research proposal on emergency contraception pdf

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Emergency contraception review: evidence-based recommendations for clinicians

Kelly cleland.

1 Office of Population Research, Princeton University, Princeton, NJ

Elizabeth G. Raymond

2 Gynuity Health Projects, New York, NY

Elizabeth Westley

3 Family Care International, New York, NY

James Trussell

4 The Hull York Medical School, University of Hull, Hull England

Several options for emergency contraception are available in the United States. This article describes each method, including efficacy, mode of action, safety, side effect profile and availability. The most effective emergency contraceptive is the copper IUD, followed by ulipristal acetate and levonorgestrel pills. Levonorgestrel is available for sale without restrictions, while ulipristal acetate is available with prescription only, and the copper IUD must be inserted by a clinician. Although EC pills have not been shown to reduce pregnancy or abortion rates at the population level, they are an important option for individual women seeking to prevent pregnancy after sex.

Introduction

Preventing unintended pregnancy is a significant concern at the public health level and is critically important for individuals seeking to determine the number and spacing of their children. Unprotected sex occurs for multiple and complex reasons; these include sexual assault or reproductive coercion, lapse in adherence to an ongoing method of contraception, a contraceptive mishap (such as condom breakage), and lack of contraceptive use. Fortunately, several options are available for contraception that can be used after unprotected sex has already occurred; these methods, collectively referred to as emergency contraception, include different types of pills and the copper IUD. Here, we describe these methods, including their efficacy, mode of action, safety, side effect profile, availability, and any special issues relevant to each method.

Overview of EC Options

The most commonly-available emergency contraceptive option is levonorgestrel 1.5 mg, sold in the United States as Plan B One-Step (Teva Pharmaceuticals, North Wales, PA) and in generic form including Take Action (Teva Pharmaceuticals, North Wales, PA), Next Choice One-Dose (Actavis Pharmaceuticals, Parsippany, NJ), My Way (Gavis Pharmaceuticals, Somerset, NJ), and Levonorgestrel Tablets (Perrigo, Allegan, MI). After years of regulatory battles, in August 2013, Plan B One-Step was approved for sale without restrictions to women and men of any age on store shelves. In February 2014, the Food and Drug Administration (FDA) approved generic versions of Plan B One-Step for unrestricted sale (until recently, these were available without prescription only to those aged 17 or older).

The other type of dedicated emergency contraceptive pill (ECP) available in the U.S. contains 30 mg ulipristal acetate, and is marketed as ella (Actavis Pharmaceuticals, Parsippany, NJ). Ella is available by prescription only for women of any age. In addition to these dedicated ECPs, many types of oral contraceptive pills can be used (in various combinations, depending on pill formulation) as EC – this is often referred to as the Yuzpe method. The Yuzpe method is less effective and causes more side effects than levonorgestrel or ulipristal acetate ECPs. A list of the oral contraceptive pills that can be used as EC can be found at http://ec.princeton.edu/questions/dose.html . The copper intrauterine device (IUD), available in the US under the trade name ParaGard T-380 (Teva Pharmaceuticals, North Wales, PA) is the most effective option for emergency contraception, and has been used as EC for more than 35 years. Although studies are currently underway, no published data are available about use of the levonorgestrel intrauterine system (sold in the United States as Mirena (Bayer Healthcare Pharmaceuticals, Whippany NJ)) as EC, and this use is not recommended at this time.

Other options for emergency contraception are available in other countries, or are under investigation as potential new methods. Mifepristone, available as EC in doses of 10 to 25 mg in a small number of countries, is safe and effective but is not currently available for use as EC in the US. When added to 1.5 mg levonorgestrel, the COX-2 inhibitor meloxicam (15 mg) has been shown to block follicular rupture even after the ovulatory process has been stimulated by the gonadotropin surge, 1 and administration of meloxicam alone (15 or 30 mg for five days) has been shown to be effective in disrupting ovulation in a pilot study; 2 these are not yet marketed anywhere as EC products.

For ongoing contraceptive methods, efficacy is usually measured as the number of pregnancies that occur among users over a given period of time. In contrast, the efficacy of emergency contraceptives is usually expressed as the proportion of expected pregnancies that are averted by the method. A complex set of assumptions must be made to produce estimates of EC efficacy, the most important of which is how many pregnancies would have occurred if EC had not been used. This assumption is often flawed and imprecise; therefore estimates based on it are also imprecise. Here, we present failure rates of EC from clinical trials (rather than the proportion of expected pregnancies averted), including comparative data showing the relative effectiveness of different methods.

The copper IUD is by far the most effective option for emergency contraception; a review of 42 studies showed that the pregnancy rate after insertion of the copper IUD for EC is less than 0.1%, 3 indicating that it averts almost all expected pregnancies. The copper IUD has the added benefit of providing at least 12 years of highly effective ongoing contraception if left after placement for EC.

Ulipristal acetate is the most effective ECP available in the United States. In clinical trials, failure rates for ulipristal acetate range from 0.9% to 2.1%. 4 – 6 Pregnancy rates following use of levonorgestrel ECPs in clinical trials range from 0.6% to 3.1%. 4 , 6 – 17 A meta-analysis of two studies comparing ulipristal and levonorgestrel ECPs found that the odds of pregnancy among users of ulipristal were 42% lower than among users of levonorgestrel in the first 72 hours after sex, and 65% lower in the first 24 hours after sex. 6 The greater efficacy of ulipristal is most likely due to the fact that it is effective at disrupting ovulation even after the luteinizing hormone (LH) surge has begun, while levonorgestrel is ineffective after the start of the LH surge. 17 , 18

Combined oral contraceptive pills that can be used for EC, which contain both estrogen and progestin, are the least effective EC method. Failure rates reported from clinical trials range from 2.0% to 3.5%. 13 , 14 , 19 In trials comparing the combined regimen with the dedicated levonorgestrel regimen, the pregnancy rate among users of the combined regimen was about twice that of women who used levonorgestrel ECPs. 13 , 14 , 20

Although ECPs are effective at reducing pregnancy risk for individuals, they have not been shown to reduce rates of unintended pregnancy or abortion at the population level. 21 , 22 This finding may be due in part to the fact that, even when provided with ECPs in advance of need, women do not use them every time they are at risk. In one trial, 45% of women who were given an advance supply of ECPs who had unprotected sex did not use ECPs; 23 in another trial, 33% of women with an advance supply of ECPs had unprotected sex at least once without using ECPs. 24 Given that most women do not have an advance supply of ECPs at home, and must go to a clinic or pharmacy to purchase ECPs after the fact, the proportion of women who have unprotected sex without using ECPs is likely substantially higher than found in these trials. Another explanation is that women who have EC readily available may increase their coital frequency or decrease their use of other contraceptives. Most studies find no evidence of such behavior change, but it was documented in one randomized trial. 25

While these findings suggest that ECPs are not a solution for reducing rates of unintended pregnancy and abortion at the population level, ECPs are nevertheless an important option for individual women who have had unprotected sex. Clinicians should remind patients about this option, especially those who are using short-term or user-dependent methods. Because levonorgestrel ECPs are now available directly from pharmacies without a prescription, clinicians may not see their patients at the time that they need EC, and therefore may wish to integrate reminders about the importance of EC into routine visits. The copper IUD is an excellent option for women who are likely to experience multiple episodes of unprotected sex, as it is highly effective at preventing pregnancy following an act of unprotected sex, as well as all subsequent acts of unprotected sex for at least 12 years. A recent study that followed women who sought EC at a clinic for one year showed that those who chose the copper IUD for EC became pregnant half as often by the end of the year as those who chose levonorgestrel ECPs, demonstrating the longer-term benefits of postcoital use of the copper IUD. 26

Efficacy and Body Weight

The efficacy of ECPs may be reduced in women of higher body weight. Although no studies have been specifically conducted to assess the relationship between weight and efficacy of EC products, a 2011 analysis showed decreased efficacy for women with higher body mass index (BMI) for both levonorgestrel and ulipristal EC; among women with a BMI of 30 kg/m 2 or higher, the failure rate was 5.8% for those using levonorgestrel and 2.6% for those using ulipristal. A model developed by the authors showed that levonorgestrel may be ineffective for women with a BMI of 26 kg/m 2 , and ulipristal may be ineffective for women with a BMI of 35 kg/m 2 . 10 No studies have been conducted to determine whether increasing the dose would improve efficacy; therefore, offering a higher dose is not recommended. If possible, women weighing more than 165 lbs should be offered ulipristal or the copper IUD. The copper IUD is the most effective EC option, and efficacy does not appear to be affected by the user’s weight. However, barriers to access may make it difficult for women to obtain ulipristal or a copper IUD quickly after unprotected sex; in this case, it may be worthwhile for the woman to take levonorgestrel ECPs, regardless of her weight, if she is able to afford it.

Efficacy and Drug interactions

Specific data about interactions of ECPs with other drugs are not available; however, experts assume that interactions would be similar to those with regular oral contraceptive pills. Drugs that reduce the efficacy of oral contraceptive pills, such as rifampin, griseofulvin, certain anticonvulsant drugs, Saint John’s wort, and certain antiretroviral drugs may also reduce the efficacy of levonorgestrel, ulipristal acetate, and combined ECPs. 27 Women using these medications who need EC should be offered the copper IUD as EC as a first-line option, as the efficacy of the copper IUD is not affected. If women using these medications prefer to use levonorgestrel EC (or if it is the only method readily available), some clinical guidelines recommend doubling the dose to 3 mg. 28 Ulipristal is not recommended in women using enzyme-inducing drugs.

Because ulipristal is a progesterone receptor modulator, and therefore blocks progestin, it may reduce the efficacy of other hormonal contraceptives containing progestin. Study of this relationship is underway, but results have not yet been published. A conservative approach for women continuing or starting progestin-only methods after use of ulipristal is additional precautions (abstinence or a barrier method) for 14 days following use of ulipristal. 28

Regimen Timing

All emergency contraceptive pills (ECPs) should be taken as soon as possible after unprotected sex. ECPs work by interfering with ovulation, and because women frequently do not know precisely when they are at the most fertile period of their menstrual cycle, 29 prompt use may improve the chance of preventing or disrupting ovulation.

The original levonorgestrel regimen consisted of two 0.75 mg pills, to be taken 12 hours apart. The two-pill regimen has almost entirely been replaced by the single-pill product (1.5 mg), but patients may encounter the two-pill regimen occasionally and should be advised to take both pills together as soon as possible after sex. Although the package insert indicates use for only 72 hours after unprotected sex, some research has shown levonorgestrel ECPs to be effective up to 4 days after sex and ineffective thereafter, 30 while other analyses suggest that levonorgestrel ECPs are effective up to 5 days after sex, but with declining efficacy. 6

Clinical guidelines recommend insertion of an IUD within 5 days of unprotected intercourse, 31 or within 5 days of ovulation (if ovulation can reasonably be determined). 28 , 32 , 33 However, a recent analysis showed that the copper IUD is highly effective at any point in the menstrual cycle, as long as a negative urine pregnancy test result is obtained prior to insertion of the IUD. 34

Women who seek EC from a clinician but prefer to not to use a copper IUD for EC should be offered another form of highly effective ongoing contraception. Studies have demonstrated that simultaneously offering EC and quick-starting depot-medroxyprogesterone acetate is safe and effective; 35 – 37 similar protocols for the levonorgestrel intrauterine system or etonogestrel implant could significantly reduce longer-term pregnancy risk. A recent pilot study in Scotland found that a simple intervention in which pharmacists provided women presenting for EC with a cycle of progestin-only pills significantly increased the probability of the women using effective contraception six to eight weeks following EC use. 38

Repeated Use of ECPs

ECPs are not intended for deliberate repeated use or use as a routine method of contraception because far more effective (and cost-effective) methods are available. Women who present for emergency contraception should be offered a copper IUD or another ongoing method of their choosing if they do not want to become pregnant. No specific data are available about the efficacy or safety of the available ECP regimens when used frequently over a long period of time. However, at least 11 studies have confirmed that levonorgestrel 0.75 mg administered multiple times per cycle causes no serious adverse events. 39 These data provide reassurance that using the levonorgestrel regimen as often as needed to prevent pregnancy after unprotected sex is safe.

Repeated use of ulipristal in the dose used for emergency contraception (30 mg) has not been specifically studied, but ulipristal in daily doses of 5 mg and 10 mg over the course of several weeks has been studied for treatment of uterine fibroids and appears to be safe and well-tolerated. 40 The National Institute of Child Health and Human Development is beginning to investigate daily use of ulipristal acetate in doses of 5 mg or 10 mg as a daily oral contraceptive. 41

Whether the efficacy of levonorgestrel ECPs is reduced by recent or subsequent use of ulipristal, which is a progesterone receptor modulator, is unknown. Therefore, if a woman who has recently used the levonorgestrel regimen has a subsequent need for emergency contraception, she should be advised to use levonorgestrel again or have a copper IUD inserted. Despite the lack of clear evidence to support or refute repeated use of ulipristal in the same cycle, the label for ulipristal EC products recommends against using the product more than once within the same cycle. If a woman who has recently used ulipristal has a subsequent need for emergency contraception, she should consider a copper IUD if that is acceptable and available; if an IUD is unacceptable or unavailable, some guidelines support use of levonorgestrel ECPs if another episode of unprotected intercourse occurs following use of ulipristal. 28

Mechanism of Action

The question of how levonorgestrel ECPs work to prevent pregnancy has been studied extensively. Two recent studies demonstrate that levonorgestrel ECPs, if taken before the luteinizing hormone (LH) surge has begun, can inhibit the LH surge, thereby disrupting the ovulatory process, but are ineffective thereafter. 17 , 18 In these studies, a combined total of 492 women presenting for EC were monitored using blood serum and ultrasound to assess their cycle day. Among those who took EC before ovulation, none became pregnant, whereas 20 pregnancies would have been expected. Those who took EC on the day of ovulation or after became pregnant at the rate that would have been expected if no contraception had been used (11 women became pregnant, and 11 or 12 pregnancies would have been expected). These studies conclude that, because levonorgestrel ECPs are ineffective after ovulation has occurred, they do not interfere with the implantation of fertilized eggs. Levonorgestrel ECPs have been postulated to interfere with sperm function, tubal transport of sperm or egg, or endometrial receptivity, but evidence of these mechanisms is inconsistent across studies. 42 Levonorgestrel ECPs have no effect if taken after implantation has occurred; the regimen does not affect an existing pregnancy or increase rates of miscarriage. 43 , 44

Ulipristal acetate has been shown to prevent ovulation both before and after the LH surge has started (but before the LH peak), delaying follicular rupture for at least 5 days. 45 In this study, ulipristal did not prevent ovulation in the vast majority of women treated with ulipristal after the LH peak. The fact that ulipristal is effective after the start of the LH surge, while levonorgestrel is not, may account for its greater effectiveness. Published post-marketing surveillance data for ulipristal acetate show no increased risk of miscarriage among women who took ulipristal when they were already pregnant, or became pregnant due to failure of ulipristal; in addition, exposure to ulipristal in utero did not increase the risk of birth defects among babies born. 46

The precise mechanism of action of the copper IUD is unknown. Copper ions released into the uterine cavity may inhibit sperm function, 42 and the presence of the IUD may also induce an inflammatory response that could impair transport of gametes or the fertilized egg or inhibit implantation. These effects may contribute to its near-perfect effectiveness as a method of emergency contraception.

Safety and Contraindications

ECPs are not dangerous under any known circumstances or in women with any particular medical conditions. According to the Center for Disease Control’s Medical Eligibility Criteria for Contraceptive Use, no circumstances exist under which the risks of using combined or levonorgestrel ECPs outweigh the benefits. 33 These criteria do not yet include ulipristal, but ulipristal would most likely receive the same safety rating. Recognized contraindications to oral contraceptives do not apply to ECPs. Furthermore, women with a history of cardiovascular disease, migraines, liver disease, and women who are breastfeeding may use levonorgestrel ECPs. 33 The U.S. label for ulipristal acetate recommends against use by breastfeeding women; however, European guidelines have been updated to reflect that ulipristal may be used by breastfeeding women, but that breastmilk should not be given to a baby for a week following its use. 47 Breastfeeding women using ulipristal should be advised to pump and discard the milk for a week to maintain supply.

History of ectopic pregnancy is not a contraindication for use of ECPs. A systematic review found that when ECPs fail, the proportion of pregnancies that are ectopic does not exceed the proportion of ectopic pregnancies in the general population. 48 Like all contraceptive methods, ECPs reduce the absolute risk of ectopic pregnancy by preventing pregnancy in general.

Concerns about pelvic inflammatory disease (PID) following insertion of an IUD may limit providers’ willingness to offer IUDs to women seeking EC. Current guidelines recommend against IUD insertion in women known to currently have PID, purulent cervicitis, active gonorrhea or Chlamydia infection. 32 However, a study of nearly 58,000 IUD insertions found a low absolute risk of PID following IUD insertion, regardless of whether patients were screened within one year before insertion, within eight weeks before insertion, on the day of insertion, or not screened at all. 49 This study suggests that, for women presenting for IUD insertion, it is reasonable to simultaneously insert an IUD and screen high-risk patients for STIs, then promptly treat those with positive results. For patients at low risk of sexually transmitted infections, who are also at very low risk of PID, requiring two visits (one to test for STI and another to insert the IUD) places significant and unnecessary burdens of inconvenience and cost on the patient. Two-visit protocols have been shown to reduce the proportion of women who ultimately receive an IUD. 50

Side effects

Emergency contraceptive pills have an excellent safety profile, and no deaths or serious complications have been causally linked to any ECP regimen. ECPs may cause some side effects that are typically mild and transient. The most common side effect of ECPs is changes in the menstrual period that follows use of ECPs. These changes may vary depending on when in the cycle the pills are taken, according to three studies designed to study the effects of levonorgestrel ECPs on the menstrual cycle. 51 – 53 These studies show that when levonorgestrel ECPs are taken early in the cycle, they shorten cycle length, but when they are taken later in the cycle, they may have no effect on cycle length or may prolong the length of the cycle. In a study comparing ulipristal and levonorgestrel ECPs, menstruation occurred on average one day earlier than expected for users of levonorgestrel ECPs, and two days later than expected for users of ulipristal ECPs. 6

Users of the copper IUD may experience changes in bleeding patterns as well, particularly heavier menstrual bleeding. However, evidence suggests that some of these changes decrease over time for many users. 54 Counseling that helps women anticipate changes in bleeding patterns, as well as the fact that these changes may subside over time, may improve both uptake and retention of the IUD. Patients may experience pain during the insertion process, as well as increased cramping following insertion. About 5% of women experience expulsion of their IUD within the first year of use, 55 and must have a new IUD placed or switch to a different form of contraception if they desire ongoing pregnancy prevention.

Nausea (rarely accompanied by vomiting) occurs in less than 20% of women using the levonorgestrel regimen, 7 , 56 and in about 12% of women using the ulipristal regimen. 5 , 6 These newer regimens induce nausea and vomiting far less often than the combined estrogen-progestin regimen; the combined regimen causes nausea in about 50% of users, and vomiting in 20%. 14 If vomiting occurs within two or three hours after taking a dose of ECPs, some experts recommend that the dose should be repeated. 28

Access and Availability

Levonorgestrel ECPs are the most widely available EC method in the US. Restrictions on the availability of levonorgestrel ECPs have no medical basis, yet the process of gaining approval for unrestricted over-the-counter sale has been long, arduous, and fraught with political interference. After years of complicated and frequent regulatory changes, all one-pill levonorgestrel ECPs are approved for sale on the shelf with no restrictions. Although the label for generic ECPs indicates that the product is for women age 17 and older, proof of age and point of sale restrictions no longer apply. 57

The cost of levonorgestrel ECPs is a considerable barrier for many women, as the out-of-pocket cost for branded product is $48 on average, while the average cost of generics is approximately $41. 58 Women may be able to have this product covered by their insurance; patients should be reminded to check with their insurance provider to determine whether a prescription is needed for insurance coverage.

The alternative dedicated ECP in the US, ulipristal acetate, is available by prescription only. The prescription requirement creates multiple potential barriers to access, as women must be aware that this more effective product is available, contact a healthcare provider to prescribe it, and find a pharmacy that has the medication in stock or can order it for next-day delivery. Ulipristal is likely to be covered by health insurance, but patients should check with their provider to ensure that it is included in their insurance company’s formulary and is available at a nearby pharmacy.

The copper IUD is the most effective EC option, but it can also be the most difficult to obtain. The use of IUDs is growing in the United States, but awareness of its use as EC is low. A 2012 study showed that, among clinicians participating in a California State family planning program, 85% of clinicians never recommended the copper IUD for EC. 59 The same study showed that the majority of providers required two visits for an IUD insertion, which is burdensome for patients and medically unnecessary. In addition, some outdated attitudes about IUDs inhibit providers from offering IUDs to all women, particularly young and nulliparous women. IUDs are safe and effective for women of any age, regardless of whether they have had a previous pregnancy; the American College of Obstetricians and Gynecologists recommends IUDs and implants as a first-line contraceptive option for nearly all women, and encourages same-day insertion protocols. 60 Cost has historically been a substantial barrier to accessing IUDs. However, the Preventive Services Provision of the Affordable Care Act, which requires that all FDA-approved contraceptives be covered by insurance plans with no co-pay, should improve access to IUDs for many women. Uninsured women may be able to obtain an IUD from a subsidized family planning clinic.

The availability of several options for emergency contraception is a benefit to all women who are at risk for pregnancy following unprotected sex. Although many women obtain levonorgestrel ECPs directly from a pharmacy without consulting a clinician, clinicians have an important role in reminding women that they have options for preventing pregnancy even after unprotected sex has occurred. Patients should be counseled that the copper IUD is the most effective option for emergency contraception; if this option is not acceptable or available, same-day provision of highly effectively long-acting methods should be offered if ongoing pregnancy prevent is desired by the patient.

Acknowledgments

Funding: Support for KC and JT is provided by the Eunice Kennedy Shriver National Institute of Child Health & Human Development, Grant #2R24HD047879

• Open access
• Published: 17 January 2022

Use and awareness of emergency contraceptives among women of reproductive age in sub-Saharan Africa: a scoping review

• Kelvin Amaniampong Kwame 1 ,
• Luchuo Engelbert Bain   ORCID: orcid.org/0000-0002-6006-2698 2 , 3 ,
• Emmanuel Manu 1 &
• Elvis Enowbeyang Tarkang 1 , 4  

Contraception and Reproductive Medicine volume  7 , Article number:  1 ( 2022 ) Cite this article

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Metrics details

Emergency contraception (EC) is a method used to avoid pregnancy after unprotected sexual intercourse. Emergency contraceptives can reduce the risk of unintended pregnancy by up to over 95% when taken within 72 h of sexual intercourse. EC is helpful to women who have experienced method failure, incorrect use of contraceptives, raped or have consented to unplanned, and unprotected sexual intercourse. We set out to systematically review the current literature on the awareness and usage patterns of ECs among women of reproductive age in Sub-Saharan Africa.

Eight hundred and sixty-seven (867) articles were selected from EMBASE and Google Scholar databases after a search was conducted. Sixty (60) full-text articles were checked for eligibility and 27 articles met our inclusion criteria. Manual data extraction on excel sheets was used to extract the authors’ names, year of publication, country, sample size, study type, objectives, awareness levels, and the EC types.

Awareness rates ranged from 10.1 to 93.5% (both reported from Ethiopia). The level of use was relatively low (ranging from 0% in DR Congo and Ethiopia to 54.1% in Nigeria). The most used types of EC were Postinor 2 (levonorgestrel), EC pills such as Norlevo (levonorgestrel only) and Nodette (levonorgestrel and estradiol), and intrauterine contraceptive device (IUCD).

Conclusions

Although variations in use and awareness do exist between countries in SSA according to the year of study, the general level of EC awareness has been on the increase. On the other hand, the level of EC use was lower compared to the level of awareness. Postinor 2 (levonorgestrel-only pills) was reported as the most type used EC. Further, studies could be done to find out the effect of culture, religion and believes on the use of contraceptive methods. It is important to understanding barriers to EC use despite high awareness rates. Emergency Contraceptive awareness and use should be promoted among women of reproductive age in SSA to reduce unwanted pregnancies and their complications.

Introduction

The prevalence of unwanted pregnancy and abortion continues to rise in sub-Saharan Africa. Unintended pregnancies remain an important public health issue. Globally, 74 million women living in low and middle-income countries (LMICs) have unintended pregnancies annually. This leads to 25 million unsafe abortions and 47,000 maternal deaths every year [ 1 ]. Unintended pregnancy and unsafe abortion can be prevented by the use of contraceptive methods including emergency contraceptives. Emergency contraceptives (EC) is a method used to avoid pregnancy after unprotected sexual intercourse. It is used before the potential time of implantation, unlike the regular contraceptive methods that are administered before sexual intercourse. Emergency contraceptives can reduce the risk of unintended pregnancy by up to over 95% when taken within 72 h of sexual intercourse [ 2 ]. The use of modern contraceptives in 2017 prevented an estimated 308 million unintended pregnancies [ 3 ]. Meeting all women’s need for modern methods of contraception would avert an additional 67 million unintended pregnancies annually [ 3 ]. Despite the benefits of contraceptives, their use in Africa is 29.4% among women between the ages of 15 and 49 years despite high rates of maternal mortality in the continent [ 4 ]. Amongst the global regions, SSA has the lowest contraceptive prevalence rate (CPR) of 29% [ 5 ]. The SSA region experiences more than 14 million unplanned pregnancies each year with an overall prevalence rate of 29% [ 6 ]. About 44% of all pregnancies worldwide are unintended, and some 56% of unintended pregnancies end in induced abortion. An estimated 56 million induced abortions took place annually in 2010–2014, which translates to an annual abortion rate of 35 for every 1000 women aged 15–44 years [ 7 ]. Sub-Saharan Africa constitutes roughly 66% of the world’s maternal deaths [ 8 ].

Emergency contraceptives provide women of reproductive age with an opportunity to prevent an unplanned or mistimed pregnancy within three to five days of unprotected sexual intercourse by preventing or temporarily stopping ovulation or by causing a chemical change in sperm and egg before they meet [ 2 ]. However, despite the availability, safety, and efficacy of the specific emergency contraceptive agents, there is still limited awareness and use of EC among women of reproductive age in SSA [ 9 ].

Contraceptive use improves women’s and children’s health in many ways, including reducing maternal mortality risks, and improving child survival through birth spacing and the nutritional status of both mothers and children [ 8 ]. The use of modern contraceptive methods such as EC could prevent the majority of abortions and many maternal deaths [ 3 ]. In developed regions, it is estimated that 30 women die for every 100,000 unsafe abortions. That number rose to 220 deaths per 100,000 unsafe abortions in developing regions and 520 deaths per 100,000 unsafe abortions in SSA. Mortality from unsafe abortion disproportionately affects women in Africa. While the continent accounts for 29% of all unsafe abortions, it sees 62% of unsafe abortion-related deaths [ 10 ]. Sub-Saharan African countries have a high rate of unintended pregnancies due to inadequate access to women’s reproductive health services [ 11 ]. This implies that most SSA countries have limited access to facilities for family planning and reproductive health rights, which in a way may not contribute to achieving the UN Sustainable Development Goal 3 (SDG 3): improving maternal health, reducing maternal mortality, and achieving universal access to reproductive health [ 12 ]. Despite several engagements to reduce or eradicate mother and child deaths globally through the century, the health consequences of unplanned pregnancies are a significant public health concern, particularly for women residing in developing countries [ 11 ].

Each year between 4.7 and 13.2% of maternal deaths are attributed to unsafe abortion. The incidence of unsafe abortion stands at 25 million annually. Three (3) out of four (4) abortions that occur in Africa are unsafe and the risk of dying from an unsafe abortion is highest in Africa [ 10 ]. A total of 295,000 women worldwide lost their lives during and following pregnancy and childbirth in 2017, with SSA and South Asia accounting for approximately 86% of all maternal deaths worldwide [ 8 ]. The adverse effects of pregnancy on maternal health that can be avoided by the use of EC are experienced mostly in SSA. Emergency Contraceptives can prevent unsafe abortions and reduce maternal mortality by reducing the number of unintended pregnancies. The limited awareness and use of EC even in situations of potential regular contraceptive failure is a public health problem in SSA. This study seeks to review and map the available evidence on the level of awareness and usage of EC among women of reproductive age in SSA and summarize available evidence to provide an overview of EC awareness and use in SSA.

Methodology

This study is a scoping review of published articles on the awareness and use of EC among women of reproductive age in SSA. The methodological framework used is according to the five-stage layout process described by Arksey and O’Malley (2005) [ 13 ]. This method follows a five-stage process. Stage one (1) involves identifying a research question; stage two (2) involves identifying relevant studies; stage three (3) involves the study selection; stage four (4) involves charting of the data and stage five (5) involves collating, summarizing and reporting the results.

Search strategy

All citations were imported into the web-based bibliographic manager Mendeley Desktop Version 1.19.4 by Glyph & Cog, LLC (Elsevier Database), and duplicate citations were removed manually with further duplicates removed when found later in the process. A systematic search was conducted in EMBASE and Google Scholar for articles that met the eligibility criteria by the authors (A.K., E.T., & M.E). The search followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The following terms were used (including synonyms and closely related words) as index terms or free-text words: “Sub Saharan Africa”, “women”, “Family Planning”, “Contraceptives”, “Birth Control”, “female”,“emergency”, “awareness”, “Knowledge”, “Practice”, and “Use”. Two reviewers independently conducted abstract screening followed by a full-article screening of selected studies, using standardized tools, with guidance from the eligibility criteria. When there were disputes, a third reviewer decided on the course of action.

The inclusion criteria used for this review were; studies that presented evidence that was published from 2000 to 2019, published on sub-Saharan Africa, and also presented evidence on emergency contraceptive awareness and use among women aged 15–49 years. The following exclusion criteria were used during this review; Articles published in languages other than English without translation, studies published with information on only one of the specific objectives (either awareness or use), and titles for which full text could not be retrieved. The search was performed with English language restriction. The date was restricted to 2000–2019.

Data extraction

The three authors participated in the article selection and data extraction processes. All citations deemed relevant after the title and abstract screening were downloaded for subsequent review of the full-text articles. A data charting table was used to extract background information and process the information from each utilized study. The data extraction form was developed, piloted, and used to extract and process relevant information from each included study by the authors (A.K., E.T., & M.E). All articles reviewed were assigned a unique code to help track them. The form captured information on: Author(s), year of publication, origin/country of origin (where the study was published or conducted), aim/purpose, sample size (if applicable), methodology (study design), and key findings that relate to the scoping review question(s).

Summary of findings

The search conducted on in PubMed and Google Scholar, yielded 856 potentially relevant citations. After duplication removal and relevant screening, 60 citations met the eligibility criteria based on title and abstract. The corresponding full-text articles were downloaded for review. After the characterization based on the objectives of the study, 33 full-text articles were excluded from the scoping review.

Three sample size categories (below 500, 500–2000, & above 2000) were used to classify the sample sizes of all the included review articles. The majority (63%)of articles included in this review had a sample size of below 500. The minimum sample size was 32 participants from a qualitative study conducted in Ghana [ 14 ] whiles the maximum sample size was 7785 (Kenyans) plus 12,487 (Nigerians) from cross-sectional studies conducted in these two countries simultaneously [ 15 ]. The articles included in this review were published from 2003 [ 16 ] to 2019 [ 17 ]. In all, five (5) studies were conducted in Ghana, eight (8) in Nigeria, one (1) in DR Congo, three (3) in South Africa, one (1) in Swaziland, two (2) in Kenya, seven (7) in Ethiopia, one (1) in Cameroon, and one (1) in Senegal. Two of these final twenty-seven selected articles were conducted on two countries simultaneously; Kenya and Nigeria [ 15 , 18 ].

In all, 18.5% of the articles were from Ghana, 22.2% from Nigeria, 26.0% from Ethiopia, 11.1% from South Africa, 7.4% from Nigeria and Kenya, and 3.7% from DR Congo, Swaziland, Senegal, and Cameroon each. The review had no limits on the study design; so, articles with varied designs were included in the study. The majority (88.9%) of the study designs were cross-sectional. Other designs included mixed-method and qualitative. Some reviews were conducted as stand-alone projects while others were undertaken as parts of larger research projects. The general characteristics of scoping reviews included in this study are reported in Table  1 . The summary of the findings are presented in Table  2 .

Awareness of emergency contraceptives among women of reproductive age in sub-Saharan Africa

Awareness of EC among women of reproductive age in SSA ranged from 10.1% in a study conducted by Tesfaye, Tilahun, and Girma (2012) [ 29 ] to 93.5% in a study conducted by Mishore, Woldemariam, and Huluka (2019) [ 40 ]. These two studies were both conducted in Ethiopia. Even though the study settings and participants differed, some countries recorded a higher level of awareness on EC than others (Table  3 ).

When three or more studies were reported on EC awareness on a country for different years, a trend analysis was done to examine the pattern of EC awareness (Fig.  1 ). A study from Nigeria conducted in the year 2003, reported 58% of 880 participants of a study were aware of EC [ 16 ]. In the years that followed, which were 2005 (61%) [ 20 ] and 2006 (67.8%) [ 21 ] were reported from other studies carried out in the same country. 72.6% level of EC awareness was reported in the year 2016 [ 36 ] which was also conducted in Nigeria. These findings indicate that the level of awareness on EC in Nigeria increased over the years. In 2017, the level of awareness reported from a cross-sectional study conducted [ 38 ] was lower (63.1%) compared to that of a study conducted in the previous year (86.5%) [ 37 ]. Figure  1 shows the awareness of EC from Nigerian studies included in the review.

Emergency Contraceptive Awareness Trends in four sub-Saharan countries

Three studies were selected from South Africa, which were published in the years 2004, 2007, and 2012. South Africa recorded an increase in the level of awareness from 16.6% in 2004 [ 19 ] to 49.8% in 2012 [ 28 ], though the study regions varied for all the three studies.

Two comparative studies were conducted in the year 2014 between Kenya and Nigeria on EC. The first study sampled 3033 and 3129 participants from Kenya and Nigeria respectively [ 18 ]. The second study sampled 7785 (Kenyans) and 12,487 (Nigerian) participants [ 15 ]. The reported level of awareness for the two studies were 79 and 58% in Kenya, while Nigeria recorded 66 and 31% [ 15 , 18 ].

A study conducted in Ethiopia by Tilahun, Assefa, and Belachew (2010) [ 25 ], recorded a level of awareness of 20% of the 660 study participants. From the year 2012, two studies conducted in Ethiopia met the current scoping review’s inclusive criteria. This year recorded the lowest level of awareness of 10.1% [ 29 ] from all the selected articles combined. In the same year, another study was conducted in a different region of Ethiopia and reported an awareness level of 84.2% [ 27 ]. About 41.5 and 69.9% awareness level were recorded from two studies from different regions in Ethiopia in the year 2014 [ 30 , 32 ]. In 2015 and 2019, other studies reported a level of EC awareness as 67.8% [ 34 ] and 93.5% [ 40 ].

A study in Ghana recorded a level of awareness of 51.4% in the year 2009 [ 24 ]. Two years down the line, another study from Ghana recorded an increase in the level of awareness to 57% [ 26 ]. A study conducted by Amalba et al. (2014) [ 31 ] in Ghana recorded a level of awareness of 69.0%. whiles a cross-sectional study conducted in Ghana in the year 2019 recorded a level of awareness of 86.9% [ 17 ]. A qualitative study was conducted in Ghana with 32 participants of which the majority (26) of the participants were aware of EC [ 14 ]. Figure 1 shows the trend of increase of the level awareness in Ghana over the years from the included articles.

A 63% level of awareness from 664 respondents was recorded from a study conducted in Cameroon to evaluate the knowledge, attitudes, and experiences on EC pills by the university students [ 23 ]. A study to examine EC use among female sex workers in Swaziland sampled 325 participants and reported that 27.5% of these workers aware of EC [ 33 ]. A cross-sectional study conducted in Senegal reported the level of EC awareness to be 20% out of 9614 study participants [ 34 ]. A study conducted in DR Congo was qualitative hence inference could not be made to the population. The number of participants that were aware of EC was not clearly stated because the study reported that few participants were aware of EC [ 39 ].

Use of emergency contraceptives among women of reproductive age in sub-Saharan Africa

Use of EC among women of reproductive age in SSA reported by the various studies included in this review ranged from as low as 0% [ 29 ] to as high as 541% [ 36 ] from Ethiopia and Nigeria respectively. The two qualitative studies reported non-use of EC from DR Congo [ 39 ], and 81.3% use from Ghana [ 14 ]. Even though the study settings and participants differed, some countries recorded use of EC above 30% [ 20 , 26 , 36 , 37 , 40 ]. Table  4 shows the level of EC use extracted from the selected articles used for the review.

When three or more studies were reported on EC use on a country for different years, a trend analysis was done to examine the pattern of EC use (Fig.  2 ). A qualitative study conducted in Ghana reported 32 of 36 (81.3%) participants to use EC [ 14 ]. The lowest level of EC use reported from Ghana from the selected review studies was 4.2% [ 24 ], while the highest was 41% in the year 2011 [ 26 ]. After the year 2011, Ghana experienced a decreasing trend [ 17 , 31 ] (Fig. 2 ).

Emergency Contraceptive Use Trends in four sub-Saharan countries

Three studies from Nigeria recorded over a 30% level of EC use [ 20 , 36 , 37 ]. The highest level of EC use in Nigeria from the selected studies was 54.1% which was also the highest recorded from the included review articles This study sampled 1328 participants and 718 reported to have used EC [ 36 ]. Compared to the level of awareness recorded in this same study, the level of use was relatively lower. Nigeria recorded the lowest level of EC use of 2.3% in 2003 [ 16 ], which increased to 31% in the year 2005 [ 20 ]. In the year that followed, a study in Nigeria reported a drop to 12.9% [ 21 ]. Two studies conducted in 2014 from Nigeria reported the level of EC use of 6.3% [ 15 ] and 17% [ 18 ]. Two years later, two studies included in this review from Nigeria reported the levels of EC use of 54.1% [ 36 ] and 30.4% [ 37 ]. Figure  2 shows the trend of EC use in Nigeria over the years from the included articles. The highest level of EC use recorded in Ethiopia from the selected studies was 30.8% [ 40 ]. In the year 2012, another study from Ethiopia that was included in this review recorded 0% EC use [ 29 ]. In the year 2014, two studies conducted in Ethiopia reported levels of EC use of 9.7% [ 30 ] and 10.8% [ 32 ] (Fig. 2 ).

Types of emergency contraceptives used among women of reproductive age in sub-Saharan Africa

Concerning the types of EC used, some of the selected studies did not report on any specific type of EC: these studies reported on “All” types of EC. About 13 out of the 27 articles reported on “All” EC since they were not specific as to the type they were reporting on [ 15 , 18 , 19 , 22 , 23 , 26 , 27 , 30 , 31 , 32 , 33 , 34 , 36 ]. Some selected articles for the review reported on several types of EC and some other non-EC methods that were used. The non-EC types used were: Menstrogen, Brown codeine, Ampicillin, Quinine, Ergometrine, Gynaecosid, antibiotics, and Cytotec [ 16 , 21 , 38 ]. All the studies that reported non-EC methods were conducted in Nigeria. It was reported in these studies that normal contraceptives were used sometimes as EC by increasing the dosage. A study from Nigeria also reported the likes of Andrews liver salt, thiazamide (MNB 760), Alabukun (local aspirin), salt and water, alcohol, lime, potash, and yoyo bitters being used as EC [ 38 ]. Table  5 contains a summary of the types of EC used by women of reproductive age in SSA.

The most commonly used EC types from all the studies in SSA used in this review were: Postinor 2 [ 14 , 20 , 21 , 24 , 37 , 38 ], Emergency contraceptive pills [ 2 , 16 , 25 , 28 , 29 , 35 , 40 ], and IUCDs [ 17 , 24 , 25 , 28 , 29 , 35 , 40 ]. Few of the selected studies reported that participants did not know the type of EC that was used or could not remember at the time of the study [ 25 , 37 ].

The awareness of ECs varies across countries, with the highest awareness rates of 93.5% recorded in Ethiopia [ 40 ].

Generally, the level of awareness on EC among women of reproductive age in SSA has been on the rise. A study by Robert et al. (2004) [ 41 ] from South Africa reported the level of EC awareness to be 57%, which is higher than that recorded by Hoque and Ghuman (2012) [ 28 ]. The reported level of EC awareness from the other selected studies conducted in South Africa were 16.6% [ 19 ], 30% [ 22 ], and 49.8% [ 28 ]. These differences could be accounted for the differences in specific questions asked to capture awareness levels regarding EC, as well as the target population. Awareness of EC among university students in Ethiopia, who are believed to have better knowledge and awareness of EC were below 50% [ 42 , 43 , 44 , 45 ]. This disconnect between high levels of education and low awareness rates could be explained by lack of EC education in comprehensive education package, as well as sub – optimal health education from the health care system. Concerning the age distribution of the study participants from the various included study articles of this review, 18 out of 27 articles reported the majority of their participants were between the ages of 20–24 years [ 14 , 16 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 28 , 30 , 33 , 35 , 36 , 38 , 39 ]. This was followed by the age group of over 24 which was reported as the majority of their participants for 5 out of the 27 included review articles [ 15 , 17 , 18 , 22 , 34 ]. The remaining articles (4 out of 27) reported below 20 years as the majority of their study participants signifying the adolescent group [ 27 , 29 , 37 , 40 ]. Based on the majority of the study participants of all the included articles in this review, it suggests that the level of EC awareness was higher in 20–24 years age group compared to that of above 24 years. This could be as a result of the 20-24 years age group having more access tertiary institution that can make information on the method readily available to them rather than the adolescent age group (15–19 years). Also the African society frowns on sexual activities by the young adult, therefore there is an inherent limit on the amount of information an adolescent can get on contraception including ECs [ 46 ].

Emergency contraceptive pills (ECPs) are now available in many countries but have failed to have the desired impact on unwanted pregnancy rates in the world especially in Africa [ 47 ]. Earlier barriers of access to EC are becoming less and less prevalent [ 48 ]. Emergency contraceptives is an essential, although often underutilized family planning option in most parts of the world including SSA. In SSA, where access to formal health care and family planning services remains limited, ECs, which are often accessed through private sector pharmacies have emerged to play an important role in preventing unwanted pregnancies. Evidence from this review is contrary to claims in some settings that the use of EC is widespread. For instance, media reports of overuse in Nigeria and Kenya are not supported by the relatively low levels of use found in these countries compared to the high level of EC awareness [ 15 , 16 , 18 , 21 , 38 ]. The findings of this study demonstrate that the trends of EC use differed from patterns of awareness. The findings from this review are in line with the report from the UN, which states that Africa has a low use of contraceptives including EC [ 49 ].

The low use of EC over the years can be a result of population increase, decreased access to services, or discontinuation of the method by users. Further studies need to be conducted to ascertain and understand the low use of EC despite its increased awareness among women of reproductive age in SSA. There was a relatively lower use of EC compared to the level of EC awareness in all the included review studies. This gives a clear indication that knowing or being aware of the contraception methods is not the only factor necessary or responsible for their use. Factors that influence the uptake or use of EC can be explored to help understand the reasons for the low level of EC use. Sub-Saharan Africa is a region with a strong culture and norms. This can be the reason why the use of EC is still generally low. The generally low level of EC use among women of reproductive age in SSA can be a reason why unintended pregnancies in Africa as a whole is still high. People in SSA have high levels of awareness of EC but relatively lower usage.

With the majority of study participants from the included review studies being in the 20–24 years age group, it also suggests that EC users in SSA are predominantly found in this age group more than adolescents and people over 24. This could be as a result that, people over 24 years might be married and hence might not need to use ECs as much as the 20–24 years. This same age group (over 24 years) are more matured and hence might practice safe sex. Adolescent age group on the other hand, might be sexually active but might lack the funds to acquire an EC on the market [ 46 ].

The review found out that some studies reported that normal contraceptives were used sometimes as EC by increasing the dosage. A worrisome observation was the wrong identification of Menstrogen and Gynaecosid as EC in some of the included review studies [ 16 , 21 , 38 ]. Menstrogen, which is an Oestrogen-only pill used in the treatment of conditions related to low hormonal levels was reported by studies as a used type of EC [ 16 , 21 , 38 ] . Gynaecosid, which is recommended for the treatment of amenorrhoea was reported to be used as EC [ 16 , 38 ]. These included review studies that reported the use of Menstrogen and Gynaecosid as EC were all from Nigeria [ 16 , 21 , 38 ]. The effectiveness of Menstrogen and Gynaecosid when used as an emergency contraceptive requires use in high doses and hence harmful to the health of the user. Also, Menstrogen and Gynaecosid are not effective in preventing pregnancies like regular ECs on the market such as Levonorgestrel-only pills [ 50 ].

A study from Nigeria also reported the likes of Andrews liver salt, thiazamide (MNB 760), Alabukun (local aspirin), salt and water, alcohol, lime, potash, and yoyo bitters being used as EC [ 38 ]. This phenomenon of using non-conventional method as EC methods could be as a result of traditionally or locally accepted methods of emergency contraception in SSA. The variety of options used seems to vary from region to region in SSA. This can also be a reason why unintended pregnancy is high in SSA since some of the non-EC methods used cannot prevent pregnancy. A qualitative study conducted in DR Congo also revealed that the participants used other methods and mechanisms as their abridged version of EC. The study reported methods like douching, drinking salted water or sodas, using herbal concoction, jumping hard, antibiotics, deworming medicines (Décaris, Tanzol), and antimalarial medicines (quinine, tetracycline) as EC [ 39 ].

The types of EC used were not known by some of the participants and some could not remember the type used. This can also serve as a reason for the low use of EC in SSA. The type of EC used by most of the participants in this review was Postinor 2 [ 14 , 20 , 21 , 24 , 37 , 38 ]. Others included ECPs, and IUCD [ 16 , 17 , 21 , 24 , 25 , 28 , 29 , 35 , 40 ].

These included review articles depict that women of reproductive age might have little knowledge on types of EC available in their region.

The emergency contraceptive awareness and use dichotomy

This study observed that women in their reproductive age were aware about EC (about 93.5%). Although they generally had high EC awareness levels, some of the included research articles suggested that their awareness lacks depth and this could be attributed to their backgrounds. Among women who have heard of EC were those who have ever used contraceptives and have higher educational qualifications. On the other hand, this was suggesting that people with lower educational background and non-contraceptive users were less likely to use EC method. Other factors that could be associated with level of EC awareness and its use were the place of residence, age of respondents, marital status and nulliparous women. In the case of place of residence, those who reside in urban areas are more likely to know about EC than their counterparts who reside in rural areas and also more likely to have availability of the method to also promote it use. These above factors listed above could be the primary reasons to why the level of EC awareness in SSA were high compared to the level of EC use.

Further studies can be done to find out the effect of demographics such as age, place or residence, type of job and marital status on the Awareness and use of EC to answer questions such as; does the age and income level of a woman in reproductive age affect the use of EC and its awareness, are single women more likely to use EC compared to married women, and factors that influence the uptake of EC in SSA.

Some other studies have examined both awareness and use of EC and identified a gap between awareness and use of EC, for example Jackson et al. (2000) [ 51 ] in the U.S.A., Sorensen, Pedersen & Nyrnberg (2000) [ 52 ] in Denmark, Aneblom, Larsson, Odlind & Tyden (2002) [ 53 ] in Sweden and Korea by Kang & Moneyham (2008) [ 54 ]. Such observations (gap between awareness and use of EC) have also been made in Africa such as Nigeria by Zeleke, Zebenay & Weldegerina (2009) [ 55 ]; Kagashie et al. (2013) [ 56 ], Kolawole, Abubakar & Zaggi (2015) [ 57 ], Tanzania by Kagashe et al. [ 56 ]. Ghana by OseiTutu, Aryeh-Adjei & Ampadu (2018) [ 58 ] and in South Africa by Roberts et al. (2004). In all these studies, a greater proportion of the respondents knew of EC than the proportion that used it. Furthermore, a smaller proportion knew of the recommended time frame for its use. These findings are similar to what this current study is pointing out; EC Awareness is generally higher than usage of EC. The 20–24 years age group generally are more aware of ECs [ 59 – 65 ].

The implication of these the included research articles could be that the respondents used in these studies could be fairly young and mostly unmarried. They are also the ones who are likely to experience unplanned pregnancies and abortions because they have the tendency to be sexually active. Understanding the discrepancy between high awareness levels and underuse of ECs is a subject of public health relevance. Being aware of EC does not guarantee its use. The reasons could be attributed to general lack of in-depth knowledge and misconceptions about their usage. There is also a probability where the context (SSA) in which this method will be used generally frowns upon sexual activities among the youths of the society and hence, women therefore do not want to use the method because it speaks to the society about, they being sexually promiscuous. Further studies could be done to find out the effect of culture, religion and believes on the use of contraceptive methods. Also, studies to understand commonalities and differences between regular contraceptives and ECs, why regular contraceptives are used as ECs in SSA and understanding traditional emergency contraceptives and its effectiveness to prevent unwanted pregnancies.

The identification of non-EC methods used by some of the study participants could also be as a result of some factors such as peer pressure, availability of EC method, cost, and lack of knowledge on EC methods. Further research can be done to find out the factors that contributes or enable the use of non-EC methods in SSA. A comparative study can also be conducted to find out why, certain groups of people prefer and use EC methods and why others do not.

Self-report of EC awareness and use was used in the included review studies. Overall, the highest and lowest rates of both EC awareness EC use were recorded from Ethiopia and Nigeria [ 29 , 36 , 40 ]. This could be explained by the various demographics of the study area participants and place the study was conducted. The study that reported the highest and lowest level of EC awareness and use had participants with demographics such as age, religion, place of stay, number of children, living with, parents’ education, marital status, occupation and educational status. When these studies [ 29 , 36 , 40 ] are compared, it could be suggested that, the rates of EC awareness and use may have been influenced by the demographics of the study population. Each of these demographic variables could cause the rates to increase or decrease. Also, the data collection tools used in the individual included research articles could also have accounted for the rates of EC awareness and use. For example, the study conducted by Tesfaye, Tilahun, and Girma (2012) [ 29 ] which recorded both the lowest rates of EC awareness and use, data was collected by researcher administered questionnaires. It could be that the participants were not comfortable sharing their sexual history with a stranger, or feared others might hear of what they are saying. Hence, participants gave answers that might be socially accepted and hence not entirely the true representation of rates of EC awareness and it use. In the context of SSA, where culture and society does not widely accept sexual association to the young and upcoming ones, this could have led to the participants of the studies giving socially accepted responses.

This review has some limitations:

The selected studies used in this study were conducted among different population or similar but at different times and intervals. There is need to adopt a standardized data collection tool to capture awareness and usage patterns of ECs. The inclusion of exclusively articles published in the English language could be a source of bias, as studies published in French, Spanish, Arabic, Portuguese speaking countries were excluded.

Although variations do exist between countries in SSA according to the year of study, the general level of EC awareness has been increasing. The level of awareness and use of ECs in SSA amongst women of reproductive age (15–49 years) was highest amongst the 20–24 years age group compared to the adolescents (15–19 years) and over 24 years group. However, the level of EC use was lower compared to the level of awareness. Sub - optimal use of ECs is a lost opportunity to prevent unintended pregnancy and unsafe abortions. It is relevant to understand the similarities and differences regarding the facilitators and barriers to the use of ECs and other types of contraceptives to allow for the design of more targeted interventions to improve use. Understanding the mismatch between high levels of awareness and low levels of use of ECs is an important area for future research.

Recommendations

Given the extremely high rates of awareness of emergency contraceptives in many of the countries studied, programmes should continue to focus on disseminating accurate information about the method, both in the general population and the vulnerable groups and those identified in this review as being unlikely to have heard of it. This will help to dispel any fears of the side effects and other misconceptions about EC and promote its use. Health promotion strategies should also be directed towards improving EC and other contraceptives utilization among the sexually active youth as part of the package of comprehensive reproductive health in tertiary schools. These health promotion campaigns should also make room for people in this age group who are out of tertiary schools. This could improve the awareness level of women of reproductive age (15–49 years) who are still in or out of schools. Promotion and advance provision of EC to the students would very likely enhance their use, just as in developed countries.

It is also recommended that governments, donors, and the non-governmental sectors should focus on meeting the need for ECs to meet the reproductive health needs of women of reproductive age in SSA countries by providing this group of people with ECs for free or at very reduced rates to encourage its usage. Health promotion strategies should be used to sensitize the general population about the need for EC to help reduce medication-related discrimination and stigmatization Further studies should be conducted to help provide more detailed investigations of social, cultural, and economic factors at work in these countries to fully make sense of differences, particularly by age and marital status that influence the use of EC in SSA. Case studies might also be useful in describing how countries such as Ethiopia and Nigeria achieved usage above 30% that was identified in this review.

Availability of data and materials

All articles included in the final review have been carefully cited.

Abbreviations

Intrauterine contraceptive device

• Sub – Saharan Africa
• Emergency contraception

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Kwame, K.A., Bain, L.E., Manu, E. et al. Use and awareness of emergency contraceptives among women of reproductive age in sub-Saharan Africa: a scoping review. Contracept Reprod Med 7 , 1 (2022). https://doi.org/10.1186/s40834-022-00167-y

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Contraception and Reproductive Medicine

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The context of emergency contraception use among young unmarried women in Accra, Ghana: a qualitative study

• Slawa Rokicki 1 &
• Sonja Merten   ORCID: orcid.org/0000-0003-4115-106X 2 , 3  

Reproductive Health volume  15 , Article number:  212 ( 2018 ) Cite this article

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Over the past decade, awareness and use of emergency contraceptive pills (ECPs) among young women has rapidly increased in Ghana; however, the rate of unintended pregnancy among this group remains high. We conducted a qualitative study to better understand the context and patterns of ECP use among young unmarried women in Ghana.

We conducted in-depth interviews with unmarried sexually active women aged 18–24 in Accra, Ghana to explore their perceptions, experiences, and opinions regarding sexual relationships and contraceptive methods, and to examine the factors that influence choice of ECPs. A total of 32 young women participated in the study.

Most participants had used ECPs at least once. Participants described being unable to plan for sexual encounters, and as a result preferred ECPs as a convenient post-coital method. Despite being widely and repeatedly used, women feared the disruptive effects of ECPs on the menstrual cycle and were concerned about long-term side-effects. ECPs were sometimes used as a back-up in cases of perceived failure of traditional methods like withdrawal. Misinformation about which drugs were ECPs, correct dosage, and safe usage were prevalent, and sometimes spread by pharmacists. Myths about pregnancy prevention techniques such as urinating or washing after sex were commonly believed, even among women who regularly used ECPs, and coincided with a misunderstanding about how hormonal contraception works.

Conclusions

ECPs appear to be a popular contraceptive choice among young urban women in Ghana, yet misinformation about their correct usage and safety is widespread. While more research on ECP use among young people is needed, these initial results point to the need to incorporate information about ECPs into adolescent comprehensive sexuality education and youth-friendly services and programmes.

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Plain English summary

Over the past decade, awareness and use of emergency contraceptive pills (ECPs) among young women has rapidly increased in Ghana. However, the rate of unintended pregnancy among this group remains high.

In this study, we interviewed unmarried women aged 18–24 in Accra, Ghana to understand when, how, and why they use ECPs. A total of 32 women participated in the study.

Most participants had used ECPs at least once. Participants described being unable to plan for sexual encounters, and as a result preferred ECPs because they can be taken after sex. Despite being widely and repeatedly used, women feared that ECPs would cause them harm by disrupting their menstrual cycle and were also concerned about long-term side-effects. ECPs were sometimes used as a back-up in cases when women used a traditional method like withdrawal, but were worried that it had not been effective. Women were also misinformed about which drugs were ECPs, and the correct dosage and safe usage of ECPs. Pharmacists were sometimes the source of the wrong information concerning ECPs. Myths about pregnancy prevention techniques such as urinating or washing after sex were commonly believed, even among women who regularly used ECPs.

In conclusion, ECPs appear to be a popular contraceptive choice among young women in Accra, yet misinformation about their correct usage and safety is widespread. While more research on ECP use among young people is needed, these initial results point to the need to incorporate information about ECPs into adolescent comprehensive sexuality education and youth-friendly services and programmes.

Worldwide, 44% of pregnancies are unintended [ 1 ]. Unintended pregnancies increase risk of maternal and infant mortality and morbidity, as well as reduce women's prospects for education and employment [ 1 , 2 ]. In sub-Saharan Africa (SSA), 30–43% of unintended pregnancies end in induced abortion, where 3 out of 4 abortions are classified as unsafe [ 1 , 3 ].

Emergency contraceptive pills (ECPs) are an essential element of contraceptive services to reduce risk of unintended pregnancy. ECPs are indicated for women who have had unprotected sex, for example due to method failure, incorrect use or non-use of contraceptives, or sexual assault [ 4 ]. They have been developed and marketed as an “emergency” or “back-up” method in order to discourage regular use [ 5 ]. Over the past decade, knowledge and use of ECPs has increased in many SSA countries, particularly among unmarried women in urban areas [ 6 ]. As access to ECPs has increased, studies have found that young women may prefer emergency contraception to long-term methods of contraception, as a convenient post-coital method with fewer side effects [ 5 , 7 , 8 , 9 ].

In Ghana, 80% of sexually active unmarried women knew about emergency contraception in 2017, up from 49% in 2008 [ 10 , 11 ]. In 2017, ECPs were the most commonly used method of contraception (either modern or traditional) among sexually active unmarried women aged 20–24 [ 10 ]. Other recent studies show similar findings. A 2018 study of youth aged 15–24 in Ghana found that ECPs were the second most popular modern or traditional method among women, next to condoms [ 12 ]. A 2016 study of female Ghanaian university students found that 63% had heard of ECPs and 37% had used ECPs [ 13 ]. A 2014 study of ECP awareness and use in the northern region of Ghana found that 69% of women aged 15–49 were aware of ECPs; among these, 40% had ever used them [ 14 ].

Yet, while use of ECPs has increased among young women, sexual and reproductive health (SRH) indicators have not improved. Results from the 2017 Ghana Maternal Health Study found that nearly half of women aged 20–24 began having sex before age 18, yet less than a third of sexually active unmarried women use a modern form of contraception [ 10 ]. In this context, the rate of unintended pregnancies is high: about 16% of women aged 20–24 have ever had an induced abortion, and a third of births to women aged 20–24 are mistimed or not wanted at all [ 10 , 15 ]. About 14% of women aged 15–19 have begun childbearing, a proportion that has remained stagnant since 1998 [ 10 ].

Given the growing awareness and use of ECPs in Ghana and other countries in SSA, it is important to examine why increased use of ECPs has not translated into improved SRH among young women. The aim of this qualitative study is to better understand the context and patterns of ECP use among young unmarried women in Accra, Ghana. We explore women’s perceptions, experiences, and opinions regarding sexual relationships and contraceptive methods, and examine the factors that influence choice of ECPs. Finally, we discuss our results in the context of expanding sexuality education curricula as well as national reproductive health policy guidelines to incorporate information about ECPs.

Study setting and participants

This study was conducted in April 2016 in Accra, Ghana. The participants were drawn from a sample of participants who completed a randomized controlled trial in Ghana that investigated the effectiveness of sexuality education text messaging programs on knowledge of SRH and on sexual behaviour [ 16 , 17 ]. Briefly, the original study sent informational text messages about reproductive health to participants for 12 weeks. The inclusion criteria for the original trial was girls aged 14–24 in their second year of secondary school in the Greater Accra region. Participants completed self-administered questionnaires at baseline, midline (3 months later), and endline (15 months later).

The study found that the text messaging programs improved knowledge of reproductive health, but did not have a clear and significant impact on sexual behaviour or use of contraception, compared to the control group. In order to further understand the results of the study, we conducted in-depth interviews one year after the end of the original trial. We used purposive sampling, inviting women who were in the treatment arms of the original trial (i.e. had received sexuality education text messages) and who had reported that they had sex in the past year at endline. We also sampled those who claimed they had ever been pregnant at endline in order to understand the contexts of those pregnancies.

Study design

We conducted in-depth individual interviews following a topic guide. Topics included perceptions about community norms surrounding sex and contraception, personal sexual experiences, attitudes about and experiences with use of modern and traditional methods of contraception, perceptions of barriers to use of contraception, experiences with pregnancy and abortion, experiences and community norms surrounding ‘sexting’ (exchanging explicit sexual messages via mobile phones), and feedback on the text messaging program they were involved in. The average interview length was 53 min with a range of 32 min to 1 h 34 min.

Interviews were conducted in local language (Twi, Ga, or Ewe) or English based on respondent preference. Two female interviewers of about the same age as respondents were trained on qualitative methods of interviewing in a 2-day training. Training materials were adapted from a field guide created by Family Health International [ 18 ]. Interviews were audiotaped, and then translated into English and transcribed simultaneously by a professional Ghanaian translator. To ensure validity, the senior field manager verified a sample of the translations.

We obtained written informed consent from each participant. Participants were informed that participation was voluntary, they could stop the interview at any time, and data would be treated confidentially. The recorded interviews did not include the participant’s name. As a token of appreciation, every respondent received 5GHC in airtime phone credit (about 1.30USD). Participants were also provided a free hotline phone number, operated by Marie Stopes International, in case of any further questions or concerns about SRH or their health. Institutional Review Board (IRB) approval was granted by the Committee on the Use of Human Subjects in Research at Harvard University (IRB13–1647) as well as the Ghana Health Service Ethical Review Committee (GHS-ERC:05/09/13). Thirty-two women signed a letter of consent and the final sample included all 32.

Data analysis

The interviews were analyzed using a thematic approach that allowed for themes to emerge through an iterative process of coding and discussion [ 19 ]. A preliminary list of codes was created using the topic guide. Transcripts were then independently reviewed by two members of the research team who assigned preliminary codes. The research team members met and discussed their findings, and codes were subsequently added, removed, and refined during these discussions. This process continued until the research team agreed on the final themes and categories. To ensure reliability, all cases of conflicting results were discussed thoroughly in an open process until consensus was reached. This process included comprehensive data treatment and deviant case analysis, in which research team members actively sought out and identified similarities and differences across accounts to ensure different perspectives were represented [ 20 ].

Data management and analysis were conducted using the computer software package NVivo™ software Version 11 (QSR International, Doncaster, Victoria, Australia). The study preserved a well-documented audit trail of materials to ensure transparency.

The demographic characteristics of the participants are shown in Table  1 . Participants were between 18 and 24 years of age. All 32 participants were unmarried; however 97% were in a relationship. The median age at first sex was 18 years. Six participants had gotten pregnant since becoming sexually active; all six had an induced abortion. None of the participants had children.

The most common forms of contraception that participants had tried at least once were condoms and ECPs, followed by withdrawal and using a menstrual calendar. Only 5 participants mentioned using oral contraceptive pills (OCPs) and only 1 had used an injectable. The most common ECP brand was Postinor-2® (Levonorgestrel); others that were mentioned were Lydia Postpil® (Levonorgestrel), Lenor® (Levonorgestrel), and (incorrectly) Primolut-N® (Noresthiesterone). Primolut-N is misused off-label as an ECP or a pre-coital contraceptive in Ghana [ 4 , 21 , 22 ].

Themes arising from the interviews are shown in Table  2 . The major themes that emerged were “unwanted and unplanned context of sexual encounters”, “popularity of ECPs”, “ECPs as back-up for traditional methods”, “negative perceptions of side effects of ECPs”, “misinformation about ECPs”, “negative perceptions of condoms”, and “misunderstanding of human reproduction and contraception”.

Unwanted and unplanned context of sexual encounters

Participants described sexual encounters as largely unplanned for a variety of reasons. Coerced or pressured sexual encounters were mentioned by the majority of participants, either as something they experienced themselves or something they noticed in the community. While six participants described having been physically forced into sexual activity, most described these encounters as partners putting pressure on them to have sex over time. Participants described their first time having sex as necessary to prove their love to their partner or else risk dissolution of the relationship.

“Well, to me, he was like, we should try it. And I said, no, I wasn’t ready for that. He was like, “for the first time then…” – as for him he thinks I don’t love him because we’ve dated for 2 years without sex.” (Age 21)

Many participants also described sex as an obligation in return for financial benefits. Participants described feeling indebted to boyfriends who provide schooling fees or take care of them financially, and feeling that eventually they had to repay the boyfriend with sex. One participant said,

“Because of the hardship I was going through that was why I went in for a guy, so if he provides my basic needs then if he ask me for sex and maybe I don’t give him, I will think he will go for another girl, which means I will forgo my basic needs.” (Age 22)

Another participant described a common situation in her neighbourhood:

“Girls may need something like pads, when you ask your mother and she doesn’t get it for you, you will definitely go and ask a guy. He will give it to you but not for free. It’s only a few that will do that for free. When he gives you today, tomorrow he will demand he have sex with you first.” (Age 18)

Finally, participants described sexual encounters, even wanted, as unexpected. Unplanned encounters happened with both regular partners and via casual sex. For example, a participant described her inability to plan for sex:

“I think sorry to say, you don’t prepare to have sex, that’s why I did it. We don’t prepare to have sex. You can say you’re not going to have sex with your man or your woman or your wife; but it is feelings…Yes, you can just have sex without knowing. You know you are doing something but you can’t control it, because it’s sex. Yes. So, that’s what happened.” (Age 20)

Previous research has found that when sexual encounters are unplanned, particularly with an imbalanced gender dynamic, young women are less able to control their sexual experiences including the use of condoms and other preventative forms of contraception [ 23 , 24 ].

Popularity of ECPs

Twenty-six of the 32 participants had used ECPs at least once. The most common brand was Postinor-2. Participants felt that ECPs were easy to take since they could be taken after having sex, rather than planning for it. Others said that aside from condoms, Postinor-2 was the only type of contraception (outside of condoms) they knew about. A number of participants mentioned hearing recommendations about ECPs from friends or aunties. Upon being asked why a participant chose to use Postinor-2, she replied,

“That was the only one I know of… I asked my friend and she told me that one was very good so I should try it. So when I tried it I realized it was good.” (Age 20)

Additionally, some participants preferred ECPs so that they could take it without their partner’s knowledge. Some participants described how a partner wanted them to become pregnant, even though they were not ready, so they took ECPs without informing their partners. One participant described her situation:

“For him he said he wants a child but I told him I’m not ready yet so if I tell him to do [use a condom], he wouldn’t do it but on my side, I prevent myself [from getting pregnant].” (Age 22)

Finally, some participants chose to use ECPs over OCPs because they felt they could not trust themselves to remember to take a pill each day. One participant said,

“I chose Postinor-2 because the other ones I know; something like Secure [a brand of OCP] they said you will take it every day. And when you missed one day you can get pregnant. So I prefer Postinor-2 after having sex within 72 hours you have to take it. So after me having sex then I take it and then I would be free. I prefer that than Secure because I may not get the time to take the medicine everyday.” (Age 19)

ECPs as back-up for traditional methods

While the majority of participants had attempted traditional calendar or withdrawal methods, they also described being fearful of the inefficacy of these methods. Many did not trust men to practice withdrawal correctly, and were afraid of becoming pregnant after its use. Some participants discussed taking ECPs after a perceived failure of withdrawal; for example, one 20-year-old participant had the following exchange with the interviewer:

Respondent: I think when the guy is about to release, the lady realizes but the guy because of the fantasies it doesn’t occur to him then he will release inside and pretend as if he didn’t. Interviewer: So using this method that you are saying you have used before were you scared of getting pregnant? Respondent: I was really scared. Interviewer: So what did you do? Respondent: It was after that I went to buy Postinor-2 and took it just to prevent anything.

Similarly, for the calendar method, many participants described not understanding how to calculate their safe period, particularly when their menstrual cycle changes. At the same time, participants were eager to understand these methods and felt that they had not been provided any information on them.

Negative perceptions of side effects of ECPs

Fears, dislikes, and misunderstanding of hormonal methods (both OCPs and ECPs) were mentioned by most participants. Participants mentioned both a dislike and a fear of any change in the schedule or heaviness of flow of their menses. Participants admitted that they were not sure about side effects of hormonal methods, and during the course of the interview, a few asked about the side effects of ECPs in particular. A number of participants mentioned fear of hormonal pills, including ECPs, as damaging the womb and preventing future ability to conceive. One participant explained,

“Definitely, everything has its disadvantage. I have learnt that taking too much of Postinor-2, it will come to a time you can’t give birth.” (Age 18)

Other participants believed that taking too many pills would lead the participant to become “addicted” to them in such a way as for the contraception to become ineffective at preventing pregnancy. One participant discussed why she stopped taking Postinor-2:

“Because if you continually take the tablets or the pills, it will get to a point where your body becomes used to; so it would not work… And also I know that it will get to a point where I will get complications with it because in everything there is a bad side and there is a good side. So I can say I’m using [Postinor-2] to prevent pregnancy but maybe I may develop some infections from it. So I’ve stopped using it.” (Age 19)

While both ECPs and OCPs elicited similar reactions, ECPs appeared to be more tolerated, most likely due to the low number of pills (usually two) and therefore the relatively short-term effect they had on the menstrual cycle as compared to OCPs. Participants did not mention dosage at all; instead taking “too much” medication referred to taking too many individual pills. One respondent mentioned that she had thought about taking OCPs but was concerned about how taking a pill every day would impact her health. The idea that taking a medicine occasionally rather than daily would imply that the health impact is less has been found in other studies of ECPs in West Africa [ 25 ].

Misinformation about ECPs

Misinformation about how to safely use ECPs was prevalent among participants, some of which was spread by pharmacists. For example, one participant described why she stopped using Postinor-2:

“Where I’ve been buying [Postinor-2], the pharmacist advised me that Postinor-2 must be taken [just] once in a year. That’s what he told me.” (Age 22)

Some participants were confused as to how to take ECPs, for example, they described taking both pills of Postinor-2 at the same time (whereas the correct dosage is one pill as soon as possible after unprotected sex, and the second pill 12 hours later). Pharmacists also misinformed participants about how to correctly take ECPs. There was also confusion among participants as to which drugs were ECPs. As previously mentioned, Primolut-N, which is indicated for treatment of endometriosis, menorrhagia and dysmenorrhea, is used off-label both as a pre-coital method and an ECP in Ghana, though the effectiveness has not been studied and no health organization or agency has recommended its use [ 4 , 21 , 22 ].

About half of participants mentioned difficulty in buying ECPs at drug shops due to their own shyness, the cost, or the pharmacist’s refusal to sell it, while the rest thought it was easy to acquire.

Negative perceptions of condoms

Participants had largely negative perceptions and experiences with condoms, a finding consistent with previous qualitative literature [ 26 ]. First, many participants felt that condoms represent distrust and lack of love and commitment in a relationship. One participant said about asking a partner to use a condom:

“Some would say maybe if you use – maybe if you tell the man, he will say you are not that into me that is why you want us to use the condom, that’s what I really know. Somebody will say you don’t love me that’s why you are saying or maybe you think I have a sickness that’s why you want us to use a condom.” (Age 22)

Use of condoms also represented promiscuity on the part of women; participants said that if a male partner wanted to use a condom, it was because he thought the woman was cheating or, in one participant’s opinion, that he thought of the woman as a prostitute.

Additionally, a number of participants mentioned a lack of trust in the effectiveness of condoms. Participants feared that condoms may easily tear and burst. Some participants were fearful of the condom tearing without their knowledge and resulting in unintended pregnancy; one participant mentioned that a condom bursting would be harmful to the womb.

Finally, 23 of the 32 participants mentioned that condoms reduce the pleasure of sex, either as their own opinion, their partner's opinion, or as community norms. Many participants mentioned the analogy of using condoms to “eating toffee in a wrapper”. Similar findings were found among studies with youth in Uganda [ 27 ], South Africa [ 28 ], and Nigeria [ 29 ], and among married women in Malawi [ 30 ].

Misunderstanding of human reproduction and contraception

Participants in general had a considerable misunderstanding of the biological process of how women become pregnant, leading to a wide variety of pregnancy prevention myths. Common myths included drinking a large amount of water or a sugary beverage to “urinate out” sperm, standing up quickly after sex, using a finger to pull out the sperm, and taking paracetamol. Similar myths have been documented in previous studies in both Ghana and other countries [ 5 , 31 , 32 ]. The myths also coincided with misunderstandings about how hormonal contraception works. For example, one 18-year-old participant described using ECPs regularly in order to prevent pregnancy. When asked how ECPs worked, she said,

“After sex when you take those ones it washes away the sperms from your system. It comes in a form of urine.”

Then she went on to describe preventing pregnancy when she does not use contraception:

“But sometimes, it’s when I don’t take the [EC] pill. I drink a lot of water after sex. … It also helps me urinate [the sperm out]”

Other participants described similar misunderstandings regarding how ECPs work, and in general, the way that hormonal contraceptives work to prevent a pregnancy was not known to most participants. Most participants felt that they had not received enough education about SRH. At the time they began having sex, many participants said they were in Junior High School rather than Senior High School, and that therefore their education on sexual health was inadequate. While average age at first sex is 18 years for girls in Ghana, it is common for girls around this age to be attending Junior High School due to late entry to school, repetition, and drop out and drop in [ 33 ].

The results of this study provide evidence on how the context of sexual encounters and the perceptions and experiences of contraception among young sexually active unmarried women in Accra, Ghana influence the use of ECPs. A number of important conclusions emerged. First, sexual encounters are often unwanted or unplanned. Young women rely on their partners financially for school fees and personal items, providing sex in return. This may reduce women’s control over the use of condoms and preventative methods of birth control, and drive women towards the use of ECPs which are within their sphere of control. A review of 45 quantitative and qualitative studies in SSA found that adolescent girls engage in sexual relationships with older men for financial benefits; while girls have, to a great extent, control over choice of partners, duration of relationships, and the start of sexual relations, they have little control over sexual practices within partnerships including condom use and violence [ 24 ]. Second, despite the widespread use of ECPs among participants, ECPs are nevertheless mistrusted due to the disruptive effect they have on the menstrual cycle. There is a pervasive belief that taking too many hormonal pills will have a negative effect on future fertility; there is also a belief that ECPs will become ineffective at preventing pregnancy if taken too many times. These findings are consistent with other qualitative studies [ 7 , 34 , 35 ]. Third, traditional methods such as withdrawal and following a menstrual calendar are used; however, when there is a perception of method failure, ECPs are sometimes used as a back-up method. Finally, there is a great deal of misinformation about ECPs, including which drugs are ECPs, how to take ECPs, and how frequently ECPs can be safely taken, some of which was spread by pharmacists.

We found that a large majority of participants had experience using ECPs; participants liked that ECPs could be used post-coitally and without their partner's knowledge. While the rate of use may be higher in our study because participants were sent an informational message about ECPs during the course of the original trial, many participants mentioned hearing about ECPs from friends and family. We also found that there is a substantial misunderstanding of the biology of human reproduction, which leads to myths about nonsensical pregnancy prevention techniques such as urinating out sperm. These myths are widespread and are believed even among women who regularly use modern contraception. A study of Nigerian University students also found that women combine ECPs with saline solution douches or with other medications to increase their certainty of preventing a pregnancy [ 34 , 35 ]. Interestingly, participants in our study had received information on the ineffectiveness of some prevention techniques, including bathing after sex and standing up during sex, during the original trial [ 16 , 17 ]. While the messaging intervention was effective at improving overall SRH knowledge, it appears that these messages were not comprehensive enough to dispel the widespread myths concerning pregnancy prevention.

Our study contributes to the larger literature on ECPs in SSA. Recent studies have found that levels of awareness and use of ECPs among young women vary considerably across countries in SSA [ 8 , 36 , 37 , 38 , 39 ]. Consistent with the findings of this study, previous research has found that young women generally find ECPs an acceptable and convenient option that fill the need of a post-coital contraception that can be taken as needed [ 4 , 5 , 7 , 25 ]. However, our results also contribute to the growing evidence on barriers to ECP access and use, including myths and misconceptions about risks of ECPs [ 5 , 25 , 34 , 35 , 40 ], poor knowledge of correct usage [ 13 , 34 , 39 ], and restrictive distribution practices of pharmacists and health care providers [ 41 , 42 , 43 , 44 ].

A critical step forward to reducing misinformation and misuse of ECPs would be to incorporate information on ECPs into comprehensive sexuality education (CSE) in schools. Ghana adopted an Adolescent Reproductive Health Policy in 2000, which led to the inclusion of a reproductive health component in the educational curriculum at primary, junior high, and senior high levels; however, a 2017 report on implementation of SRH education policies in Ghana found that fewer than half of the students reported that they had learned about contraceptive methods [ 45 ]. The majority of students who started learning SRH in senior high school said that they would have liked to have started earlier, a finding that is supported in our study. Among teachers, only 54% reported teaching about ECPs at all, while 99% reported teaching about condoms and 83% reported teaching about OCPs [ 45 ]. Educational curricula should include a wider range of contraceptive options, along with information on the mechanisms of how methods work and a comprehensive, accurate discussion of their side effects. In addition, our findings provide more evidence that gender and power need to be addressed within CSE, including topics of partner communication, equitable relationships, and harmful gender norms [ 46 , 47 ]. Finally, as young women demonstrate high rates of pharmacy utilization for obtaining contraceptives [ 48 ], pharmacists and health care providers also need comprehensive training on correct dosage, safe usage, and side effects of ECPs. Previous research has found low knowledge of ECPs among providers in Ghana [ 41 ] and Senegal [ 49 ].

Lastly, reproductive health policies need to address the growing access to and use of ECPs among youth. The Ghana Health Service Family Health Division 2015 Annual Report, for example, details a Family Planning Programme describing trends and progress in uptake of long-acting contraceptive methods, OCPs, injectables, male and female condoms, and permanent methods, but makes no mention of ECPs at all [ 50 ]. Moreover, guidelines that address ECPs should take the social and sexual context of young women’s sexual experiences as well as their preferences into account. While ECPs were originally developed as an “emergency” method, our results support the findings of other studies that young women prefer ECPs as a post-coital method and use it repeatedly [ 5 , 7 , 8 ]. While ECPs are not as effective as preventative methods of contraception, repeated use has been found to be safe, though more evidence is needed [ 51 ]. Results from our study show that women are reluctant to use condoms and OCPs consistently, so the idea of “bridging” young women who use ECPs to long-term preventative methods of contraception may be challenging, a finding consistent with previous literature [ 4 , 5 ]. We also find that young women are fearful of overuse of ECPs and are worried about their side effects. Therefore, misinformation about the dangers of repeated use and side effects of ECPs may lead women to rely on ineffective and possibly dangerous “prevention” methods (like urinating or taking a large dose of paracetamol). Conversely, encouraging young women to use ECPs regularly may increase the spread of sexually transmitted infections (STIs). Overall, more research is needed to understand how uptake of ECPs affects rates of STIs.

Strengths and limitations

Our study has strengths and limitations. First, as this is a qualitative study, our results are not generalizable to other contexts and populations beyond young unmarried women in Accra, Ghana. In addition, participants in our study were originally recruited as secondary school students in Accra, thus our results also may not generalize to other demographic or geographic groups in Ghana. However, we find that characteristics of our sample, such as median age at first sex, are similar to those of women aged 20–24 in Ghana [ 15 ]. In addition, many of our findings are consistent with those of other studies conducted in Ghana [ 5 , 7 , 13 ]. Second, participants received a 12-week sexuality education intervention as part of the original trial, which may have impacted on their behaviour and thus their sexual experiences and preferences. However, this is a strength of our study as well in that interviewer debrief notes indicated that the fact that participants had received information from the sexuality education program (with which the interviewer was affiliated) allowed participants to feel more comfortable with sharing personal sexual information with the interviewer. For example, six participants provided long and detailed stories about their abortion experiences, indicating that they trusted the interviewers to discuss this information. Since sex is often a taboo topic in Ghana, interviewer trust is essential to obtaining complete and honest responses and ensuring credibility of the study.

Continued investment in adolescent CSE, youth-friendly health services, and effective youth and community programs are essential to protect sexual and reproductive health and rights [ 52 , 53 , 54 ]. However, for programs  to be effective they must be tailored to the particular needs of sexually active youth. Our results show that ECPs are an important component of a comprehensive SRH strategy that is currently left out of policy and educational guidelines. Young women’s preference for ECPs may be at odds with HIV prevention approaches that solely promote condoms. The development of a youth SRH strategy must consider the social and sexual context of ECP use among young women, as well as how best to integrate ECPs into a dual-protection strategy to reduce risk of unintended pregnancy as well as HIV/AIDS and STIs.

Abbreviations

Comprehensive sexuality education

Emergency contraceptive pill

Institutional Review Board

Oral contraceptive pill

Sexual and reproductive health

Sub-Saharan Africa

Sexually transmitted infection

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Acknowledgements

We thank Shannon Glaspy for research support and Günther Fink for support of the study. We are grateful to the participants who took the time to share their experiences with us. We thank Comfort Bonney Arku, Grace Gletsu, Charles Sefenu,  Christine Papai, and the IPA staff who contributed to this study for their hard work and support. We thank Grace Kafui Annan and staff at the Ghana Health Service Health Promotion Unit for their guidance and support.

This research was funded by the Weiss Family Fund for Research in Development Economics, the Harvard Lab for Economic Applications and Policy, and the Harvard Institute for Quantitative Social Science. Study sponsors had no role in study design, data collection, analysis, interpretation, writing of the report, or decision for publication.

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Rokicki, S., Merten, S. The context of emergency contraception use among young unmarried women in Accra, Ghana: a qualitative study. Reprod Health 15 , 212 (2018). https://doi.org/10.1186/s12978-018-0656-7

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Received : 20 September 2018

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