Emergency contraception among female undergraduates in Ogun State, Nigeria. 

Olufemi T. Oladapo FWACS, Peter O. Adefuye FWACS, Okanlawo L. Odusoga FWACS, Idris A. Okewole FWACS FMCOG, *Olusoji J. Daniel MPH ,FWACP.

Consultants, Department of Obstetrics and Gynaecology & *Community Medicine and Primary Care Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria.

ABSTRACT

The persistently high incidence of premarital sexual activity, poor condom use and induced abortion among Nigerian undergraduates calls for emergency contraception (EC) as a second chance approach if the incidence of unintended pregnancy and clandestine abortions are to be kept to the barest minimum. A survey of 584 randomly selected female undergraduates of Olabisi Onabanjo University, Ogun State, Nigeria was conducted over a two-month period to evaluate the knowledge, practice and perception of EC. Sixty two point eight percent of the students had experienced sexual intercourse. A total of 446 (76.4%) of the respondents were aware of EC pills but only 18.5% of the sexually experienced students had used it previously. The level of awareness was poor among the younger respondents and those in the lower levels of study. Only 6.1% of the students who knew about postcoital pills identified the correct timing of administration for maximal efficacy. Most respondents cited friends/relations (54.5%) and mass media (23.7%) as their main sources of knowledge while 3.8% and 5.4% of the respondents knew about EC through the Family Planning Clinic and the University Health Centre, respectively. Concerns about future fertility and encouragement of sexual misbehaviours were cited reasons for disapproval of increased advertisement of EC by 30.3% of the students. In order to reduce the gap between knowledge and utilization of emergency contraceptives among female undergraduates, there is a need to properly disseminate reliable contraceptive information as well as make EC pills more accessible especially to younger students and those in the lower classes of study.


Key words: Emergency contraception, Induced abortion, Unwanted pregnancy, Undergraduates

INTRODUCTION

Despite the introduction of emergency contraception into clinical practice over three decades ago, its role in preventing unwanted pregnancies and illegal abortion is still under-utilised1. This is because in spite of the increasing awareness, utilization of this method of contraception remains disappointingly low2,3,4. According to WHO estimation, unintended pregnancies lead to at least 20 million unsafe abortions and account for 20-50% of over 500,000 maternal deaths that occur annually5. This figure excludes other maternal deaths that result from unintended pregnancies that do not involve an abortion. Studies have shown that three out of every four potential pregnancies can in fact be prevented by this contraceptive method6,7,8.

Unlike in the past, many Nigerian youths are now marrying late, are more interested in acquiring a formal education and are increasingly having premarital sex1,9,10. The concept of emergency contraception appears appropriate for this category of individuals who engage in sporadic and casual sexual intercourse and sparingly use regular contraceptives2,11. Though many family planning programmes are now providing emergency contraception as part of their routine services, the University students have never been a target group. Interview of female undergraduates who reported to our gynaecological clinics and those admitted for abortion-related complications suggests that only a few actually know the correct method of use of emergency contraception though many appear to be aware of its existence. In view of the rising incidence of premarital sexual activity, induced abortion and poor condom use among undergraduates, this study was designed to evaluate the knowledge, perception and practice of emergency contraception among female undergraduates in a Nigerian University. The findings may have profound implications on the formulation of policies and educational programs for improving the accessibility and utilization of emergency contraception among female undergraduates in particular, and female adolescents and young adults in general.

MATERIALS AND METHODS

The survey was conducted at Olabisi Onabanjo University, Ago-Iwoye campus and the College of Health Sciences wing of the institution at Sagamu over a two-month period. The institution is a state-owned University, which admits students mainly from the south-western part of Nigeria. The female population of the institution at the time of study was 7,652. Using a multistage sampling technique and proportional allocation scheme, a total of 620 students between the first and sixth year of study were randomly selected in such a way that the same proportion of respondents were chosen from each level depending on the total female population at each level.

The respondents were interviewed using a pre-tested structured self-administered questionnaire to obtain information on the following; basic socio-demographic characteristics, their knowledge and practice of emergency contraception and sexual behaviours in relation to use of regular and emergency contraception. Others include their sources of procurement and information on emergency contraception as well as their attitude towards advertisement of emergency contraception. The confidentiality of information was expressed in the introductory part of the questionnaire. Concerned faculties and class representatives were contacted for consent and relevant data before the commencement of the study. For the purpose of this study, sexual experience describes ever having heterosexual vaginal intercourse. Younger students refers to those who were  25 years of age while lower years of study refers to the first and second years of academic study.

Data was entered into a database and analysed using Epi-Info version 6.04d statistical package12. The influence of selected characteristics such as age and year of study on certain variables were explored in bivariate analyses. Statistical analyses were performed using the X2 test and odds ratio where appropriate. When comparing data from two groups, observed differences were considered statistically significant when p < 0.05 or confidence limits did not embrace unity (1).

RESULTS

Characteristics of Respondents
A total of 584 correctly completed questionnaires were analysed out of the 620 questionnaires distributed, giving a response rate of 94.2%. The respondents were aged between 16 and 34 years with a mean age of 22.1 years and SD 5.6 years. Five hundred and seventy five (98.5%) of the respondents were single while nine (1.5%) were married. Seven (1.2%) of the respondents had children, two of whom were single mothers. Three hundred and forty five (59.1%) of the respondents were Christians while 239 (40.9%) were Muslims. Five hundred and twenty nine (90.6%) of the students belong to the Yoruba speaking tribe while Ibo, Hausa and other tribes constituted forty one (7.0%), eight (1.3%) and six (1.0%) of the respondents, respectively.

Sexual Experience and Practice of Regular Contraception
A total of three hundred and sixty seven (62.8%) of the respondents had had sexual intercourse (Table 1). Younger students (16-25 years) were less sexually experienced compared to the older ones (26-34 years) {59.8% vs. 68.2%; X2=4.13 p=0.04. There was no significant difference between the proportion of sexually experienced students in lower (1st and 2nd) and higher levels of study (3rd-6th) {58.8% vs. 66.1%; X2=3.28; p=0.07. The majority (85.9%) of the respondents approved of family planning although only 56 (9.6%) of the respondents regularly used modern contraception. Thirty-nine of these students used condoms, 9 used oral contraceptive pills, 5 used injectables, 1 used IUCD while 2 used “other methods”. The duration of use ranged from 6 to 24 months. Forty-six (82.1%) of those who use regular contraceptives were students from 3rd year of study and above.

Practice of Unprotected Sexual Intercourse
As shown in Table 2, a total of 168 (28.9%) of the respondents admitted that they have had at least one unprotected sexual intercourse in the past two months. Practice of unprotected sexual intercourse was significantly higher in the younger compared to the older age groups (31.9% vs. 23.2%; X2=4.96 p=0.03) and in the lower compared to higher levels of study (36.2% vs. 22.9%; X2=12.33 p=0.004.

Awareness and Knowledge of EC
Table 3 shows that more than three-quarters of the respondents were aware of the existence of emergency contraception. Awareness appears to increase with age and was highest among the 31 to 35-year age group. Younger respondents were significantly less aware compared to the older ones (72.4% vs 83.4%, X2=9.08; p=0.003. Respondents in the lower years of study were less aware compared to those in higher years of study (59.9% vs. 89.2%; X2=68.80, p< 0.0001). All the 446 respondents knew of progesterone-only pills (PostinorR) as an emergency contraceptive while 54 (12.1%) of them knew that the combined pills could also be used for EC. Knowledge of existence of IUCD for emergency contraception was found in only 31 (5.3%) of the respondents while 38 (6.5%) claimed knowledge of “other methods” of emergency contraception of no proven efficacy such as postcoital douching and use of “APC” a mild oral analgesic.

Source(s) of Knowledge of EC
The source of knowledge of emergency contraception was identified as friends and/or relations by 243 (54.5%) of the students, mass media (newspapers and magazines) by 106 (23.7%), radio and

television by 47 (10.5%) and workshops/seminars by 41 (9.2%) of the respondents. The Family Planning Clinic and University Health Centre were cited by 17 (3.8%) and 24 (5.4%) of the respondents, respectively.

Previous Use and Timing of EC
Table 4 shows that 68 (18.5%) of the sexually experienced students had used emergency contraception before. This figure translates to 11.6% of the total number of respondents studied. Fewer younger students (16-25 years) had practiced emergency contraception compared to their older counterparts (11.7% vs. 29.2%; X2=17.77, p< 0.001. Junior respondents were less likely to have previously used any form of emergency contraception compared to the senior ones (10.6% vs. 24.1%; OR: 0.37 (0.19-0.71). Out of 446 students who had knowledge of postcoital pill, only 27 (6.1%) of the students identified the correct timing of use for utmost effectiveness (up to 72 hours after unprotected intercourse8). Eleven (35.5%) of those who knew about the postcoital use of IUCD identified the correct timing of effectiveness (up to 5 days after unprotected intercourse13).

Source of Procurement of EC
Three hundred and forty six (59.2%) of the respondents knew where to obtain EC while 238 (40.8%) reported they did not. The University Health centre and the Family planning clinic were identified as the sources of supply by 16 (2.7%) and 27 (4.7%) of the respondents respectively. Patent medicine stores, pharmacy shops and market were cited by 232 (39.8%), 62 (10.6%) and nine (1.5%) of the respondents respectively. A total of 77.6% of those who were aware of EC knew where to obtain it.
Should EC be more Widely Advertised?
by Age and Year of Study
Two hundred and thirty six (52.9%) of the respondents who were aware of EC were in
favour of its wide advertisement, 177 (39.7%) of them were against increased advertisement while 33(7.4%) were neither against nor in favour of advertisement (Table 5). The proportion of those in support of increased advertisement in lower years of study was significantly higher than those in the higher levels of study (60.4% vs. 41.5%; X2=15.26 p=0.0001. Students between the ages of 16 and 25 were also more in favour of increased advertisement compared to those in older age groups (63.6% vs. 47.3% OR: 1.95, X2=10.85 p< 0.0001. Table 6 enumerates the reasons cited by the respondents who disapproved of wide advertisement for emergency contraception.a

DISCUSSION

This study focussed on female undergraduates who were predominantly unmarried adolescents and young adults perceived to be at risk of unintended pregnancy. Similar to findings in other studies14,15, the level of awareness of oral emergency contraception (especially levo-norgestrel) was generally high in this population, though majority of the respondents were not aware of the accurate timing of its administration to achieve maximum effectiveness. The majority of the respondents were not familiar with the use of an intrauterine contraceptive device (IUCD) as a method of emergency contraception. Despite its superior effectiveness over other methods of emergency contraception, an IUCD is usually not recommended for young women who have not yet had children and certainly not for women at risk of sexually transmitted infections16 like undergraduates.

Regardless of the fact that over three-quarters of the respondents were aware of emergency contraceptive pills, only 18.5% of the sexually experienced students had ever used it previously. This value is significantly less than that obtained in the study by Obionu and Okonkwo14, probably as a result of the variation in sexual behaviours of the studied populations. The poor practice of emergency contraception recorded in this study is quite unfortunate considering the prevalence of unprotected sexual intercourse among this population. Contrary to other studies13,17, there was evidence of less awareness of emergency contraception among younger respondents and those in the lower classes of study. The practice of unprotected sexual intercourse also appears to be higher among this same category. This is understandable since most students in lower levels of study are younger and are eager to explore their feminity, having recently escaped parental surveillance which had kept them in check. Youths who are not sexually active have been found to tend to know less about contraception and are not likely to institute contraceptive use when they initiate sexual activity18. It appears that the junior female undergraduates in this institution tend to learn more about emergency contraception as they progress from one level of study to another.

Similar to observations made by other workers1,4, information on emergency contraception was obtained mainly through friends/relations (54.5%) and newspapers and magazines (23.7%), thus corroborating the influence of peers and print media on this group of individuals. As in previous studies,14,19 the family planning clinic was cited by only 3.8% of those who knew about EC as their main source of knowledge on emergency contraception. The University Health Centre also appears not to be student-friendly with regard to contraception as only 5.4% of them acquired their knowledge through this source. This finding is not unexpected as many students still regard the family planning clinic as a centre essentially meant for married people. The poor contribution of the Health Centre to dissemination of contraceptive information may not be unconnected with the poor knowledge and prescribing attitude, which was reportedly common amongst healthcare providers20. This indicates that there is more work to be done, as these two channels would have provided the most reliable sources of information about the correct knowledge and appropriate timing for emergency contraception.

Increased advertising of emergency contraception was favoured by over half of the respondents but the higher proportion of those in favour were the younger students and those in the lower years of study. Those who were against it cited encouragement of promiscuity and fear of possible interference with future fertility as their reasons for disapproval. Such reasons have been cited as some of the reasons why sexually active youths avoid contraception and prefer to opt for abortion when the need arises18. Contrary to the students’ general belief, studies have shown that emergency contraception does not encourage adolescents to engage in sex, if they were not otherwise inclined to do so17,19. In addition, as the duration of the regimen is short, emergency contraceptive pills are safe for most women to use21.

Despite the low prevalence of use of emergency contraception, a considerable number of the students knew where to purchase the emergency contraceptive pill. It was however evident from the result that some of the students who were aware of emergency contraceptive pills do not know where to obtain it judging by the disparity between the level of awareness and those who knew where to procure it. The main sources of supply for most students were the patent medicine stores and the pharmacies. The University Health Centre and the Family Planning Clinic were recognized as the sources of supply by only a small percentage of the students. This shows that there is need to encourage consultation about reproductive health issues at the school-based clinics.

CONCLUSION

In conclusion, the use of emergency contraception appears to be in disparity with the prevalence of unprotected sexual activity especially among the young and junior students. This is in spite of their generally poor use of regular contraceptives. Our findings also suggest that the low level of emergency contraceptive utilization arose from perceived risk of side effects and concern about sexual misbehaviours if it is encouraged. It is therefore essential that while maintaining that the barrier method of contraception remains the recommended method of choice to prevent sexually transmitted infections and unintended pregnancies among the female undergraduates in this era of HIV/AIDS, effort should be made to offer emergency contraception as a second chance approach when this method fails or is not utilised. Consequently, there is a need to educate the undergraduates and especially the female population about emergency contraception. This can be done by proper dissemination of reliable information on its advantages, safety and efficacy by extensive advertising campaign through seminars, television talk shows, radio programs, school-based magazines and printed media. Making access to emergency contraception easier, such as providing emergency contraception through school-based health centres, pharmacies, convenience stores or other environments where students are comfortable seeking health care services and products, would help many female undergraduates avoid the trauma of an unplanned pregnancy and perhaps a subsequent illegal abortion.

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ACKNOWLEDGEMENT

The authors are grateful to all the students who participated in this study, as well as their class representatives and the University authority. Correspondence to: Dr. O.T Oladapo Department of Obstetrics and Gynaecology, Olabisi Onabajo University Teaching Hospital, PMB 2001, Sagamu, Ogun State, Nigeria.

 


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