Emergency contraception in South Africa: knowledge, attitudes, and use among public sector primary healthcare clients^☆

Abstract

To determine knowledge of, attitudes toward, and use of emergency contraception (EC), interviews were held with 1068 clients of 89 public sector primary healthcare facilities in two urban and two rural areas of South Africa. Only 22.8% of the clients had heard of EC. Awareness was significantly lower in the most rural area and among older, less educated women. Knowledge of EC was superficial, with 47.1% unsure of the appropriate interval between unprotected intercourse and starting EC and 56.6% not knowing whether it was available at the clinic. Few (9.1%) of those who knew of EC had used it. After explaining EC, attitudes toward its use were found to be positive, with 90.3% indicating that they would use it if needed. Awareness was lower than in developed countries, but higher than in other developing countries. Findings indicate that if women know of EC, where to get it, and how soon to take it, they would use it if needed.

Introduction

Calls for more research on the availability, provision, and use of emergency contraception (EC) in developing countries have been made for some time [1], [2], [3]. Results from the handful of studies undertaken in developing countries indicate that few women know of EC and even fewer women use it. For instance, findings from population or health service surveys undertaken in Mexico in 1997 [4], in Kenya in 1996 [5], and in Nigeria in 1997 [6], show that 17.8%, 11%, and 4% of respondents surveyed, respectively, had ever heard of EC. No study has been published on knowledge and use of EC among potential clients in South Africa.

Issues in the literature illustrating the urgent need for EC in developing countries are the consequences of unwanted pregnancies, the youthful age structure, and social conditions such as migration where intercourse may be infrequent, or where the incidence of rape is high [2]. In South Africa, these issues are all relevant, compounded by high rates of teenage pregnancy, with 35% of teenage girls reported to be pregnant by 19 years of age [7], and soaring HIV and AIDS rates, with one in four women attending antenatal clinics in 2000 found to be infected with HIV [8]. The long-acting hormonal injectable contraceptive is the most popular method, with 30.1% of sexually active South African women aged 15–49 years reporting this as their current contraceptive method [7]. However, there is increasing emphasis on the need for condom use and other barrier methods of protection against HIV and other sexually transmitted infections (STIs) [9]. In this context, the importance of EC, as a back-up contraceptive method where condom failure occurs, cannot be overemphasized. Termination of pregnancy (TOP) has been legally available in South Africa since 1997, and abortion rates have increased dramatically since its legalization [10]. However, TOP services still remain inaccessible to many women because of provider resistance and lack of designated facilities, especially in rural areas [11], and the rates of illegal abortion are still high [12]. Wider accessibility to EC could lead to a reduction in both legal and illegal abortion.

EC is available free at public sector health facilities in South Africa and is usually supplied in the form of ordinary combined oral contraceptives (COCs), most often Ovral-28. The EC course is cut from regular cycles of COCs at the time of provision, or pre-packaged by dispensary staff, and is seldom accompanied by written instructions for use. A dedicated combined estrogen/progestogen EC product has been available since 1999, and a dedicated levonorgestrel-only EC product was released in January 2001. These dedicated products are expensive, and thus not generally available at public sector facilities. As of November 2000, EC products have been available in private sector pharmacies without prescription; prior to this, a doctor’s prescription was required.

Despite its availability in South Africa, little is known about use of and the barriers to accessing EC. To design innovative and successful intervention programs to promote EC use, a situational analysis was undertaken at public sector primary healthcare facilities in three provinces in South Africa. This article reports on knowledge of, attitudes toward, and use of EC among public sector primary healthcare facility clients.