The Sale Rates of Oral Contraception and Emergency Contraceptive Pills - Research Paper Example

? Trevlig omslagsbild! The sale rates of oral contraception and emergency contraceptive pills in comparison with the development of abortion rates Forsaljningsutvecklingen av p-piller och dagen-efter-piller i jamforelse med abortfrekvensen  Arian.Mandegari@gmail.com Supervisors: Sahra Barzi, Cecilia Bernsten, Tommy Westerlund Sahlgrenska Akademin, Goteborgs Universitet Table of Contents Title Page …………………………………………………………………………….. 1 Summary in Swedish ……………………………………………………………….. 4 Abstract ……………………………………………………………………………… 5 Introduction …………………………………………………………………………. 6 Aim…………………………………………………………………………………… 12 Methodology ………………………………………………………………………… 13 Research Design …………………………………………………………….. 13 Population and Setting……………………………………………………… 13 Data Gathering Tool ………………………………………………………... 13 Results ………………………………………………………………………………. 14 Discussion ………………………………………………………………………….... 16 Conclusion …………………………………………………………………………... 20 References …………………………………………………………………………... 21 Summary in Swedish Syftet med den har studien var att undersoka graden av konsumtion av preventivmedel under perioden 2000-2010, bade nar det galler p-piller och dagen-efter-piller och jamfora den med antal aborter under samma period. Uppgifterna angaende forsaljningsantalet och abortstatistiken togs ur Socialstyresens halso- och sjukvardsrapport och Concise. Concise ar ett program som omfattar forsaljningsstatistiken fran de olika apoteken i Svergie. Forsaljningen av p-pller okade kraftigt under 2000-2010, medan forsaljningen av dagen-efter-piller forblev relativt oforandrad. Samtidigt okade antalet aborter.  Trots tillgangligheten av dagen-efter-piller, fortsatte antalet aborter att oka i Sverige under studieperioden. Sammanfattningsvis kan vi saga att mer forskning behovs om ytterligare eventuella faktorer som paverkar forsaljningen av preventivmedel och antalet aborter. The Sale Rates of Oral Contraception and Emergency Contraceptive Pills In Comparison With the Development of Abortion Rates Abstract Objective: Contraception is nowadays an accepted means of preventing pregnancies. The aim of this study was to explore the rate of consumption of contraceptive pills in Sweden in 2000-10, both birth control (BC) and emergency (EC), to compare with the rate of abortions during the same period of time. Methods: This study included women, consuming contraceptive pills, as well as women who underwent abortion in the past ten years. The study covered research on the current rate of sale of BC pills as well as the sale of EC from data collected by Concise which is a program that includes sales statistics from the different pharmacy services in Sweden.  It also involved obtaining information from the National Board for Health and Welfare (Socialstyrelsen) on the total number of abortions performed. Results: The sale rates of oral contraceptives steadily increased in 2000-2010. The rate of sale of emergency contraceptives, on the other hand, was relatively unchanged during the study period with some minor ups and downs. At the same time, the rate of abortions increased. Conclusion: The abortion rate in Sweden increased during the study period, despite both tripled sales of oral contraceptives and stable sales of emergency contraceptives. Further research is needed to add knowledge regarding additional factors affecting the birth control pill sales, emergency contraceptives sales and the abortion rates. For established data regarding the said rates, further studies are needed to compare and correlate the relationship between these factors. Introduction Through the years, advancements have been made in different aspects of life, from technology to healthcare. These advancements were directed towards the improvement of the health of mankind. Indeed, these developments, especially those in modern medicine, have greatly improved our way of life. One aspect in life that has been touched by these advancements is the prevention of conception and abortion in women. Family planning has been a constant battle of right and wrong after it was introduced in the early times. Comments and disapproval from religious sectors in the community, as well as passed laws, were obstacles to a widespread use. Contraception is the use of different devices such as drugs, chemical agents, surgical procedures or sexual practices to prevent conception or pregnancy [1]. The word is a contraction of the words “contra” and “conception”, contra which means against, and conception, meaning fertilization [2]. Contraception can take place both naturally and via artificial means in humans and in animals. Natural contraception includes the techniques such as basal body temperature, cycle beads, withdrawal, and abstinence. Artificial contraception on the other hand includes condom (male and female), diaphragm, caps, injections, implants, patch, rings, sterilization, and most of all oral and emergency contraception [3]. The introduction of birth control (BC) and emergency contraception (EC) medicines for women, which was once unacceptable to the world due to different beliefs and practices, has been gradually accepted. This wide use of birth control pills according to Gebbie & Hardman [4] has been largely due to the fact that BC not only helped in family planning and preventing unwanted pregnancies, but that it has also served as a means of treatment for women suffering from medical conditions including hormonal imbalances. The BC drugs provide the hormones needed by the body to balance the normal rhythm of menstruation for these women suffering from the condition. The development of life in women’s bodies or the presence of a growing fetus in their womb would prompt women to resort to other means of preventing or stopping the process. Since EC is helpful in preventing pregnancies, it is also in a way to spare women from needing an abortion for an unwanted pregnancy. This possibility points to a possible relationship between an increase in the use of contraceptives, and a decrease in the rates of abortion. Oral contraception, an artificial means of contraception is considered to be the most socially significant medical advancement in our current time. It is also known as a birth control pill by medical practitioners and is consumed by over 60 million women globally. It is a pill that typically contains progesterone or estrogen, which inhibits the process of ovulation in women [5]. Birth control pill is a form of contraception that requires the woman to take it on a daily basis. The pill works by inhibiting the maturation of the egg in the woman's ovary during her menstrual cycle by preventing the release of a certain hormone responsible for the development of the egg [6]. The pill also contains another artificial progestin hormone, which increases the production of cervical mucus and prevents the development of the uterine lining to further impede pregnancy. Recent studies have shown that the pill can effectively prevent pregnancy by 99% [7]. Emergency contraception on the other hand refers to a birth control technique that prevents conception after sexual intercourse. As compared to birth control pills which is used before and on a regular basis, emergency contraceptives are used 1 to 5 days after. It is oftentimes referred to as the “morning after” or “the day after” pill. Unlike birth control pills that contain progesterone and estrogen hormones, emergency contraceptives contain progestin, which is synthetic progesterone. It has a higher ability to disrupt the meeting of the sperm and the egg cell than normal birth control pills since it contains higher doses of the hormones. It can be used immediately up to five days after the intercourse, but the risk of conceiving will increase with each passing day [8]. Taking the pill one day later or approximately within 24 hours after reduces the risk of conception to 0.4 %. If ingested 48 hours after, the risk of pregnancy rises to 1.2% and if taken in 72 hours later, it again rises to 2.7% Emergency contraception will reduce the risk of getting pregnant but it is not as effective as birth control that is used before sexual intercourse (i.e. condoms and pills). Nor does it protect the individual from sexually transmitted diseases like condoms do [9]. EC pills are divided into three types; the progestin-only method, the combined method, and Ulipristal acetate [10]. According to Angus & DeVoe, Progestin-only method uses progestin levonorgestrel in a measured dosage of 1.5 mg; it can be given at one time in a single dose or twice in 12 hours interval as 750 ?g dose. It is available as an emergency contraceptive product under many names worldwide but it is widely known as Plan B in the U.S. and Canada; Levonelle in UK, Australia, New Zealand, Ireland, Italy and Portugal. It is more commonly known in Sweden, however, as NorLevo or Postinor-2. The pill takes effect up to 72 hours after sexual encounter. The combined or Yuzpe regimen, ingested at a 12-hour interval in two doses, the regimen makes use of larger doses for estrogen and progestin. The method is now considered less effective and less tolerated than the earlier mentioned method.  Ulipristal acetate, better known as Ella in the US and Ellaone in Europe, was approved as an EC in Europe in early 2009 and in the US in August 2010. It works for up to 120 hours after intercourse.  Mifepristone (RU486, Mifeprex), which is often used as an abortive pill, should not be lined together with EC pills. The term "emergency contraceptive pill" does not refer to mifespristone, which is most commonly used in 200- or 600-mg doses as an abortifacient [11]. However, in China and Russia only, mifepristone is available as either emergency contraception or as an abortifacient, depending on whether it is used before or after the development of the fetus. If used as emergency contraception, a low dose of mifepristone is slightly less effective than higher doses, but has fewer side effects. As of 2000, the smallest dose available in the USA was 200 mg. Mifepristone, however, is not approved for emergency contraceptive use in the United States. A review of studies in humans concluded that the contraceptive effects of the 10-mg dose are due to its effects on ovulation, but understanding of its mechanism of action remains incomplete. Higher doses of mifepristone can disrupt implantation and, unlike levonorgestrel, mifepristone can be effective in terminating established pregnancies. Abortion is termed the termination of pregnancy before the age of viability, which is often said as the ability of the fetus to survive outside the mother. Abortion can either be spontaneous (more commonly called a miscarriage), or induced (which is deliberate or provoked) [12]. In medical terms, it is the disruption of pregnancy due to several reasons. The leading reasons that approve the mother to have a legal abortion in Sweden involve reasons, such as the fetus is threatening her life or if the fetus has died inside the womb. Other reasons for a legal abortion include the mother’s choice and poverty. About one third of pregnancies in Sweden are unplanned and 20% of these end in an abortion, hence about 7% of all pregnancies [13]. Different countries in the world have passed laws to legalize abortion. In the years before 1970, the records regarding the total number of illegal abortions being performed in Sweden were unavailable. Also, the records show that Sweden only had a minimal number of performed legal abortions. There were about 5,000 legally performed abortions in the country while the estimated number of illegally performed abortions in the 1950’s would range from 10,000 to 100,000 per year [14]. Starting 1970, the cost of a legal abortion till the 18th week was covered by the national health insurance which made illegal abortions an unappealing choice. Whether or not it had an effect on the sale rate of both the BC and EC will be seen in the following parts of the paper. Also, induced abortion has been allowed for medical emergencies only to be performed in accredited hospitals and clinics in Sweden. Cases where the pregnancy may bring harm to the health of the mother prompt the doctors to terminate it. Since then, illegal abortions have gone down but allowed minors to seek abortion even without parental supervision [15]. Abortions are now performed in Sweden up to the twelfth week of pregnancy rather than 18 weeks. In coordination with the legalization of abortion, contraceptive agents were also introduced to help in preventing conception. The specific age rates vary in the total abortion rates (TAR) in Sweden. Age varies from late thirties down to teenagers. Since 1975, the rate for women above twenty having an abortion performed remained fairly stable, while the teenage abortion rate rose steadily. The alarming news is the fact that abortions are primarily performed in teenage pregnancies. In 1980, seven out of ten teenage pregnancies led to abortion [16]. One reason for the further increase in teen abortions may be due to the fact that parental consents are not required since 1990, when adolescents try to require an abortion order. The 1995 statistics that 17 out of every 1000 females in Sweden had an abortion rose to 22 out of 1000 in 2001. A total of 5,665 teenage abortions were recorded in 2001. In her study which tested the relationship between contraception and abortion in India, Arora concluded that the use of regular contraception as the main method and the emergency contraception as a backup plan reduce the incidence of induced abortion [17]. There are also different factors that can be considered to likely affect the studied rates. One of these would be the level of knowledge in the study population. Smith and Whitfield [18] surveyed the level of knowledge in women using the birth control pills, as well as the emergency contraceptives. He stated that out of 406 women who were using oral contraceptives, 71% were properly informed about the duration and appropriate use the drug. It was also stated that out of the same number of participants, 29% of them were not knowledgeable that emergency contraceptives are available from their respective healthcare provider. In another study by Abbot and Feldhouse, it was found that out of 122 women, 25% did not have enough knowledge regarding emergency contraceptive pills as a way of preventing pregnancy after unprotected intercourse. The study also stated that after being given the proper information, women are more knowledgeable and are able to use the product more properly. Another factor to be considered that may affect the rate of sale of the contraceptives is the attitude of the consumers toward the product. A study made by Beaulieu [19] took into account the reasons for the underuse of the emergency contraceptive pills by adolescents and young couples when the plan A contraceptives (BC pills, condoms, etc) are not used as a primary prevention. The study showed that emergency contraception is not used by young couples for different reasons. One reason is that they are not given enough information on how to use the drugs and another reason involves the fact that they are not given the information regarding the positive effects of the drug. The positive effects of the drug include reduced risk of ovarian and uterine cancers. It also reduces the risk of fibrocystic breast disease, anemia, pelvic inflammatory disease, tubal pregnancy, endometriosis and ovarian cysts when the drug is used on a correct dosage and frequency [20]. These effects, however, according to the study were only recorded on women who have used EC on a prolonged amount of time. More studies are being conducted to be able to determine whether the effect of the drug can be useful on prolonged use. Brown University reports that women on birth control pills may improve acne. Some women may have lighter and shorter periods when on the birth control pill [21]. According to Abbot [22], the sale of the drug corresponds to the knowledge of the public regarding the drug: once they are able to learn more about a certain medicine, they have the confidence and trust that the contraceptive would help them in a positive way. Aim The aim of this study was to explore the rate of consumption of contraceptive pills in Sweden in 2000-10, both birth control (BC) and emergency (EC), to compare with the rate of abortions during the same period of time. Methodology Research Design A descriptive research design was used. This method provides an accurate portrayal or account of characteristics of a particular individual, situation or group [23]. This method will be used as a means to discover new meanings, describe what exists, describing the frequency in which one occurs and categorizing information obtained from the observation in such a way that it is not to be affected by the researcher. Population and Setting The population under study is the total number of women currently consuming BC or EC pills in Sweden. The population will be compared to the total number of women, who underwent abortion during the same time period in Sweden. The rates would then be discussed in further details in the paper. Data Gathering Tool The study covers research on the current rate of sale of BC pills, as well as the sale of EC, from Concise which is a program that includes sales statistics from the different pharmacy services in Sweden.  It also involves obtaining information from the National Board for Health and Welfare (Socialstyrelsen) on the total number of abortions performed. The source is an authority that records and collection of the statistics in the different aspects of life in Sweden ranging from birth up until the death statistics. Results This part of the paper will present the results of the data that will be analyzed in the next part of the paper. Figure 1 presents the sale of birth control pills packages from 2000 to 2010. Figure 2 shows the sale of emergency contraceptive pill packages, while Figure 3 shows the rate of abortions during the same period in Sweden. Figure 1. Sale of Birth Control Pill Packages Figure 1 shows the rate of sale of BC packages in the past years. A pack contains the amount of BC needed to prevent conception for one month. It can be observed that there was an increase in sales with every passing year. The highest increase was between the years 2001-2002, when the rate of sale increased by 76% from 68,480 sales of 2001 to 120,501 sales in 2002. During those years, information campaigns regarding BC have been at its highest [24]. The lowest increase on the other hand, happened in the years 2008-2009, when the rate of sale only increased by 0.53% from 196,971 in 2008 to 198,018 in 2009 Figure 2. Sale of Emergency Contraceptive Pills Figure 2 shows the sale for emergency contraceptive packs from the year 2000 up till 2010. A pack contains the amount of EC needed to prevent one conception. The figure shows that the highest year of sale was in the year 2004 where sales reached up to 1549351 while the lowest year of sale was in 2001 where the sales were 1442664. It can be observed that the sales dipped in 2001, 2005, 2006, and 2007 on different levels. On the other hand, the increases were noted in the years 2002, 2003, 2004, 2008, 2009, and 2010. Figure 3: Abortion Rate Figure 3 shows the abortion rate from 2000 to 2010. It can be seen that the only years that a decrease has been noticed were in 2004 and 2009, where it dipped by 0.05% and 1.39%, respectively. An increase was noted in the other years, out of which 2008 showed the greatest number of abortions recorded, 38,053. The table also shows that there was an average increase of 600 abortions per year. Discussion The BC sale increases and the EC availability do not show a concrete effect on the rate of abortions, unless the fact that the abortion rate is likely to have been even higher without the availability of EC. According to Sun [25], in a study conducted concerning factors affecting emergency contraceptive sales, EC is still a very different matter when it comes to women in Sweden. They tend to distrust such information when they are not given enough information regarding the different aspects concerning the drug. When asked which contraceptive pill they would choose as a means of family planning, most women chose BC rather than EC in a way that when BC method fails, they do not search for further choices to prevent pregnancy [26]. A study conducted by Edgardh studied the awareness of women ages 19 to 30 regarding birth control methods such as BC pills and EC. He stated that ever since 2000, the awareness has risen up in as much as 30 %. This means that 3 out of 10 women are knowledgeable of the use of BC and EC. The study also showed that when it comes to EC, women are not that familiar with the term. They stated that they have heard of it but dismissed it for they were already contented with using BC as their primary birth control method. A study by Hobbs, et al on Australian women showed that 95% of the women had heard of the EC and 26% had used it. The majority of women agreed with pharmacy availability of the EC (72%); however, only 48% were aware that it was available from pharmacies without a prescription. About a third (32%) believed the EC to be an abortion pill. The most common reason for not using the EC was that women did not think they were at risk of getting pregnant (57%) [27]. The level of rate of sale can be attributed to the fact that proper information regarding EC has not been disseminated by the different healthcare institutions. A study by Hobbs, Taft, & Amir [28] showed that women who received BC and EC from their respective healthcare providers were unable to use the drugs properly. The main reason discovered was that they were not given enough information by the dispensing provider regarding the proper use of the drugs. The common problem regarding the sale, according to Prata, is due to the fact that women of all ages are not properly informed regarding the availability of the drug. That aside from pharmacies and in some countries dispensing groceries, women may also seek assistance regarding EC in healthcare clinics and facilities that are licensed to dispense the drugs. In the US, the health secretary issued an order which requires individuals to acquire a prescription and to be older than 17 years old to be able to acquire EC from the drugstores [29]. The issue would also assure the health department that the use of other birth control methods will be used by the teenagers. In Australia women ages 18-45 prefer to make use of birth control methods other than EC. Aside from being uncomfortable with using EC, a requirement of subjecting themselves to counseling before being able to buy the drug may be an obstacle [30]. As stated by the National Board of Health and Welfare [31], the abortion rate has been in a constant rise. This shows that women, even armed with the knowledge that there are different ways to prevent conception, they are still unable to protect themselves from conceiving and are seeking assistance for an abortion. More women are now turning to different health facilities for an abortion due to the fact that the law allows them to and it does not burn a hole in their pockets, as the government itself not only allows but also pays for the costs of a legal abortion. Anderson [32] stated that women know where they can find sources of emergency contraception when they ask for help from healthcare facilities. A study regarding the effect of having an abortion to women was done by Rasch [33]. The study revealed that women who submit themselves to an abortion would likely be questioned by the community and the church. Aside from the censure that they are receiving, guilt has been found to plague the conscience of some women who had an abortion. Another study showed that women who submit themselves for abortion mostly turn to the church for help and forgiveness. According to the study results, women who had an abortion (legal or not) are more frequently visiting the church than women who have not [34]. It can then be stated that the increase or decrease of the rate of abortion cannot be the direct result of the rate of sale in birth control and emergency contraceptive agents. A study by Meyer, Gold, & Haggerly [35] demonstrated that even with the distribution of EC in advance to a number of women, it did not report any change in the pregnancy and the abortion rates. It is also stated in the same study that there is no significant relationship between the sale of contraceptives and the abortion rate. However, a study conducted by Rimpela [36] in Finland on teenage contraception and abortion yielded a different result. He stated that use of emergency contraceptives is very effective in decreasing abortion and fertility rates among teenagers. Also, a study done by the Committee on Adolescence in the US [37] stated that emergency contraception has the potential to reduce teenage pregnancy rates which otherwise eventually leads to induced abortion. They also stated that the sale of contraceptives is greatly effective in reducing the number of unwanted pregnancies that leads to abortion. A review regarding emergency contraception was done by the same committee; from the definition, its formulation, mechanism of action, efficacy, including contraindications and safety issues. The results showed that the positive effect of the drug greatly outweighs the negative effects and supported the over-the counter availability of emergency contraception. According to Szalavitz, the main fact that the rate of teen pregnancy dropped in Netherlands was due to the fact that the birth control pills were disseminated starting the ‘70s [38]. It must also be seen that further researches related to this study be conducted to confirm the findings, as well as to add to the storage of our knowledge base regarding healthcare, reproduction, and birth control. The continuity of studies in a more extended period of time would be a great benefit for the improvement in the continued development of healthcare. Conclusion Results of the study showed that birth control pill sales have increased markedly in ten years. The sales of emergency contraceptive pills have however remained relatively unchanged. Lastly, the abortion rate had also increased. It can be concluded that the increased birth control pill sale rate as well as the stable emergency contraceptive sales cannot be discounted to have an effect on the rate of abortion, due to the fact that the rate of abortion did not decrease. It led the researcher to conclude that further information dissemination regarding the availability of the contraceptive drugs can further reduce the rate of abortion. But more information and education about how to use it and where to obtain it are still needed.  The women populace will be greatly affected by such actions because after the dissemination, they will be more equipped with knowledge regarding ways to prevent unwanted pregnancies and abortion. Reference List 1. Center for Disease Control and Prevention. Unintended pregnancy and contraception [Internet]. 2011 [updated 2011 June 29; cited 2011 November 11]. Available from: http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/Contraception.htm 2. The American Heritage Medical Dictionary. New York: Houghton Mifflin; 2004. Contraception; p.120. 3. Norwood C. Women, microcredit and family planning practices: A case study from rural Ghana. Journal of Asian and African Studies. 2011; 169-183. 4. Gebbie A, Hardman C. Contraception in the perimenopause – old and new. Menopause International. 2010; 33-37. 5. Whalen, Karen L, Renee Rose. Estradiol Valerate/Dienogest: A novel oral contraceptive. Annual Pharmacotheraphy. 2011; 1256-1261. 6. Vlieg A, van Hylckama F, Helmerhorst M, Rosendaa, FR. The risk of deep venous thrombosis associated with injectable Depot–Medroxyprogesterone Acetate contraceptives or a Levonorgestrel Intrauterine Device. Arteriosclerosis Thrombo Vascular Biology. 2010; 2297-2300. 7. Mansour R, Say D. Contraceptive choice for young people. Journal of Family Planning and Reproductive Health Care. 2009; 81-85. 8. Tsui AO, McDonald-Mosley R, Burke A. Family Planning and the burden of unintended pregnancies. Epidemiology Review. 2010; 152-174. 9. Williamson LM, Buston K, Sweeting H. Young women's continued use of oral contraceptives over other hormonal methods: findings from a qualitative study. Journal of Family Planning and Reproductive Health Care. 2009; 167-172. 10. Angus L, DeVoe J. Evidence that the citizenship mandate curtailed participation in Oregon’s Medicaid family planning program. Health Affiliation. 2010; 690-698. 11. Ambegaokar M, Lush L. Family planning and sexual health organizations: management lessons for health system reform. Health Policy Planning. 2004; i22-i30. 12. Rimon-Zarfaty C, Nitzan K, Jotkowitz A. The Israeli abortion committees' process of decision making: an ethical analysis. Journal on Medicine and Ethics. 2011; 1136. 13. Paton SL, Fernando I, Lamont RF. A comparison of sexual and reproductive health services provided by genitourinary and family planning clinics for adolescents. International Journal of STD AIDS. 2010; 642-647. 14. Treno C. Obama: Morning-after pill decision 'common sense' hormonal contraception and thrombotic risk. Evaluation Review Journal. 2006; 12-21. 15. Blume A, Tobin J, Kidsley S, Davies G. Improving the interface between family planning services and genitourinary medicine in Portsmouth, UK: a ‘virtual corridor’. Journal of Family Planning and Reproductive Health Care. 2007; 113-115. 16. Prata N. Making family planning accessible in resource-poor settings. Phil Trans R Soc B. 2009; 3093-3099. 17. Gebbie A. The role of need for contraception in the evaluation of interventions to improve access to Family-Planning methods. Evaluation Review. 2011; 3-13. 18. Smith LF, Whitfield MJ. Women's knowledge of taking contraceptive pills correctly and of emergency contraception effect of providing information leaflet in general practice. Social Medicine. 1995; 409-414. 19. Beauliieu MJ. Cummings Study Guides: Abortion [Internet]. 2011 [updated 2011 November 1; cited 2011 November 8]. Available from: http://www.cummingsstudyguides.net/Guides3/aborition.html 20. Heikinheimo G. Pharmacy access to the emergency contraceptive pill: a national survey of a random sample of Australian women. Mother and Child Health Research. 2004; 1-39. 21. Holley C. Livestrong: Side effects of contraceptive pill [Internet]. 2009. [update 2009 October 27. cited 2011 December 2]. Available from: http://www.livestrong.com/article/18536-side-effects-contraceptive-pill/> 22. Abbot C. Disquieting times: Further Reflections on sales of contraception. Common Knowledge. 2011; 394-410. 23. Selltiz C, Wrightsman LS, Cook SW. Research in Social Relations. New York: Holt, Rinehart and Winston; 2003. 24. Sucker C. Use of oral contraceptives by adolescents and its consequences in Finland 1981-91.British Medical Journal. 1992; 1053. 25. Sun X. The impact of the national Family Planning program on the quality of care in China. Journal of Health Management. 2000; 1-39. 26. Leon FR, Lundgren R, Sinai I, Jennings V. The role of need for contraception in the evaluation of interventions to improve access to Family-Planning methods. Evaluation Review. 2011; 3-13. 27. McDaid L. Emergency contraception policy: how moral commitments affect risk evaluation. Law Probability and Risk. 2010; 187-199. 28. Hobbs A, Taft C, Amir H. Missed opportunities: Teenagers and emergency contraception. Arch Pediatr Adolesc Med. 2005; 727-733. 29. Iversen L. Effects of oral and vaginal administration of levonorgestrel emergency contraception on markers of endometrial receptivity. Hum Reprod. 2010; 874-883. 30. Gatiss S. Contraception in women with medical problems. Obstet Med. 2008; 78-87. 31. Dhanjal M. The National Board of Health and Welfare [Internet]. 2009. [updated 2009 October 5. cited 2011 November 17] http://www.socialstyrelsen.se/ 32. Anderson D. The emergency contraceptive pill rescheduled: a focus group study of women's knowledge, attitudes and experiences. J Fam Plann Reprod Health Care. 2009; 87-91. 33. Rasch A. Induced abortion in Denmark: effect of socio-economic situation and country of birth. European Journal of Public Health. 2008; 144-149. 34. Gurunath F, Pandian C, Anderson A, Bhattacharya S. Defining infertility—a systematic review of prevalence studies. Human Reproductive. 2011; 575-588. 35. Meyer C, Gold S, Haggerly D. Measuring family planning sustainability at the outcome and programme levels. Health Policy Planning. 2004; 88-100. 36. Marions L. Use of oral contraceptives by adolescents and its consequences in Finland. European Health Journal. 1992; 1053. 37. Bentley R. Adolescence Committee on Emergency Contraception. Pediatrics. 2005; 116: 1026-1035. 38. Szalavitz J. Contraception among girls who have had more than one partner by age 16 years: method use and pregnancy risk-taking behavior. Fam Plann Reprod Health Care. 2010; 141-146. Read More