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Case Studies in From Six Countries By Anna Glasier, Evert Ketting, V.T. Palan, Lesley Browne, Susheel Kaur, Xiao Bilian, Josue Garza-Flores, L. Vasquez Estrada, Grace Delano, Grace Faoye, Charlotte Ellertson and Elizabeth Armstrong

n countries where emergency contra- emergency contraceptive methods are mar- ment after five days “might be considered ception is offered, its availability and keted legally, but family planning organi- an abortion.”3 The following year, an an- Iuse vary widely, according to such fac- zations shy away from offering them. tiabortion lobbying group filed several tors as regulations and policies regarding In China, postcoital methods have long complaints against clinics providing emer- the method, providers’ and women’s un- been offered by the government family gency contraception; the group based its derstanding of and attitudes toward it, planning service. However, these meth- argument on the Offences Against the Per- and cost. The experiences with the meth- ods have not been separated into those ad- son Act of 1861, which made it illegal for a od in six countries—the United Kingdom, vocated for emergency use only and those woman or her doctor to “intend to procure the Netherlands, Malaysia, China, Mexi- recommended for ongoing use. a miscarriage.” In response, the attorney co and Nigeria—illustrate a range of is- Finally, in Mexico and Nigeria, aware- general ruled that emergency contracep- sues involved in introducing and en- ness of emergency contraception contin- tion administered within 72 hours after in- couraging the acceptability of emergency ues to be low among both health care tercourse was not a criminal offense, rea- contraception. providers and the public. soning that “preventing implantation is not Emergency contraception first became Research, both on a way to create knowl- procurement of a miscarriage.”*4 available in most of these countries in the edge of emergency contraception and on At the request of the Department of late 1960s and early 1970s. Today, in the Unit- a way to publicize the methods, has been Health, the Committee on Safety of Med- ed Kingdom and the Netherlands, the meth- largely concentrated in European coun- icines undertook a review of emergency od is an accepted part of family planning tries; many developing countries, and even contraception in 1983 and determined that practice and is well-known among doctors many developed ones, have yet to conduct the method was “acceptably safe for oc- and women. This acceptance may be part- any research on this topic. For example, casional use.” The pharmaceutical com- ly due to the method’s inclusion in the health Mexico’s first clinical trial of an emergency pany Schering submitted an application insurance systems of these countries. contraceptive method (a combination of for a product based on Eugynon 50 to the Another factor explaining the estab- and ethinyl , ad- Medicines Division in August 1983 and re- lished role of emergency contraception, at ministered orally or vaginally) is under ceived a license in January 1984. PC4 (50 least in the Netherlands, is the lack of way, fully 30 years after the original re- mcg of ethinyl estradiol and 0.5 mg of moral debate surrounding the method. search on the method was conducted. in each of four tablets) was on Only its side effects and efficacy seem to In the case studies that follow, we sum- the market by October 1984. engender controversy; the need for emer- marize information on experiences with Discussion is under way with regard to gency contraception is acknowledged and emergency contraception in each of these making PC4 available from pharmacists accepted even for teenagers, for whom countries. We then draw on these experi- without a doctor’s prescription, a step that sexual activity is socially sanctioned. ences to suggest lessons for other coun- most professional organizations support. By contrast, in Malaysia, as in other coun- tries seeking to introduce or expand the The Royal College of Obstetricians and tries where abortion is strictly regulated, use of this method. Gynecologists organized meetings about the matter in December 1994 and July Anna Glasier is a consultant gynecologist and director United Kingdom 1995. It is up to Schering to apply to of family planning at Family Planning and Well Women History of Emergency Contraception change the license, and the company thus Services, Edinburgh, United Kingdom. Evert Ketting is a sociologist and deputy director at the Netherlands In- Although British doctors occasionally ad- far seems reluctant to do so. stitute of Social Sexological Research, Utrecht, Nether- ministered high-dose or insert- lands. V.T. Palan is regional director, and Lesley Browne ed an IUD for the purpose of emergency Availability and Prevalence is program adviser, East & South East Asia and Oceania contraception in the early 1970s, it was not General practitioners are the major source Region (ESEAOR), International Planned Parenthood until 1974 and the publication of the first of emergency contraception in the Unit- Federation (IPPF), London. At the time this article was written, Susheel Kaur was operations research officer, article on emergency contraception using ed Kingdom. Everyone in the United ESEAOR, IPPF, Kuala Lumpur, Malaysia. Xiao Bilian is a combined estrogen- regi- Kingdom is entitled to register with a gen- director emeritus, National Research Institute for Fam- men that the method’s use became wide- eral practitioner. For contraceptive ser- ily Planning, Beijing. Josue Garza-Flores is senior scien- spread in the United Kingdom.1 The Na- vices, women may also visit a general tist, Department of Reproductive Biology, National In- tional Association of Family Planning practitioner other than the one they are stitute of Nutrition Salvador Zubiran, and director, Center for the Assistance in Human Reproduction, Mexico City. Doctors met in 1982 to discuss emergency registered with, although this option is not L. Vasquez Estrada is head, Obstetrics and Gynecology contraception and a year later published widely known. Unit, Hospital Gea Gonzalez, Mexico City. Grace Delano a set of clinical guidelines establishing two is vice president, and Grace Faoye is program director, combined pills, Ovran and Eugynon 50, *Abortion is legal in the United Kingdom under the terms Association for Reproductive and Family Health, Ibadan, as the preferred hormonal regimens.2 of the 1967 Abortion Act, which requires agreement by Nigeria. Charlotte Ellertson is program associate at The two doctors that a woman has grounds for terminating Population Council, New York. Elizabeth Armstrong is In 1982, the Department of Health stat- a pregnancy. A report of the abortion, signed by the two a doctoral candidate at the University of Pennsylvania, ed that treatment up to 72 hours post- doctors and specifying the grounds for termination, must Philadelphia, Penn., USA. coitally was “probably legal,” but that treat- be made to the Department of Health.

Volume 22, Number 2, June 1996 57 Case Studies in Emergency Contraception

Women in most cities and large towns with two spares in case she vomits. Oth- (This regimen is commonly known as the may also seek emergency contraception at ers add an antiemetic, at a cost of around 5x5 method.) In around 1980, the “Yuzpe National Health Service family planning 16 cents per tablet. An IUD costs the Na- method” was introduced in the Nether- clinics. Since 1972, these clinics have pro- tional Health Service about $11–$16, al- lands. This regimen, which came to be vided contraceptives free of charge. The though clinics that buy in bulk may pay known as the 2x2 method for its two doses clinics offer anonymity to women reluctant considerably less. of two pills taken 12 hours apart, quickly to consult their general practitioner and A recent study of the cost-effectiveness replaced the 5x5 method; for example, by may be open in the evenings and on week- of contraception estimated considerable 1985, 83% of prescriptions for emergency ends; however, not all towns—and few vil- savings to the National Health Service contraception from general practitioners10 lages—have such centers, and at least half from the use of emergency contraception and 97% of those from the Rutgers Stich- of these clinics are open only once a week. to prevent unintended pregnancy.6 Even ting were for the Yuzpe method.11 How- The nonprofit Brook Advisory Centres, on the basis of failure rates as high as 25 ever, over the last 10 years, the side effects which provide services to young people births per 100 users of emergency contra- and efficacy of both methods have been in cities throughout England and in Ed- ception per year, the study estimated that the subject of vigorous debate among inburgh, Scotland, provide emergency prescribing PC4 costs between $19 and practitioners and researchers. Several spe- contraception. Some hospitals’ accident $74, depending on the provider, and saves cialists feel that the 5x5 method provides and emergency departments also provide the government health service $727–$806. far too heavy a hormonal dose, while oth- hormonal emergency contraception. Estimates of costs averted did not include ers are of the opinion that the 2x2 meth- National data on the prevalence of emer- such costs to society as those associated od is not sufficiently reliable. gency contraception do not exist, but re- with education and social services. This debate has spilled over into the ports from clinics suggest that use has been general public’s consciousness and has at rising rapidly. Knowledge of emergency Netherlands times affected the willingness of physi- contraception is fairly high; surveys from History of Emergency Contraception cians to prescribe certain regimens and of the late 1980s found that 65–75% of women Emergency contraception has been used women to use them. The 5x5 method, undergoing induced abortion had heard in the Netherlands since 19647 and is sometimes referred to in the mass media of emergency contraception.5 A small, un- widely known and accepted there. The as a “hormonal bomb,” has been subject- published survey conducted by Schering Netherlands places a high priority on pre- ed to particularly harsh criticism. After ar- in 1994 found that 90% of women had venting unwanted pregnancy, and infor- ticles critical of the method were pub- heard of emergency contraception. How- mation on emergency contraception has lished in 1987, the number of emergency ever, many women continue to be unaware always been included in family planning contraception prescriptions written by of the 72-hour time limit or of the method’s education programs and materials. The general practitioners fell by 25% from the ready availability. Levels of knowledge of level of contraceptive use is generally year before.12 Today, some doctors re- postcoital IUD insertion are low. high, and the incidence of unwanted preg- portedly prescribe their own emergency Schering’s sales data for PC4 indicate nancy and abortion is low. Thus, while contraception regimens,13 and some that about 353,700 packets were sold in emergency contraception is free of moral women devise their own. 1992, and 420,500 were sold in 1993. Scher- debate, is not considered an In response to this controversy, in 1987, ing has sold 2.5 million packets of PC4 and is considered acceptable for teenagers, the Rutgers Stichting adopted a policy of since the regimen was licensed in 1984. the need for it is reduced by the high lev- offering women a choice of the 5x5 or the One clinic in Edinburgh reports that the els of effective contraceptive use among 2x2 regimen or IUD insertion. More re- use of emergency contraception has dou- women of all ages.8 cently, there have been calls to make bled in the last five years and now ac- As early as 1970, emergency contra- available for emergency con- counts for about 4% of the 47,000 visits ception was covered in the first family traception in the Netherlands.14 made to the facility annually. planning handbook for Dutch doctors,9 There is no way of estimating the extent and within a few years, the method be- Availability and Prevalence to which Ovran is prescribed for emer- came widely available through general Partial data on use of emergency contra- gency contraception or how many IUDs practitioners, who form the backbone of ception in the Netherlands are available are inserted for postcoital indications, the Dutch health care system. (Every cit- through 1991, collected as part of the na- since these contraceptives are also used on izen is registered with a general practi- tional sentinel system of general practi- an ongoing basis. tioner.) The Dutch Family Planning As- tioners. General practitioners provide sociation, the Rutgers Stichting, also began about three-quarters of the prescriptions Cost offering the method in the early 1970s. for emergency contraception in the All contraception in the United Kingdom, However, overall use of emergency con- Netherlands; in 1991, they wrote 28,000 including emergency contraception, is free traception declined by 50% between 1974 emergency contraception prescriptions.15 to the patient. Schering sells the PC4 com- and 1983, primarily because of a sharp in- This level had remained more or less sta- bination to the National Health Service at crease in the use of ongoing methods of ble since 1985. The Rutgers Stichting prob- a cost of about U.S. $2.20 per treatment. contraception after their inclusion in the ably provides an additional 2,000–7,000 Many family planning clinics and some national health insurance program. prescriptions annually. Data on IUD in- general practitioners make up their own The original emergency contraception sertion for emergency contraception are supplies using Ovran, at a cost of about regimen used in the Netherlands consist- not available, although use of this meth- 25 cents for the four tablets. The actual cost ed of five pills of ethinyl estradiol taken od is presumed to be rare because most to the clinic is somewhat higher because for five days—a total dosage of 25 mg, or women requesting emergency contra- of packaging costs. In addition, some clin- the equivalent of three years’ worth of ceptive services are young and have never ics provide six tablets, to leave a woman modern low-dose oral contraceptives. been pregnant. In total, the rate of use is

58 International Family Planning Perspectives about one per 100 women per year. the AWBZ. Consequently, many adoles- pharmacies indicate that at least 20,000 In 1991, of all women receiving emer- cents seek emergency contraception at the women obtained emergency contracep- gency contraception from general practi- Rutgers Stichting clinics rather than from tives in 1994. The exact number is difficult tioners, about 70% were younger than 25, their general practitioners. to determine because some women pur- and 34% were younger than 20.16 The pro- chase just the tablets they need to cover portion of emergency contraception pre- Malaysia one act of unprotected intercourse, where- scriptions that are for adolescents, how- History of Emergency Contraception as others buy extra pills. ever, is higher (51%) at the Rutgers Although hormonal emergency contracep- Few women receive emergency con- Stichting clinics. tion has purportedly been available in traception from FFPAM clinics; only 60 A pair of studies conducted in Amster- Malaysia since 1966, the first emergency con- did so in 1993. These women were 20–40 dam17 suggest that condom failure prompt- traception regimen, Postinor, was not offi- years old and requested emergency con- ed the request for emergency contraception cially registered there until 1987. Three years traception for a variety of reasons: unex- in 19–29% of cases and that missed pills ac- later, a second regimen, Estinor, was regis- pected and unprotected intercourse, counted for 13–25% of requests. Slightly tered. These are reportedly the most com- missed pills and ruptured condoms. In ad- fewer than half of the women in these stud- mon specifically registered methods used. dition, some pharmacies report that Esti- ies had had unprotected intercourse at mid- Both brands consist of 0.75 mg tablets nor is used by sex workers, as well as by cycle, suggesting that many women seek of levonorgestrel, and the recommended rape victims. emergency contraception even when the dose is a single tablet to be taken within At pharmacies in Malaysia, the strip of risk of pregnancy is slight. one hour after unprotected intercourse. If 10 pills—enough to cover five episodes of the woman has engaged in more than one unprotected intercourse—costs the pur- Cost act of intercourse, the manufacturers rec- chaser $3–$6. At private clinics, the cost The cost to a Dutch woman of emergency ommend that a second dose (two Postinor for 1–3 tablets is approximately $4, which contraception is determined by the type tablets or one Estinor) be taken eight hours includes the consultation fee. of health insurance that covers her. The later. These brands are usually sold in 10- largest insurance carrier is the Sick Fund, tablet strips, and physicians often divide China which is publicly controlled but private- strips and provide women with only as While postcoital contraception is a topic ly administered and covers about 60% of many pills as they need. of research for China’s State Family Plan- all citizens. The remaining 40% of citizens In Malaysia, emergency contraception is ning Commission program, and postcoital are privately insured. In addition, all often erroneously viewed as an “abortion methods are included in the government Dutch citizens are covered by the Gener- pill.” Since abortion is stringently regulat- family planning program, figures on the al Law on Exceptional Medical Cost ed, this misperception may have led to re- prevalence of emergency contraceptive (AWBZ), a national form of insurance in- luctance on behalf of some service providers use are not available. tended primarily to cover catastrophic and and program administrators to provide Postcoital contraception was first de- long-term care, but recently expanded to emergency contraception or even infor- veloped in China in the 1970s, primarily include the cost of medical . Sick mation about its existence and benefits. for use by married couples living at a dis- Fund members may receive tance from one another. Thus, the focus of free of charge directly from their phar- Availability and Prevalence postcoital contraception has been on a macy. Privately insured patients must pay Data on emergency contraception are not “visiting pill” for ongoing use by couples for out of pocket, but can be available from the national family plan- who are only infrequently exposed to the reimbursed by the AWBZ. ning program, and the literature on the risk of pregnancy. Although the literature At pharmacies, the price of the 2x2 method in Malaysia is scant. Government- on the use of visiting pills is extensive, method is about $7–$9. The 5x5 method, run family planning clinics do not provide there are few reports of their use for emer- including an antinausea medication, costs emergency contraception, and the private gency contraception. around $41. In order to receive the pre- practitioners who do are reluctant to speak Preparations packaged as visiting pills scription, however, women must consult about it. Although the Federation of Fam- (also known as vacation pills and quick- their general practitioner. This visit is free ily Planning Associations, Malaysia action pills) often consist of high doses of for women covered by the Sick Fund; pri- (FFPAM) prefers to stress regular use of , acetate or vately insured women must pay a fee of an effective method, rather than distrib- norgestrel. Other compounds, such as approximately $20. uting something that acts as an “abortion quingestanol, and norethis- The Rutgers Stichting provides the 2x2 pill,” FFPAM members follow guidelines terone acetate-3-oxime, are also used.19 regimen free, but charges a consultation for the provision of emergency contra- The most commonly used visiting-pill fee that varies from around $10 to $20, de- ception established in a 1992 Internation- formulation is anordrin, a compound syn- pending on whether the woman is older al Planned Parenthood Federation quali- thesized in Shanghai in 1975.20 One 7.5 mg than 18. Women who obtain the 5x5 meth- ty assurance manual.18 tablet is taken the morning after unpro- od from the Rutgers Stichting pay about Emergency contraception is, however, tected intercourse, and one is taken every $20 for the pills and antinausea medica- available from both pharmacies and private night for three nights. The cost of the reg- tion, in addition to the consultation fee. physicians in Malaysia. Although Postinor imen is only a few cents. Both the Sick Fund and the private in- and Estinor both fall under the regulations Reportedly, some women obtain IUDs surance system may impose obstacles for of the Poisons Act, they may be purchased after experiencing contraceptive failure (for adolescents. Young people must either re- without prescription if the woman provides example, when a condom has broken), but quest the Sick Fund card from their par- her name, address and identification card it is difficult to distinguish when an IUD has ents or pay directly and then request re- number to the pharmacist. been inserted for emergency contraception. imbursement, through their parents, from Very rough estimates based on sales by Researchers at the International Peace

Volume 22, Number 2, June 1996 59 Case Studies in Emergency Contraception

Maternal Hospital in Shanghai have ex- ty. The importance and the role of emer- A further point for planners to consid- perimented with levonorgestrel suppos- gency contraception can easily be over- er is that there is more than one way to ad- itories, in the hopes that vaginal admin- shadowed by family planning’s tradi- minister emergency contraception; coun- istration would reduce the nausea and tional mission to ensure consistent, tries might experiment with different vomiting associated with the elevated hor- effective contraceptive use, particularly delivery mechanisms and regimens, as monal dosage of emergency contracep- in developing countries, where the focus China has done and as Mexico plans to do tion. The tablets, however, were not suf- may be on lowering fertility. in its current study. ficiently soluble to be highly effective. Emergency contraception is most wide- The remaining lessons concern uses of China is also testing mifepristone as an ly used in countries where it is well inte- emergency contraception that have not tra- emergency contraceptive, both alone and grated into general family planning ser- ditionally been the focus of most Western in conjunction with other hormones. As vices and information and education countries. For example, as China has yet, mifepristone is available only in clin- efforts, such as the United Kingdom and demonstrated, emergency contraception ical trials, but family planning advocates the Netherlands. It has a key place both may have applications beyond preventing hope it will be introduced soon for gen- within family planning’s traditional em- pregnancy after a single exposure to un- eral use as an emergency contraceptive. phasis, as a backup for method or user fail- protected intercourse. Methods like the vis- ure, and as a last resort in the instance of iting pills used in China may well be ap- Mexico unexpected intercourse. propriate for use in other countries where Emergency contraception is little known Another lesson is that a clear distinction couples have intercourse infrequently. In in Mexico, among either providers or con- must be drawn between emergency con- Malaysia, meanwhile, the reported use of sumers. Since oral contraceptives are avail- traception and abortion, especially in Estinor by sex workers suggests another able without prescription, women have countries where abortion is legally re- group for whom emergency contraception potential access at least to the Yuzpe regi- stricted or carries a moral stigma. A con- may be particularly valuable. men (which would cost about 50 cents); fusion of emergency contraception with Finally, the Dutch case reveals that however, they may not be aware of it. abortion can seriously impede efforts to emergency contraception may be partic- Although requests for emergency con- prevent unintended pregnancy through ularly important for adolescents. As traception reportedly are frequent in Mex- use of emergency methods, as in Malaysia. young people establish their sexual iden- ico, providers themselves lack adequate Emergency contraception should be cast tity and contraceptive practice, they may information on this method. One objective as an important way to reduce the need be likely to use contraceptives ineffectively of a clinical trial currently under way in for abortion. and subsequently experience contracep- Mexico is to increase knowledge of emer- Furthermore, the experiences in the tive failure. For them, emergency contra- gency contraception among health pro- United Kingdom and the Netherlands il- ception may provide a crucial safety net fessionals, including family doctors and lustrate that even in countries that have in the event of intercourse they did not ex- general practitioners, and pharmacists. good data on emergency contraception, pect or adequately prepare for, as well as information about its use is incomplete. a bridge to more regular and sustained Nigeria Data on emergency contraception should contraceptive use. Traditional fertility control methods in be collected along with other routine fam- Nigeria include several that are used either ily planning statistics. To date, efforts to Conclusion immediately after unprotected intercourse examine the use of emergency contra- Although emergency contraception has or when a pregnancy is first suspected. ception have been complicated by the fact been available for about three decades, its Among these are potash mixed with blu- that the IUD and combined oral contra- potential to reduce the incidence of unin- ing, lime taken in high concentration with ceptives may be used for either regular or tended pregnancy and abortion is just be- cayenne pepper seeds, and a codeine tablet emergency contraception. In the future, ginning to be realized. In only one of the six used together with illicit gin. Nigerian efforts should be made to distinguish the countries examined here, the Netherlands, women are also gradually learning that al- different uses of these methods. has the method settled into a well-accept- tered doses of oral contraceptives can func- The case studies also show that emer- ed niche so that efforts can focus on refin- tion as emergency contraceptives. gency contraception should be available ing the regimens and informing women No data are available on the prevalence from a variety of sources—certainly gen- about them. Even in the United Kingdom, of emergency contraception or on the costs eral practitioners or family doctors, as well the use of emergency contraceptives has of hormonal regimens in Nigeria. An IUD as family planning clinics, which offer been growing rapidly, which suggests that insertion costs $23 in a private hospital. more anonymity. The British and Dutch the method is still regarded as “new.” Codeine and gin costs about $2.25; the experiences demonstrate the importance Emergency contraception may well fill other traditional emergency contracep- of both a network of highly informed, an important gap among groups whose tives are very inexpensive. properly motivated, easily accessible ser- needs have gone unmet by traditional vice providers and wide dissemination of family planning programs. The experi- Lessons Learned information among them and the lay pub- ences of these six countries suggest that The experiences with emergency contra- lic. While the success of emergency con- family planning researchers and practi- ception described in this article highlight traception in these countries probably can- tioners must be both persistent and inno- several issues that may be relevant in not be separated from the overall high vative as they work to make emergency other countries as well. quality and accessibility of their health contraception available to more women As the case studies demonstrate, both care and contraceptive services, it appears in more countries around the world. providers and potential users need to be that emergency contraception is most well informed about emergency contra- widely used when it is well integrated into References ception, how it is used and its availabili- routine care. 1. A. A. Yuzpe et al., “Post Coital Contraception—A Pilot

60 International Family Planning Perspectives Study,” Journal of Reproductive Medicine, 13:53–58, 1974. Interception), in J. Kremer and P. Bangma, eds., Nieuwe coitale anticonceptiemethoden” (The Risk of Unintend- inzichten in orale anticonceptie (New Insights in Oral Con- ed Pregnancy After a Single Unprotected Intercourse: Re- 2. National Association of Family Planning Doctors, Clin- traception), Medialert, Leusden, The Netherlands, 1989, flection on the Current Postcoital Contraception Meth- ical and Scientific Advisory Committee, “Post-Coital Con- pp. 77–88. ods), Ned Tijdschr Geneeskd, 136:2159–2161, 1992. traception—Notes for Doctors,” British Journal of Family Planning, 9:42–44, 1983. 8. E. Ketting and A. Ph. Visser, “Contraception in the 15. NIVEL, “Continue morbiditeitsregistratie peilsta- Netherlands: The Low Abortion Rate Explained,” Patient tions Nederland—Jaarverslaf 1982” (Continuous Sen- 3. “Reports: Post Coital Birth Control,” editorial, British Education and Counseling, 23:161–171, 1994. tinel Morbidity Registration: Netherlands—Annual Re- Journal of Family Planning, 8:66–69, 1982. port 1982),” Utrecht, The Netherlands, 1983; and ——, 9. J. Kremer and A. A. Haspels, Geboortenregeling bij de 4. 1993, op. cit. (see reference 10). K. Norrie, “Post Coital Anti-Pregnancy Techniques Mens (Human Birth Control), De Tijdstroom, Lochem, and the Law,” in A.A. Templeton and D. Cusine, eds., The Netherlands, 1970. 16. ——, 1993, op. cit. (see reference 10). Reproductive Medicine and the Law, Churchill Livingstone, 17. J. Boeke, 1988, op. cit (see reference 13); and J. Boeke Edinburgh, U.K., 1990, pp. 11–17. 10. Nederlands Institut voor Onderzoek van de Gezond- heidszorg (Netherlands Health Care Research Institute et al., “De morning-after pil: 5x5 of 2x2” (The Morning- 32: 5. T. A. Johnston and P.W. Howie, “Potential Use of Post [NIVEL]), Continue morbiditeitsregistratie peilstations Ned- After Pill: 5x5 or 2x2), Huisarts en Wetenschap, 292–294, Coital Contraception to Prevent Unwanted Pregancy,” erland—Jaarverslag 1992 (Continuous Sentinel Morbidi- 1989. 290: British Medical Journal, 1040–1041, 1985; R. Burton, ty Registration: Netherlands—Annual Report 1992), 18. East & South East Asia and Oceania Region, Inter- W. Savage and F. Reader, “The ‘Morning After Pill’ Is the Utrecht, The Netherlands, 1993. national Planned Parenthood Federation, Essential Clin- Wrong Name for It: Women’s Knowledge of Post Coital ical Standards for Contraceptive Service Delivery for IPPF 11. J. Rademakers and E. Ketting, “Hoe betrouwbaar is Contraception in Tower Hamlets,” British Journal of Fam- Family Planning Associations in East and South East Asia, de ‘alternatieve’ 2x2 morning-afterpil?” (How Reliable ily Planning, 15:119–121, 1990; and G. Duncan et al., “Ter- London, 1992. mination of Pregnancy: Lessons for Prevention,” British Is the ‘Alternative’ 2x2 Morning-After Pill?), Medisch Con- 42: Journal of Family Planning, 15:112–117, 1990. tact, 89–92, 1987. 19. Shanghai Clinical Research Coordinating Group on Antifertility Tablet #53, “Clinical Observation of the Home 12. NIVEL, 1993, op. cit. (see reference 10). 6. A. McGuire and D. Hughes, “The Cost Effectiveness Leave Antifertility Tablet #53,” Chinese Medical Journal, of Emergency Contraception,” in D. Paintin, ed., The Pro- 13. J. Boeke, “De morning-after pil” (The Morning-After 10:610–620, 1977. vision of Emergency , Royal Col- Pill), Huisarts en Wetenschap, 31:412–413, 1988. 20. H. P. Lei and Z. Y. Hu, “The Mechanisms of Action lege of Obstetricians and Gynecologists Press, London, 14. J. V.Th. H. Hamerlynck and M. H. Mochtar, “Het risi- of Vacation Pills,” in C.F. Chang and D. Griffin, eds., Sym- 1995, pp. 69–75. co van een onbedoelde zwangerschap na een onbescher- posium on Recent Advances in Fertility Regulation—Beijing, 7. A. A. Haspels, “Post-coitale interceptie” (Postcoital mde coitus; beschouwing bij de huidige hormonale post- ATAR S. A., Geneva, 1981, pp. 70–82.

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