The authors respond to “Failure to monitor or prevent unintended pregnancy is the key intergenerational problem, not the pregnancy outcome”
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* Ning Liu
* M. Michèle Farrugia
* Simone N. Vigod
* Marcelo L. Urquia
* Joel G. Ray

We too hold in high regard the observed reduction in teen pregnancy in Canada over time, as pointed out in the letter by Drs. Norman and Munro.1 Their definition of what constitutes “a considerable proportion of abortions” among teens differs from ours, however. Of all teenage pregnancies in Canada, more than 70% are unintended,2 and 51% end in induced abortion.3 The document cited by Drs. Norman and Munro, published in 2016 by the Canadian Institute for Health Information, undercaptured the number of induced abortions performed within Ontario, outside of a hospital setting.4 Rather, as the Canadian Institute for Health Information subsequently clarified,5 and others have noted,6 the number of induced abortions is much higher, at about 40 000 per year, which is close to that estimated by the algorithm used in our study.7

Our study did not evaluate the economic determinants of having, or not having, an induced abortion. However, we did observe a consistent effect size for the phenomenon of intergenerational induced abortion across income quintiles (Appendix 2 in our paper).7

Although we appreciate the recent provision of Canadian federal funding to address the issues of sexual and reproductive coercion8 and reproductive rights,9 we are not sure that such measures can be entrusted to governments alone. As concluded in our paper, and in agreement with Drs. Norman and Munro, education and the widespread availability of highly effective contraception is part of any effective strategy to reduce unintended teen pregnancy.7 Rather than taking “a stab in the dark,” our study also introduces a core social determinant of health that appears to heighten the risk of unintended pregnancy, and consequential induced abortion: that of the family experience.7 Beyond time-consuming and expensive population surveys, we welcome the testing of evidence-informed interventions, at the family, peer, school and individual levels, which may be a more efficient way to reduce unintended teen pregnancy (and the resultant need for induced abortions).

## Footnotes

*   **Competing interests:** None declared.

## References

1.  Norman WV, Munro S. Failure to monitor or prevent unintended pregnancy is the key intergenerational problem, not the pregnancy outcome [letter]. CMAJ 2018;190:E600.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMToiMTkwLzE5L0U2MDAiO3M6NDoiYXRvbSI7czoyMjoiL2NtYWovMTkwLzE5L0U2MDEuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

2.  What mothers say: the Canadian Maternity Experiences Survey. Ottawa: Public Health Agency of Canada; 2009. Available: [www.phac-aspc.gc.ca/rhs-ssg/pdf/survey-eng.pdf](http://www.phac-aspc.gc.ca/rhs-ssg/pdf/survey-eng.pdf) (accessed 2018 Feb. 6).
    
    

3.  McKay A, Barrett B. Trends in teen pregnancy rates from 1996–2006: a comparison of Canada, Sweden, USA, and England/Wales. Can J Hum Sex 2010;19:43–52.
    
    

4.  Induced abortions reported in Canada in 2014. Ottawa: Canadian Institute for Health Information (CIHI); 2016. Available: [www.cihi.ca/sites/default/files/document/induced\_abortion\_can\_2014\_en\_web.xlsx](http://www.cihi.ca/sites/default/files/document/induced\_abortion\_can_2014_en_web.xlsx) (accessed 2018 Feb. 6).
    
    

5.  Induced abortions in Canada in 2015. Ottawa: Canadian Institutes for Health Information; 2017. Available: [www.cihi.ca/sites/default/files/document/induced-abortion-can-2015-en-web.xlsx](http://www.cihi.ca/sites/default/files/document/induced-abortion-can-2015-en-web.xlsx) (accessed 2018 Feb. 6).
    
    

6.  Statistics — Abortion in Canada. Vancouver: Abortion Rights Coalition of Canada; 2017. Available: [www.arcc-cdac.ca/backrounders/statistics-abortion-in-canada.pdf](http://www.arcc-cdac.ca/backrounders/statistics-abortion-in-canada.pdf) (accessed 2018 Feb. 6).
    
    

7.  Liu N, Farrugia MM, Vigod SN, et al. Intergenerational abortion tendency between mothers and teenage daughters: a population-based cohort study. CMAJ 2018;190:E95–102.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo5OiIxOTAvNC9FOTUiO3M6NDoiYXRvbSI7czoyMjoiL2NtYWovMTkwLzE5L0U2MDEuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

8.  New funding in support of women’s sexual and reproductive health [news release]. Ottawa: Status of Women Canada; 2017 Mar. 6. Available: [www.canada.ca/en/status-women/news/2017/03/new\_funding\_in\_supportofwomenssexualandreproductivehealth.html](http://www.canada.ca/en/status-women/news/2017/03/new_funding_in_supportofwomenssexualandreproductivehealth.html) (accessed 2018 Feb. 6).
    
    

9.  York G, Zilio M. Canada spending $650-million on reproductive rights, including fighting global antiabortion laws. Globe and Mail [Toronto] 2017 Mar. 8 (updated 2017 Apr. 14). Available: [www.theglobeandmail.com/news/politics/ottawa-announces-650-million-for-sexual-and-reproductive-health/article34237503/](http://www.theglobeandmail.com/news/politics/ottawa-announces-650-million-for-sexual-and-reproductive-health/article34237503/) (accessed 2018 Feb. 6).