Reducing teenage pregnancy sexual activity what works and

Reducing teenage pregnancy & sexual activity: what works and what doesn’t Professor David Paton Nottingham University Business School 25 th March 2010

Law Reform Commission Proposals Provide confidential access to contraception for: 16 -17: consent presumed 14 -15: child encouraged to inform parents 12 -13: parents informed (but consent not necessary) WHY? • Commission argues that: access to contraception is essential in reducing teenage pregnancy & STI rates • confidentiality is crucial in increasing take-up of services (cf. Gillick ruling in England)

Sexual Health in Ireland 2. 0 U 16 Pregnancy rate 2008 (abortion + births) 1. 5 0. 9 1. 0 Rate/ 1000 0. 5 0. 0 Ireland

Sexual Health in Ireland 6. 0 U 16 Pregnancy rate 2008 (abortion + births) 5. 5 Rate/1000 4. 0 0. 9 2. 0 0. 0 Ireland England

Sexual Health in Ireland 5. 5 6. 0 U 16 Pregnancy rate 2008 (abortion + births) 80. 018 -19 Pregnancy rate 78. 9 2008 (abortion + births) 60. 0 38. 9 Rate/1000 4. 0 40. 0 2. 0 0. 9 20. 0 Ireland England

Sexual Health in Ireland 6. 0 5. 5 U 16 Pregnancy rate 2008 (abortion + births) Rate/1000 4. 0 2. 0 0. 9 1. 1 0. 0 Ireland England Netherlands (2007)

Sexual Health in Ireland 1. 5 U 16 Birth Rates 2008 1. 3 1. 0 Rate/1000 0. 6 0. 5 0. 0 Ireland England

Sexual Health in Ireland U 16 birth, pregnancy & abortion rates Ireland 1995 -2008 1. 6 1. 4 1. 2 1 Rates/ 0. 8 1000 0. 6 0. 4 0. 2 0 1995 1997 Pregnancy 1999 Birth 2001 Abortion 2003 2005 2007

Sexual Health in Ireland STI diagnosis rates amongst all teenagers: 15. 8 2007 16. 0 14. 0 12. 0 Rates/100 10. 0 8. 0 3. 8 6. 0 4. 0 2. 0 0. 0 Ireland England

Be careful before changing anything !!

Parental consent & contraception Get contraception elsewhere Family planning clinic? Don’t use clinic Have sex anyway Don’t have sex Tell parents & use clinic

Research Evidence 1: access to family planning • Access to family planning (schools, clinics, pharmacies) is not associated with lower pregnancy rates amongst minors (Paton, 2002, 2006; Di. Censo, 2002; Clements et al, 1998; Wilkinson, 2006 etc. ) • Access may increase abortions/lower births (Wilkinson, 2006) • Evidence overwhelming that emergency birth control (morning after pill) has no impact on unwanted pregnancy rates (Raymond et al, 2007; Girma & Paton, 2006 etc. ) • EBC may lead to increase in unprotected sex/STIs (Paton, 2006; Raymond & Weaver, 2008)

Evidence 2: Confidentiality and Family Planning Experiment 1. Gillick Ruling in England & Wales (Journal of Health Economics, 2002)

Family Planning & U 16 Conception Rates, Eng & Wales: 1980 -1989 20 Gillick Ruling rates 15 10 5 1980 1985 year U 16 Family Planning rate 1989 U 16 conception rate

Family Planning, U 16 & 16 -19 Conception Rates, Eng & Wales: 1980 -1989 110 20 Gillick Ruling 90 rates 15 10 70 5 50 1985 year U 16 Family Planning rate 16 -19 conception rate 1989 U 16 conception rate

Evidence 2: Confidentiality and Family Planning Experiment 1. Gillick Ruling in England & Wales (Journal of Health Economics, 2002) Imposition of parental consent did not increase underage conceptions relative to older teenagers or to Scotland. Experiment 2. Mc. Henry County, Illinois ( American Jnl of Public Health, 2004, 2005). Introduction of parental consent led no significant change in pregnancies

Evidence 3: Confidentiality and abortion Over 30 US States have imposed parental involvement laws for abortion since 1984 §Teenage abortion rates down §Teenage births don’t change or go down §Overall teenage pregnancy rates down. §Teenage STIs down (see e. g. Levine, 2003; Klick & Stratmann, 2008)

Evidence 4: What else affects teenage pregnancy/sexual activity? §Poverty §Religious affiliation §Family stability §Educational achievement (see, e. g. , Paton, 2001; Wilkinson, 2006; Evans et al, 2002 etc.

Why doesn’t access to family planning work? 1. More sexual activity ? 2. High failure rates, especially for adolescents Examples: England: 50% of minors having abortions had been prescribed the pill in previous year (Churchill et al, 2001) Netherlands: two thirds of those having abortions were using contraception (Rutgers, 2008) Condom users: 17% of condom users can expect to experience pregnancy over 12 months (Kost et al 2008)

The English experience: • Confidential access to family planning since mid-70 s (interrupted by Gillick ruling in 1985) • Teenage pregnancy strategies launched in 1992 and 1997 • Massive investment in and promotion of EBC, school clinics, “signposting” of services etc.

Progress of English Teenage Pregnancy Strategy 60 50 Teenage Pregnancy Strategy starts Rates 40 2004 target 30 2010 target 20 10 0 1995 2000 U 18 conception rate 2005 U 16 conception rate 2010

Progress of English Teenage Pregnancy Strategy

U 16 Family Planning & Conception Rates, England 1975 -2007 100 Gillick Ruling Health of the Nation Rates 80 Teenage Pregnancy Strategy 60 40 20 0 1975 1980 1985 1990 U 16 Family Planning rate 1995 2000 2008 U 16 conception rate

Likely effects of Law Commission Reforms • Pregnancy rates no change • Early sexual activity up • More pressure for abortion

Are you sure you want to copy the English?

References Colman S. , T. Joyce and R. Kaestner (2008), ‘Misclassification Bias and the Estimated Effect of Parental Involvement Laws on Adolescents’ Reproductive Outcomes’ American Journal of Public Health, 98(10): 1881 -5. Di. Censo A. , G. Gordon, W. Andrew and L. Griffith (2002), ‘Interventions to reduce unintended pregnancies among adolescents: systematic review of randomised controlled trials’, British Medical Journal, 324(15, June): 1426 -34. Evans W. N, W. E Oates and R. M. Schwab (1992), ‘Measuring peer group effects: a study of teenage behavior’, Journal of Political Economy, 100(5, Oct): 966 -91. Girma, S and D Paton (2006), ‘Matching Estimates of the Impact of Over-the-Counter Emergency Birth Control on Teenage Pregnancy’, Health Economics, 15 (Sept): 1021 - 32. Glasier, A, K Fairhurst, S Wyke, S Zirebland, P Seaman, J Walker & F Lakha (2004), ‘Advanced Provision of Emergency Contraception Does not Reduce Abortion Rates’, Contraception, 69: 361 -6. Joyce T. , R. Kaestner and S. Colman (2006), ‘Changes in Abortions and Births and the Texas Parental Notification Law’, New England Journal of Medicine, 354(10, March): 1031 -8. Klick J. and T. Stratmann (2008), ‘Abortion access and risky sex among teens: parental involvement laws and sexually transmitted diseases’, Journal of Law, Economics and Organization, 24(1, May): 2 -21. Kost K. , S. Singh, B. Vaughan, J. Trussell and A. Bankole (2008), ‘Estimates of contraceptive failure from the 2002 National Survey of Family Growth’, Contraception, 77: 10 -21. Levine, PB (2003), ‘Parental involvement laws and fertility behavior’, Journal of Health Economics, 22 (5, Sept), 861 -78. Paton, D (2002), ‘The Economics of Abortion, Family Planning and Underage Conceptions’, Journal of Health Economics, 21 (2, March): 27 -45 Paton, D (2006), ‘‘Random Behaviour or Rational Choice? Family Planning, Teenage Pregnancy and STIs’, Sex Education, 6 (3, August): 281 -308. Raymond, EG, J Trussell & CB Polis (2007), ‘Population Effect of Increased Access to Emergency Contraceptive Pills: a systematic review’, Obstetrics & Gynecology, 109 (1, Jan): 181 -8. Raymond E. G. and M. A. Weaver (2008), ‘Effect of an emergency contraceptive pill intervention on pregnancy risk behavior’, Contraception, 77: 333 -6. Stanford J. B. (2008), ‘Emergency Contraception: overestimated effectiveness and questionable expectations’, Clinical Pharmacology and Therapeutics, 83(1, Jan): 19 -21. Trussell, J. , E. B. Schwarz, K. Guthrie and E. Raymond (2008), ‘No such thing as an easy (or EC) fix’, Contraception, 78: 351 -4. Wilkinson P. , R. French, R. Kane, K. Lachowycz, J. Stephenson, C. Grundy et al (2006), ‘Teenage conceptions, abortions and births in England: 198942003, and the national teenage pregnancy strategy’ Lancet, 368(Nov): 1879 -86. Zavodny, M (2004), ‘Fertility and parental consent for minors to receive contraceptives’, American Journal of Public Health, 94(8): 1347 -1351. Zavodny, M (2005), ‘Erratum In: Fertility and Parental Consent for Minors to Receive Contraceptives’, American Journal of Public Health, 95(1): 194.