODS ............................................................................................................. 64 4.1 DATA FROM SURVEYS ................................................................................................ 64 4.2 ROUTINE AND CENSUS DATA ..................................................................................... 80 5 COMPARING REPORTING OF ABORTIONS IN THREE NATIONALLY REPRESENTATIVE SURVEYS: METHODOLOGICAL AND SOCIAL-CONTEXTUAL INFLUENCES ................... 94 5.1 INTRODUCTION .......................................................................................................... 94 5.2 ARTICLE ...................................................................................................................... 96 5.3 CONCLUSION ............................................................................................................ 112 6 CONCEPTION BEFORE AGE 18 IN FRANCE ............................................................. 113 5 7 HOW DO DIFFERENCES IN SEXUAL ACTIVITY AND CONTRACEPTIVE USE CONTRIBUTE TO DIFFERENCES IN CONCEPTION AND ABORTION RATES AMONG UNDER 20S IN BRITAIN AND FRANCE? ........................................................................................ 117 7.1 INTRODUCTION ........................................................................................................ 117 7.2 ARTICLE .................................................................................................................... 119 7.3 CONCLUSION ............................................................................................................ 134 8 GENDER, DISADVANTAGE AND SEXUALITY: A FRENCH-BRITISH COMPARISON OF THE TIMING AND CIRCUMSTANCES OF FIRST SEX ........................................................ 135 8.1 INTRODUCTION ........................................................................................................ 135 8.2 ARTICLE .................................................................................................................... 137 8.3 CONCLUSION ............................................................................................................ 157 9 UNDERSTANDING DIFFERENCES IN CONCEPTION AND ABORTION RATES AMONG UNDER 20S IN BRITAIN AND FRANCE: EXAMINING THE ROLE OF DISADVANTAGE . 158 9.1 INTRODUCTION ........................................................................................................ 158 9.2 ARTICLE .................................................................................................................... 161 9.3 CONCLUSION ............................................................................................................ 185 10 THE ASSOCIATION BETWEEN AREA-LEVEL DISADVANTAGE AND YOUNG PEOPLE’S CONCEPTION AND ABORTION RATES IN ENGLAND AND WALES AND FRANCE ....... 186 10.1 INTRODUCTION ........................................................................................................ 186 10.2 ARTICLE .................................................................................................................... 188 10.3 CONCLUSION ............................................................................................................ 208 11 DISCUSSION ........................................................................................................ 210 11.1 SUMMARY OF FINDINGS .......................................................................................... 210 11.2 INTERPRETATION OF FINDINGS ............................................................................... 213 11.3 STRENGTHS AND LIMITATIONS ................................................................................ 217 11.4 IMPLICATIONS FOR RESEARCH ................................................................................ 226 11.5 IMPLICATIONS FOR PRACTICE .................................................................................. 229 11.6 RECOMMENDATIONS FOR FUTURE RESEARCH ....................................................... 235 11.7 CONCLUSIONS .......................................................................................................... 237 12 REFERENCES ........................................................................................................ 239 VARIABLES AVAILABLE IN NATSAL-3 AND FECOND ................................. 257 SUPPLEMENTARY MATERIAL FOR CHAPTER 6 ......................................... 262 SUPPLEMENTARY ANALYSES FOR CHAPTER 8 ......................................... 264 SUPPLEMENTARY ANALYSES FOR CHAPTER 9 ......................................... 272 SUPPLEMENTARY MATERIAL FOR CHAPTER 10 ........................................... 282 6 CHANGES IN CONCEPTIONS IN WOMEN YOUNGER THAN 18 YEARS AND THE CIRCUMSTANCES OF YOUNG MOTHERS IN ENGLAND IN 2000-2012: AN OBSERVATIONAL STUDY ...................................................................................... 283 7 LIST OF TABLES TABLE 4.1: AVAILABLE INDICATORS OF SOCIOECONOMIC CHARACTERISTICS IN NATSAL-3 AND FECOND, THEIR SUITABILITY FOR ANALYSIS OF YOUNG PEOPLE’S SEXUAL AND REPRODUCTIVE HEALTH, AND THEIR COMPARABILITY ACROSS SURVEYS ........................................................................................................................................................... 75 TABLE 4.2: CHANGES BETWEEN CENSUS YEARS IN DEFINITION OF QUALIFICATIONS USED IN INDICATOR OF DISADVANTAGE, AGE GROUP FOR WHICH THE DATA WAS AVAILABLE, AREA LEVEL AT WHICH THE DATA WAS AVAILABLE, CENSUS SAMPLE FROM WHICH DATA WERE COLLECTED, AND SOURCE OF DATA, BY COUNTRY AND YEAR .................................................. 93 TABLE 5.1: ABORTION RATES BY AGE GROUP IN THE NATSAL-2, NATSAL-3 AND FECOND, COMPARED TO NATIONAL STATISTICS. .......................................................................................................................................... 111 TABLE 6.1: PREVALENCE AND ODDS OF REPORTING A CONCEPTION BEFORE AGE 18 AMONG WOMEN AGED 18-24 .......... 115 TABLE 8.1: PROPORTION REPORTING FIRST INTERCOURSE BEFORE 16 BY SOCIOECONOMIC CHARACTERISTICS, BY AGE GROUP AND SEX, 16-49 YEAR-OLDS, BRITAIN AND FRANCE ..................................................................................... 146 TABLE 8.2: PROPORTION REPORTING A SMALL AGE DIFFERENCE (<2 YEARS) WITH THEIR FIRST SEXUAL PARTNER BY SOCIOECONOMIC CHARACTERISTICS AND BY SEX, 16-29 YEAR-OLDS, BRITAIN ................................................... 148 TABLE 8.3: ADJUSTED ODDS OF REPORTING SEX BEFORE 16 BY SOCIOECONOMIC CHARACTERISTICS, BY AGE GROUP AND SEX, 17-49 YEAR-OLDS, BRITAIN AND FRANCE. ................................................................................................ 155 TABLE 8.4: AGE DIFFERENCE OF FIRST OPPOSITE SEX PARTNER BY SEX AND AGE GROUP AMONG RESPONDENTS AGED 16-29, BRITAIN AND FRANCE. ........................................................................................................................... 156 TABLE 9.1: CHARACTERISTICS OF THE SAMPLE IN TERMS OF SOCIOECONOMIC CHARACTERISTICS AND REPORTING OF EACH OUTCOME IN THE PATHWAY TO ABORTION, 17-29 YEAR-OLDS, BRITAIN AND FRANCE. ....................................... 181 TABLE 9.2: PREVALENCE AND ODDS OF REPORTING FIRST SEX BEFORE 16 BY PARENT SOCIOECONOMIC GROUP AND INDIVIDUAL LEVEL OF EDUCATION, 17-29 YEAR-OLDS, BRITAIN AND FRANCE. ................................................................... 182 TABLE 9.3: PREVALENCE AND ODDS OF REPORTING NO CONTRACEPTIVE USE AT FIRST SEX BY PARENT SOCIOECONOMIC GROUP AND INDIVIDUAL LEVEL OF EDUCATION, 17-29 YEAR-OLDS, BRITAIN AND FRANCE. ............................................ 183 TABLE 9.4: PREVALENCE AND ODDS OF REPORTING A CONCEPTION BEFORE AGE 20 BY PARENT SOCIOECONOMIC GROUP AND INDIVIDUAL LEVEL OF EDUCATION, 20-29 YEAR-OLDS, BRITAIN AND FRANCE. ................................................... 184 TABLE 9.5: PREVALENCE AND ODDS OF REPORTING AN ABORTION BEFORE AGE 20, AMONG WOMEN WHO CONCEIVED BEFORE AGE 20, BY PARENT SOCIOECONOMIC GROUP AND INDIVIDUAL LEVEL OF EDUCATION, 20-29 YEAR-OLDS, BRITAIN AND FRANCE. ............................................................................................................................................. 185 TABLE 10.1 NUMBER OF EXPECTED CONCEPTIONS IN FRANCE IF FRANCE HAD THE SAME DISADVANTAGE-SPECIFIC CONCEPTION RATES AS ENGLAND AND WALES, AND CORRESPONDING STANDARDISED CONCEPTION RATE RATIO (2009) ........... 200 8 LIST OF FIGURES FIGURE 3.1: CONCEPTUAL FRAMEWORK SHOWING FACTORS SHAPING SEXUAL AND REPRODUCTIVE HEALTH OUTCOMES AMONG YOUNG PEOPLE. THOSE INFLUENCES THAT CAN BE EXPLICITLY EXAMINED USING THE AVAILABLE DATA ARE HIGHLIGHTED IN BOLD. ............................................................................................................................ 48 FIGURE 3.2: INCOME INEQUALITY IN BRITAIN AND FRANCE (INTERDECILE S90/S10 RATIO) COMPARED TO OTHER EUROPEAN UNION COUNTRIES, 2012. ....................................................................................................................... 51 FIGURE 3.3: TRENDS IN INCOME INEQUALITY (GINI COEFFICIENT), SELECTED EUROPEAN COUNTRIES, 1985-2012 ............ 51 FIGURE 7.1: PROPORTION OF WOMEN REPORTING FIRST SEX BEFORE 16, BY YEAR IN WHICH THEY TURNED 16, BRITAIN AND FRANCE 1975-2010 ............................................................................................................................ 123 FIGURE 7.2: PROPORTION USING MEDICAL METHOD OF CONTRACEPTION AMONG 18-19 YEAR OLD WOMEN, BRITAIN AND FRANCE .............................................................................................................................................. 124 FIGURE 7.3: SEXUAL ACTIVITY AND CONTRACEPTIVE USE AMONG 16-17 AND 18-19 YEAR-OLDS, BRITAIN AND FRANCE, 2010. (SAMPLE: WOMEN AGED 16-17 AND 18-19 WHO HAVE EVER HAD SEX AND ARE NOT PREGNANT OR TRYING). ......................................................................................................................................................... 125 FIGURE 7.4: CONCEPTION RATES, ABORTION RATES, BIRTH RATES AND THE ABORTION RATIO AMONG 15-17 AND 18-19 YEAR OLDS, ENGLAND AND WALES AND FRANCE 1976-2011 .............................................................................. 126 FIGURE 7.5: CONCEPTION RATES AMONG ALL WOMEN AND SEXUALLY ACTIVE WOMEN, 1980-2011 ............................ 128 FIGURE 8.1: PROPORTION OF MEN AND WOMEN REPORTING FIRST INTERCOURSE BEFORE AGE 16, 1980-2010, BRITAIN AND FRANCE BY YEAR IN WHICH RESPONDENT WAS AGED 16 ............................................................................... 145 FIGURE 9.1: DISTRIBUTION OF LEVEL OF EDUCATION AMONG WOMEN REPORTING SUCCESSIVE SEXUAL HEALTH OUTCOMES, 20-29S, BRITAIN AND FRANCE. .............................................................................................................. 173 FIGURE 10.1: DISTRIBUTION OF AREA LEVEL OF DISADVANTAGE (PROPORTION WITHOUT A UNIVERSITY DEGREE OR EQUIVALENT QUALIFICATION) IN ENGLAND AND WALES AND FRANCE. ............................................................ 195 FIGURE 10.2: CORRELATION BETWEEN AREA-LEVEL DEPRIVATION AND CONCEPTION RATES (LEFT) AND THE ABORTION RATIO (RIGHT) AMONG 15-19S, ENGLAND AND WALES, 2009 .............................................................................. 195 FIGURE 10.3: CHANGE OVER TIME IN CORRELATION BETWEEN AREA LEVEL DISADVANTAGE AND CONCEPTION RATES (LEFT) AND ABORTION RATIO (RIGHT) AMONG 15-19S, ENGLAND AND WALES (EXCLUDING LONDON), 1992-2011 .............. 196 FIGURE 10.4: CORRELATION BETWEEN AREA LEVEL DEPRIVATION AND CONCEPTION RATES (LEFT) AND THE ABORTION RATIO (RIGHT) AMONG 15-19S, FRANCE, 2009 ................................................................................................. 197 FIGURE 10.5: CHANGE OVER TIME IN CORRELATION BETWEEN AREA LEVEL DISADVANTAGE AND CONCEPTION RATES (LEFT) AND THE ABORTION RATIO (RIGHT) AMONG 15-19S, FRANCE (EXCLUDING PARIS), 1980-2009. ............................... 198 FIGURE 10.6: MAPS OF DISADVANTAGE, CONCEPTION RATES AND THE ABORTION RATIO, 2009, BRITAIN (LOCAL AUTHORITY LEVEL) AND FRANCE (DÉPARTEMENT LEVEL) ............................................................................................... 199 9