Original research articleEmergency contraception in South Africa: knowledge, attitudes, and use among public sector primary healthcare clients☆
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.
Section snippets
Materials and methods
This multicenter study was undertaken at 89 public sector primary healthcare facilities in three provinces of South Africa. Between November 1999 and August 2000, clients and health providers were interviewed at all primary healthcare facilities in a deep rural area (n = 14) in the province of KwaZulu-Natal (KZN) and at 17 purposively selected health facilities in an urban area of Gauteng Province (GP). Random samples, weighted according to patient load, of 30 Western Cape Province health
Results
A total of 1068 clients were interviewed, with a response rate of 86.5%. The main reason for refusal was insufficient time, and refusals occurred more often in the urban areas and where clients were asked to participate in the survey after their consultation rather than while they were waiting to see the health provider. The demographic characteristics of respondents for each of the four study sites are summarized in Table 1. Only 27.1% of the clients were married; many had completed secondary
Discussion
Findings indicate that awareness of EC is low among women from both urban and rural areas of South Africa. Because respondents were primary healthcare clients, just over a quarter of whom were family planning clients, it is likely that awareness is even lower in the general population [3]. Although awareness of EC was generally far lower in South Africa compared with that in the developed country studies reviewed by Ellertson et al. [3], awareness was higher than that found in other developing
Acknowledgements
We thank the health services for making this study possible and the clients who participated so willingly.
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Cited by (37)
Awareness and use of emergency contraception among women of childbearing age at the family health care centers in Alexandria, Egypt
2013, Journal of Taibah University Medical SciencesCitation Excerpt :Findings also indicate that the vast majority of these study participants lack the awareness about emergency contraception. These findings came in accordance with the data from other Muslim countries like Kuwait, Turkey and Iran, also developing countries as Mexico and South Africa that reported limited or just wrong information about EC among the majority of their participants,16,17,22–24 but contradict those of the developed countries.25,26 Considering the barrier against the use of EC, results of this study came in line with previous studies which revealed many participants among those ever heard about EC had the misconception that emergency contraception is an abortifacient.22,23
Representations and uses of emergency contraception in West Africa. A social anthropological reading of a northern medicinal product
2012, Social Science and MedicineCitation Excerpt :There are no quantitative data from representative samples about trends in perceptions and use of EC in West Africa. Studies have examined particular population groups: health centre clients (Klitsch, 2002; Smit et al., 2001), students and young people (Addo & Tagoe-Darko, 2009; Byamugisha, Mirembe, Gemzell-Danielsson, & Faxelid, 2009; Opoku, 2010), refugee populations (Goodyear & McGinn, 1998), family-planning providers (Creanga, Schwandt, Danso, & Tsui, 2011; Judge, Peterman & Keesbury, 2011; Maharaj & Rogan, 2011) or victims of violence (Dessalegn, 2008). These studies mainly cover opinions and (more rarely) knowledge about EC, and acknowledge that on their own they cannot report on its use, with the exception of Opoku's study (2010) of a non representative sample of women aged 18 to 35 in the Kumasi metropolis in Ghana, according to which less than 4% of them were using EC.
Awareness of hormonal emergency contraception among married women in a Kuwaiti family social network
2007, European Journal of Obstetrics and Gynecology and Reproductive BiologyCitation Excerpt :In younger age groups, 84%, 57%, 54% and 43% of female university students in Jamaica [21], South Africa [22], Nigeria [23], and Ghana (male and female students) [24], respectively, were aware of emergency contraception. However, in older age groups, 23% of female primary health care clients in South Africa [25] and potential clients in Mexico City [26] knew of emergency contraception but only 11% of educated working women at a hospital in India [27]. There has only been one study on the awareness or use of hormonal emergency contraception in a Muslim country – 8% of 250 married women of child-bearing age in Iran knew about emergency contraception [28] – and none in Arabic countries.
Dual protection and contraceptive method use among women in heterosexual relationships in Mahikeng, South Africa
2017, African Journal of Reproductive HealthKnowledge, attitudes and practices of health professionals in public health institutions on emergency contraception in Pietermaritzburg, Kwazulu-natal Province, South Africa
2017, South African Journal of Obstetrics and Gynaecology
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This research was supported by a grant from the Wellcome Trust (Grant Number 050522/Z/97/Z).