Awareness, use and associated factors of emergency contraceptive pills among women of reproductive age (15-49 years) in Tamale, Ghana

Emergency contraception (EC) is defined as any method women can use after intercourse to prevent pregnancy [1]. The differing methods of EC include the use of intrauterine devices and hormone pills (referred to as emergency contraceptive pills (ECPs), such as the over-the-counter hormonal method known as Plan B [2]. The most commonly used EC method in developing countries including Ghana is the ECPs.

ECPs referred to as postcoital contraception are mostly hormone-based regimens, including a combination of ethinyl estradiol with levonorgestrel (Yuzpe regimen) and levonorgestrel alone [3], Ulipristal acetate30 mg [4]. Just like any other EC method they are administered after unprotected intercourse. In the past, ECPs were considered to be effective only within 72 hours after intercourse; however recent studies have indicated that they are effective for up to 120 hours [5‐7]. Their effectiveness has been claimed to be between 75–80 percent [8].

Increasing the availability and promotion of EC has the potential to reduce the incidence of unintended pregnancies [9‐11]. Uniquely, it is the only immediate option left for a woman who has had unprotected intercourse and is unprepared for a pregnancy [12].

Each year, about 210 million women around the world become pregnant [6] from which about 75 million of these pregnancies (36%) are unplanned and/or unwanted [13]. Unplanned/unwanted pregnancy is one of the leading causes of maternal mortality and morbidity in developing countries [6]. In the developing countries, the World Health Organization (WHO) estimates that one woman dies every eight minutes due to unsafe abortion [14, 15].

In Ghana, ECPs have now become an integral part of contraceptive services to prevent conception following unprotected and unplanned exposure or contraceptive accidents like burst condom, slippage of diaphragm and forgotten pills. Also ECPs are used by victims of rape cases. There has been very extensive campaign and dissemination of knowledge on contraceptives. Currently, the knowledge of any contraceptive method is almost universal in Ghana, with 98 percent of all women and 99 percent of all men knowing at least one method of contraception [16]. However, while 47.4% of Ghanaian women have a history of contraceptive use only 20% are current users [16].

Since the introduction of ECPs in Ghana, limited studies have been conducted to assess awareness and usage of ECPs among women of reproductive age. The few studies available were conducted among college students.

This study investigated the awareness and use of ECPs among reproductive age (15–49) women in Tamale, Ghana. Furthermore factors associated with the use of ECPs were investigated.

The general characteristics of the women are presented in Table 1. Generally, 67.5% (n = 135) had attained a high level of education, 84.5% (n = 169) were married, 44.0% (n = 88) self-employed, 49% (n = 98) Muslims and 34.5% (n = 69) had an income level below 200GHC ($ 77). The cost of ECPs ranged from 5GHC to 20GHC ($1.5 to $6) depending on the brand.

This study assessed the awareness, knowledge and use of emergency contraceptive pills (ECPs) as well as factors associated with its use among reproductive age women in Tamale, Ghana.

The awareness level of ECPs among the reproductive women in this study was found to be 69.0%, which is higher than the level reported among Egyptian women (24.5%) aged 19-49 years [14], among women in California (38.2%) aged 18-44 years [18] and 11.2% among educated women in India [19] and among university students in Ghana (43%) [20] and Cameroon (63%) [21]. Our findings however are lower than those reported among English reproductive women (90%) [22‐24] and University students in the USA (94%) [25] and Jamaica (84%) [26].

In contrast to several studies [7, 14, 19, 27, 28], health workers were the major source of information on ECP for the study participants rather than radio/television and other sources like family and friends. However, our findings are in agreement with the results of Irfan and colleagues who found a large proportion of women saying they knew about EC through a health care provider [29].

Another important finding of this study was that, about 85% of the participants who had awareness on ECPs were able to determine the correct time frame for using ECPs. This is higher than the 38% reported among reproductive age women in California [18], 14.9% reported among female college students in India and 18% in University students in Nigeria [30]. Several studies have reported that many women who are aware of the existence of ECPs do not have adequate knowledge on the appropriate interval between unprotected intercourse and taking the ECPs [31, 32]. Probably, our findings could be attributed to the fact that a large proportion of the study participants had a high level of education. Also the participants indicated health workers as their major source of information on ECPs, which might have contributed to the high level of knowledge on the correct time frame to use ECPs. These factors have been shown to influence knowledge and awareness levels of ECPs in several studies [18, 19, 31].

In agreement with several findings we found that participants said they would use ECPs in cases of rape, unprotected intercourse, and failed regular methods [6, 7, 14]. This finding was also confirmed by the reasons participants gave for using ECPs which included prevention of unwanted pregnancies and unsafe abortions.

About 40% of the women who had awareness on ECPs had ever used them. This is higher than the 24.5% reported among Egyptian women aged 18-49 years [14]. The higher prevalence of ECP use in this study as compared to others studies [18, 19, 31] could be due to the fact that a large proportion of the women said ECPs were available (92.0%) and affordable (87.7%). Further confirming our findings, our univariate and multivariate logistic regression analysis indicated that participants who said ECPs were available and affordable were more likely to use them as compared to those who said it was not. This suggests that availability and affordability may be significant determinants of the use of ECPs. To increase the current usage prevalence and to consequently realize the benefits of ECP in reducing unwanted pregnancies and abortions, the health authorities should continue to make ECPs available to reproductive age women.

Surprisingly, women who said the use of ECPs were not acceptable in their culture and their religion was significantly more likely to use ECPs compared to their counterparts who said their culture and religion accepted it.

Most of the women interviewed in this study were either Muslims or Christians. In both religions, sex is generally considered for procreation. In Catholicism all forms of abortion and emergency contraception are prohibited [33] except for measures normally taken to save a mother that result in the death of the foetus [34]. In Islam abortion of a viable foetus is considered a serious crime equivalent to that of murder [35]. However, the prevailing view in Islam is that emergency contraception and abortion are permissible in certain situations [36]. Depending on the Islamic school and length of gestation of the foetus, religious opinion varies from unconditional permissibility to unconditional prohibition [37]. The values that an individual woman holds may not be in keeping with the documented official teachings of her religion or the expected cultural norms reported by other members of the same culture [38]. Through education and interaction with health workers, women have realized the need to live a quality life and also take good care of their children. This might have contributed to the high use of ECPs despite reporting religious and culturally unacceptability.

The use of ECPs by women against religious and cultural unacceptability could also be due to the notion that using ECPs is less unacceptable in comparison with other methods of terminating unwanted pregnancies such as abortion, which could easily be stigmatized.

It is worth noting the limitations of this study. Due to the nature of the cross-sectional design, cause and effect could not be investigated. Also the study participants comprised of reproductive age women in Tamale, which is an urban town. Hence it’s difficult to generalize the findings of this study to women from the rural communities of Ghana. However, this study is explorative in nature to evaluate the awareness and use of EC among women and forms as a basis for future elaborative studies.

A relatively high awareness level and use of ECPs has been found. Factors found to be associated with the use of ECPs were availability and affordability. Religious and cultural unacceptability did not hinder the use of ECPs. Health authorities should continue to make ECPs available to reproductive age women.