Only about one in four women attending public-sector health clinics in South Africa reported having heard of emergency contraception, according to a study conducted in three provinces; levels of knowledge were even lower in rural areas and among less-educated and older women.1 Very few of the women who were interviewed had ever used the method, and the majority who knew of the method were uncertain whether it was offered at the facility where they were interviewed. Nevertheless, once interviewers explained emergency contraception to the study participants, about nine in 10 said they would be interested in using it in the future, would recommend it to friends and would be willing to pay for emergency contraception if they needed to use it.
Emergency contraception has been available for some time in South African public-sector health facilities. Clients may not always know when a service is available, however, and there is little information on how widespread knowledge about emergency contraception is among South African women.
To determine knowledge of and attitudes toward emergency contraception among a broad range of South African women, researchers conducted a survey of clients and providers at 89 public-sector health care facilities between November 1999 and August 2000. Fifty-eight of these facilities were in urban (30) or rural (28) areas of Western Cape Province, which were randomly sampled according to client load. In addition, surveys were conducted at all 14 primary health care facilities in KwaZulu-Natal, a rural province, and at 17 selected facilities in an urban section of Gauteng Province.
A team of interviewers visited each facility and interviewed at least 10 consecutive clients aged 15-49. The structured questionnaire asked about women's demographic characteristics, their sexual history and contraceptive use, how much they knew about emergency contraception and whether they had ever used emergency contraception. All clients were interviewed in their preferred language, by trained staff who were fluent both in that language and in English.
Overall, 1,068 health care clients were interviewed, nearly 87% of those who initially were approached. (Most of those who refused to participate said that they did not have time to complete the interview.) Twenty-seven percent of those interviewed were married, while 47% were unmarried but in a stable relationship. The proportion married was highest in the urban areas of Western Cape Province (37%) and lowest in KwaZulu-Natal (14%). Sixty-eight percent of the women had completed 8-12 years of schooling; few had no formal education (4%). The sample was fairly evenly divided among women who were currently employed (29%), those who were unemployed but seeking a job (30%) and other unemployed women (28%); the remainder (13%) were students.
Most survey respondents had ever had sexual intercourse (93%) and had had sex within the past year (87%). Eighty-seven percent had ever been pregnant, and there were sizable regional differences in pregnancy history: The proportion who had ever been pregnant ranged from 90-91% in the rural sections of Western Cape Province and KwaZulu-Natal to 77% in Gauteng Province. Similarly, 48% of those who were sexually experienced had become pregnant as teenagers, with this proportion ranging from 40% in Gauteng Province to 60% in KwaZulu-Natal. Sixty-five percent of the women said they had become pregnant at least once when they were not ready--varying from 59% in the rural parts of Western Cape Province to 78% of women in KwaZulu-Natal. Among the women who had been sexually active in the year preceding the survey, 68% were currently practicing contraception; most (71% of users) relied on an injectable contraceptive, while 15% used the pill and 12% condoms.
Twenty-three percent of the women had heard of emergency contraception; this proportion was highest in urban sections of Western Cape Province (34%) and was lowest in KwaZulu-Natal (11%). Knowledge of emergency contraception was about twice as great among 15-24-year-olds and 25-34-year-olds (25% each) as among older women (13%), and was more than twice as great among those with at least some secondary education (28%) as among the less-educated (11%).
A logistic regression analysis revealed that awareness of emergency contraception was related to three background characteristics. Compared with clients from KwaZulu-Natal, women from urban areas of Western Cape Province were substantially more likely to know about emergency contraception (odds ratio, 4.4) and those from the other two regions were somewhat more likely to know about it (2.1-2.3). Similarly, knowledge of emergency contraception was greater among women aged 15-34 than among 35-49-year-olds (2.0-2.1). Finally, compared with women with at least some secondary schooling, clients with none or with only a primary education had reduced odds of knowing about emergency contraception (odds ratio, 0.4).
Nearly all clinic managers interviewed knew that their facility offered emergency contraception, but 57% of women who knew of the method did not know if one could obtain it from the facility where they were interviewed. Moreover, even women who had heard of emergency contraception in general often were misinformed about its specific attributes. For example, 47% who knew of the method were uncertain about how soon after unprotected intercourse emergency contraception needs to be taken.
Just 9% of the women who knew about emergency contraception had ever used it (about 2% of all women interviewed), and none had used it more than once. However, after the method was explained to respondents, 90% of clients who were interviewed said that they would use it in the future if the need arose, 89% reported they would be willing to pay for it and 92% said they would recommend it to a friend.
Even with these low levels of knowledge about emergency contraception, the researchers note, the South African women who were interviewed may be more knowledgeable than the general population, as they were clients of primary health care facilities and were of reproductive age.
The researchers comment that it is encouraging that the women had generally positive attitudes toward emergency contraception and would be willing to pay for it, "suggesting that a major barrier to [emergency contraception] use in South Africa is a lack of awareness of the method." They also note that emergency contraceptive products have been offered at private-sector pharmacies without a prescription since November 2000, shortly after the survey was conducted. However, while public-sector clinics provide emergency contraception by cutting apart cycles of combined oral contraceptives, the several dedicated emergency contraception products available in South Africa are too expensive for most public-sector facilities to offer.--M. Klitsch
1. Smit J et al., Emergency contraception in South Africa: Knowledge, attitudes, and use among public sector primary healthcare clients, Contraception, 2001, 64(6):333-337.