Transcript Does pharmacy provision of emergency birth control reduce teenage pregnancy? An analysis of quarterly data from England

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
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.
100
Underage Conceptions & Family Planning Rates: England
Health of the
Nation
Teenage Pregnancy
Strategy
40
rates
60
80
Gillick Ruling
0
20
Morning After Pill
Family Planning
Conceptions
1975
1980
1985
1990
year
1995
Rates per 1000 females aged 13-15
Family Planning figures related to attendance at family planning clinics
2000
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)
Controversies:
• abortion?
• health risks?
• rights of parents?
•will free EBC at pharmacies
actually cut teenage pregnancies?
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.
3. Theory
No sex
Not pregnant
Works
Not pregnant
FP
Pregnant
No MAP
Not pregnant
Fails
Sex
Works
Not pregnant
Fails
Pregnant
MAP
No FP
Pregnant
No MAP
Not pregnant
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
ENDOGENEITY PROBLEM:
Services more likely to be put in place in high
pregnancy areas.
Solutions:
1. Difference in difference approach
2.Matched sample
3.Treatment regression
4.LAD specific time trends
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.
6. SELECTED RESULTS
Variables
All
Matched
LAD-specific
Trends
Treatment
Pharmacy EBC
-0.086
-0.120
-0.148
-0.903*
FP clinics
0.475***
0.452***
0.619**
0.452***
APause
-6.022*
-6.476*
3.296
-6.358***
GP FP
1.498***
1.369*
0.396
1.369***
GP practices
1.216
0.737
-15.04*
0.693
Unemployment
-0.167
-0.249
0.074
-0.273
% Lone parents
-2.333*
-2.22*
-1.371
-2.267
Prop Kids in Care
0.005**
0.003*
-0.003
0.004*
% No quals
0.327***
0.301***
0.468***
0.290***
N
2646
1908
1908
1908
Mean Dep Vble
11.88
12.31
12.31
12.31
*** = sig at 1%; ** at 5%; *** at 10%
Why is there no EBC effect?
• Low statistical power?
• Schemes not attracting young people?
• Schemes substituting for other sources of EBC?
• Behaviour change?
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%
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:
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