David Paton Nottingham University Business School September 2004

1. Does pharmacy provision of emergency birth control reduce teenage pregnancy? An analysis of quarterly data from England David Paton Nottingham University Business School September 2004

2. 1. BACKGROUND • England Teenage Pregnancy Strategy aims to cut U18 conception rate by 50% between 1998 and 2010. • Historically, very difficult to cut teenage pregnancies.

4. Background (cont.) • High hopes that greater access to emergency birth control (morning after pill) will work. • 2000: EBC available OTC from pharmacists, but only for over 16s and for a charge. • Pilot areas introduced free EBC OTC from pharmacists and in schools. • Similar policies actively being considered in other countries (e.g. USA)

5. Controversies: • abortion? • health risks? • rights of parents? • will free EBC at pharmacies actually cut teenage pregnancies?

6. 2. EXISTING EVIDENCE • Churchill (2000): teenagers accessing EBC from GPs more likely to have subsequent abortions than others. • Gold et al (2004): teenagers provided with EBC no more likely to engage in risky sexual behaviour than control group. • Paton (2004): no significant impact of pharmacy EBC on annual conception rates, but very early in life of scheme.

7. 3. Theory

8. 4. EMPIRICAL APPROACH • Panel regression models of quarterly U18 conception rate in LAD1 areas on: • PHARM: pharmacy EBC scheme • CLINICA: FP clinic sessions per km2(or per person) • APAUSE: % 15-17 covered by APAUSE sex ed • + series of other FP and socio-economic variables • 2-way fixed effects with panel-corrected standard errors

9. ENDOGENEITY PROBLEM: • Services more likely to be put in place in high pregnancy areas. • Solutions: • Difference in difference approach • Matched sample • Treatment regression • LAD specific time trends

10. 5. DATA • 147 LADs from 1998 Q1 to 2002 Q2 = 2642 observations. • 53 had EBC scheme by end of sample: 2000: 11 2001: 34 2002: 53 • LAD1s matched by (i) ONS clustering and teenage pregnancy rate = 1904 observations in matched sample (ii) by propensity scores.

11. 6. SELECTED RESULTS

12. Why is there no EBC effect? • Low statistical power? • Schemes not attracting young people? • Schemes substituting for other sources of EBC? • Behaviour change?

13. explanations (cont.) E.g. consider Enfield • 250 U18 conceptions per year; rate = 48 per 1000 • Pharmacy EBC scheme, U18 take up: 300 • Cost: £40,000 • From 300 EBCs, expect 6-24 pregnancies, 5–20 avoided (Trussell et al 1998) ≈ 2-8% drop in conception rate • Using 5% sig level: 2% drop, power = 58% 8% drop, power = 100%

14. explanations (cont.) E.g. consider Enfield • 250 U18 conceptions per year; rate = 48 per 1000 • Pharmacy EBC scheme, U18 take up: • Cost: • Pregnancies avoided (Trussell et al 1998) • Using 5% sig level:

15. Conclusions • Pharmacy EHC schemes do not appear to have a measurable impact on teenage pregnancy rates • Possible reasons are substitution from other EHC sources &/or that schemes induce behaviour change. • Early evidence from APause sex education programme encouraging. • Pharmacy EHC is probably not a good use of scarce resources aimed at tackling teenage pregnancy