THE EFFECT OF CHANGES IN STATE AND FEDERAL POLICY FOR NONPRESCRIPTION ACCESS TO EMERGENCY CONTRACEPTION ON YOUTH CONTRACEPTIVE USE: A DIFFERENCE-IN-DIFFERENCE ANALYSIS ACROSS NEW ENGLAND STATES

I. INTRODUCTION Data from the U.S. Centers for Disease Control and Prevention (CDC) indicate that in 2006 approximately 48% of all pregnancies in the United States were unintended (CDC 2012). In addition to unplanned disruptions to parents' lives, unintended pregnancies are associated with higher rates of abortions, inadequate prenatal care, and higher risk of adverse birth outcomes (Barber, Axinn, and Thornton 1999; Baydar 1995; Brown and Eisenberg 1995; Finer and Henshaw 2006; Joyce, Kaestner, and Korenman 2000). Increased access to a broad portfolio of contraception options is an important public health goal, particularly for youth, since the majority of teenage pregnancies are unintended. Contraceptive policy is therefore an important--though politically controversial--area of study. One of the more contentious recent policy changes in the United States involves decisions by several state legislatures and the Food and Drug Administration (FDA) to permit sales of emergency contraceptives (EC) on a nonprescription basis. These policy changes were motivated by a desire to provide women options for reducing pregnancy risk following an unprotected sexual encounter. Despite widespread political debate, there is limited evidence on the impact of allowing nonprescription access to EC on individual sexual behaviors. In this article, we examine the effect of allowing behind-the-counter (BTC) sale of EC on the use of more effective birth control technologies by public school students in four New England states. Currently, nine states (Alaska, California, Hawaii, Maine, Massachusetts, New Hampshire, New Mexico, Vermont, and Washington) in the United States have some legislation in place that permits pharmacists to dispense EC without an active prescription from a physician to women of any age. The FDA approved Plan B, an EC pill, for BTC sale to individuals 18 years and older on August 24, 2006 (expanded to 17-year-olds in 2009; GAO 2005; FDA 2006). Subsequently, two other EC products, Plan B One-Step[R] and Next Choice[R], have been made available in the United States without a prescription (a third EC option, ella, requires a prescription for women of any age). The controversy over offering EC without a prescription continued through the end of 2011, when the Obama administration declined to extend BTC status for EC to younger women (Harris 2011; Wood, Drazen, and Greene 2012). Finally, following a ruling by a federal judge that the FDA's age restriction was impermissible, the FDA removed any limits on access to EC in June 2013 moving it to true over the counter status (Shear and Belluck 2013). By reducing the risk of pregnancy, EC lowers the opportunity cost of unplanned and unprotected sex; when the opportunity cost of anything falls, one expects the amount of that thing to increase. Further, if increases in EC use crowd out more effective means of birth control, then there may be negative unintended public health consequences. Current estimates of contraceptive efficacy suggest that with typical (i.e., not perfect) use, 18% of women who rely on condoms will have an unintended pregnancy in the first year of use (Trussell 2011). For birth control pills and Depo-Provera the rate of unintended pregnancy is 9% and 7%, respectively (Kost et al. 2008). However, over the course of a year a woman relying only on EC would have around a 35% chance of an unintended pregnancy, though the failure rate could be as high as 53% (Trussell and Raymond 2011). To the extent that high-school youths' decisions about reproductive health suffer from poor knowledge, secrecy, and impulsivity, then they may be particularly at risk for unintended pregnancy if they substitute from more effective contraceptive methods to EC. Further, given that evidence from the National Survey of Family Growth suggests that less than 0.2% (two-tenths of a percent) of women aged 15 to 24 years actually use EC (Trussell 2011). Youth may find themselves in the doubly problematic situation of making sexual choices as if EC is highly effective, and then not actually accessing EC when it is needed. …