More than half of family planning providers and clients in Mexico City,1 and the great majority of providers and clients in Nairobi, Kenya2 support the introduction of emergency contraception in their countries. Two studies of knowledge, attitudes and practices concerning emergency contraception in these cities found that although clients in both cities lacked accurate information about the Yuzpe method, the overwhelming majority (84% in each) said they would use the method or recommend it to friends. However, a large proportion of providers and clients in both cities cited concerns about emergency contraception's side effects.
The Mexico City Study
Interviews were conducted with 40 health care providers and 1,127 clients at three family planning clinics and a university health clinic between January and June 1997. The providers included physicians, nurses, psychologists, social workers and one administrator.
The providers were first asked if they had heard of emergency contraception and whether they knew what it is. Of all of the providers, 68% claimed to have heard of emergency contraception; family planning providers were more likely than university clinicians to have heard of the method (88% vs. 54%).
Only 30% of providers knew that emergency contraception is a postcoital method, and the respondents who reported having heard of it were no more likely than the others to know what it is. In fact, providers at family planning clinics that offered emergency contraception were no more likely than others to identify it correctly. Most providers thought that emergency contraception is a contraceptive used during intercourse or an abortifacient.
The interviewers then briefly explained the method's timing, effectiveness, side effects and composition. Once providers were informed about emergency contraceptive pills, 55% reported that they would support a dedicated product's introduction in Mexico, 10% said that they would oppose its introduction and 35% were unsure. Providers who were older and those with more years of clinical experience were significantly more likely than others to support the introduction of the method. Among the concerns cited were side effects (53%), misuse or too frequent use (40%) and self-administration (30%). Many providers also mentioned legal and social obstacles (58%), including civil and religious resistance (28% and 18%, respectively).
The great majority of providers said that emergency contraception should be offered in hospitals and clinics (88%), while much smaller proportions said that it should be available from midwives (33%) or at schools (28%), at pharmacies (18%) or from vending machines (10%). More than nine out of 10 providers believed that emergency contraception should be dispensed by doctors, while more than half thought that it could be dispensed by nurses. Fewer providers said that other professionals, such as pharmacists, sex education teachers or community health workers, should provide the method.
Among the clients surveyed, 83% were female and 73% were aged 20-34. More than half (51%) had had more than a high school education, and 39% had completed high school. Most of the clients (83%) had had sexual intercourse, and 59% of those who were sexually active were practicing contraception; 48% had previously been pregnant. Only 18% of the clients had ever heard of emergency contraception. Logistic regression analysis showed that those who had had more than a high school education or who had ever been sexually active were significantly more likely than others to have heard of the method (odds ratios of 8.3 and 2.4, respectively).
Of the 200 clients who claimed to have heard of emergency contraception, just 10% gave accurate answers to four questions about its composition, effectiveness and use; 32% answered three out of four of these correctly. Only 1% of the sample reported having used the method. The clients were then given the same information on emergency contraception as the providers.
Nearly two-thirds (63%) of the clients agreed or agreed strongly with the statement that emergency contraception should be offered in Mexico; 78% said it should be available to all women. Eighty-four percent said that they would use emergency contraception or recommend it to a friend. Nevertheless, 73% reported that they had concerns about the method. Health problems and side effects were the most commonly cited issues (52%); concerns about frequent use or substitution for a regular method (20%), effectiveness (10%), and the possibility of congenital defects (8%) or future infertility (8%) were also reported.
Multivariate regression analysis revealed that clients who had had sex were more likely than those who had not to support the introduction of emergency contraception in Mexico. University students, clients who were currently practicing contraception and those who had previously been pregnant were significantly less likely to support the method's introduction; however, these groups were at least as likely as others to report that they would use the method or recommend it to friends.
The more education clients had, the more likely they were to express concerns about emergency contraception (odds ratios of 2.6 for those with a high school education and 4.5 for those with higher education). Clients who were currently practicing contraception were more likely than those who were not to cite concerns (1.4).
Having heard of emergency contraception was positively associated with willingness to use and recommend the method, but not with support for its introduction in Mexico. Among clients who had heard of emergency contraception, those with more knowledge about the method were significantly less likely to support its introduction in Mexico.
Most clients believed that if emergency contraception is introduced in Mexico, it should be available at hospitals (93%), clinics (90%) and pharmacies (62%). Exactly half said that it should be dispensed in schools and through midwives. A smaller proportion (30%) thought the method should be offered in vending machines. Some 97% of clients believed that physicians should dispense emergency contraception, and more than half thought that other health care professionals such as nurses (60%), psychologists (51%) and community health care workers (51%) should do so; 74% believed that sex education teachers and counselors should also be able to dispense the method.
The Nairobi Study
A study of attitudes toward and knowledge and practice of emergency contraception in Nairobi addressed the same questions more broadly. In addition to surveying public and private health care providers and family planning clients, the researchers looked at policy documents and service guidelines and interviewed five national family planning policymakers. All data were collected in August and September 1996.
The researchers did not find any policy documents, client materials or service guidelines dealing with or mentioning emergency contraception.
Four out of five policymakers were fairly knowledgeable about the method. All wished to widen access to emergency contraception in Kenya. However, they were split about teenagers' access to the method. None of those interviewed believed emergency contraception to be an abortifacient. The policymakers agreed that emergency contraception should be distributed by doctors, nurses and clinical officers, and some believed that community-based distributors should be able to dispense it as well. All felt that emergency contraception should be sold over the counter, but some thought that the introduction process should be gradual.
The investigators interviewed 93 randomly selected physicians, nurses, clinical officers, pharmacists and community-based distributors. There were 68 public-sector providers and 25 private-sector providers in the sample.
Of the public-sector providers, 34% had heard of emergency contraception, compared with 80% of private providers. Only 4% of public-sector providers were offering emergency contraception at the time of the interview; 46% of private-sector providers were doing so. There was very little demand for the method, which was given to any woman who asked for it, with the exception of one provider who did not dispense it to adolescents.
More than 90% of public and private providers reported that they would support the use of emergency contraception in their own clinics and in Kenya in general. Those who favored providing the method cited reasons such as its ability to prevent unwanted pregnancies for women whose husbands refused to practice contraception or for women who had been raped, and its possible contribution to reducing the abortion rate.
The small proportion of providers who were opposed to the method (10%) voiced concerns about efficacy and potential misuse. They feared that its introduction might cause a decline in condom use and thus help spread HIV and other sexually transmitted diseases.
The providers disagreed about who should distribute emergency contraception in Kenya. All felt that physicians and nurses should be responsible for supplying the method, but some questioned the ability of community-based distribution workers and pharmacists to oversee distribution. There was also disagreement within the sample concerning who should have access to emergency contraception. Most providers believed that access should be unrestricted, but many also felt that examining women and educating them about the method was especially important in Kenya, where a large proportion of women are illiterate. The question of distribution to teenage girls was the most divisive issue.
The providers had mixed feelings about supplying women with packets of emergency contraception in advance. Those who were against the idea mostly cited the lack of monitoring by a health care professional. Providers who felt that distributing advance supplies was a good idea simply stated that this would facilitate use and help women in remote areas. The providers were split again between those who felt this option should be offered only to married women and those who believed that groups with a high rate of sexual activity--such as teenagers and sex workers--would benefit from advance distribution. All of the providers surveyed supported the idea of offering a dedicated product for emergency contraception, rather than breaking up existing packets of oral contraceptives.
Clients were recruited from 10 public and private clinics in Nairobi, which were chosen to ensure the respondents were of varying socioeconomic status. Interviewers approached every other client at the sites until they had a sample of 282 women. The mean age of the women was 26 years, and more than half had completed more than eight years of schooling. The great majority (92%) had given birth and 80% were currently using a contraceptive method.
Most of the clients did not know about emergency contraception; only 11% knew the method by name. The majority (61%) believed that there was nothing they could do to prevent pregnancy after unprotected intercourse.
Of the clients who were familiar with emergency contraception, 80% had heard of it very recently. Most knew about the method through friends or family (47%) or through the media (23%). A very small proportion (3%) had heard about emergency contraception from a clinic or pharmacist.
Even the clients who had heard of the method were not well informed. More than half (60%) of those who reported familiarity with emergency contraception were not sure if the method was appropriate for use when a menstrual period was late. Only two women knew that emergency contraception is effective up to 72 hours after unprotected intercourse; most thought that it had to be used immediately or within 24 hours. Almost two-thirds of the clients were not sure about emergency contraception's effectiveness, and just one respondent knew that the method is 75% effective. Only 17% of women who knew about the method understood that its ingredients are the same as those in oral contraceptives. However, more than two-thirds of the respondents who were familiar with emergency contraception knew of at least one place where it was distributed.
Four out of five family planning clients said that emergency contraception is a suitable method for women in Kenya. A slightly larger proportion (84%) reported that they would use or recommend emergency contraception if it were needed.
More than half (56%) of the clients thought that emergency contraception should be available to all women without restriction, but 18% believed that young adolescents should be denied access. The vast majority of respondents (98%) felt that doctors should distribute emergency contraception, while two-thirds thought that any health center staff member could do it and 50% said that pharmacists could do it; only 12% thought that it should be available over the counter. Some 64% of those who thought women would pay believed that the method should be priced at 50 shillings ($6.00) or less. However, almost 40% of the clients did not think women would pay or were not sure.--L. Gerstein
1. Langer A et al., Emergency contraception in Mexico City: what do health care providers and potential users know and think about it? Contraception, 1999, 60(4): 233-241.
2. Muia E et al., Emergency contraception in Nairobi, Kenya: knowledge, attitudes and practices among policymakers, family planning providers and clients and university students, Contraception, 1999, 60(4):223-232.