In Kenya and Nigeria, the Common Stereotype Of Emergency Contraceptive Users Does Not Apply
In urban Kenya and Nigeria, women who have used emergency contraceptives in the past year are more likely than those who have never used the method to be in their 20s, unmarried and educated, according to a recent study.1 Although recent users of emergency contraceptives in Kenya were more likely than never-users to have had two or more sex partners in the past year (coefficient, 0.7), users generally were no more likely than nonusers to have engaged in risky sexual behavior. These findings contrast with the common perception that the typical emergency contraceptive user in Africa is an adolescent who frequently has risky sex.
Nigeria and Kenya have the highest rates of emergency contraceptive use in Sub-Saharan Africa, though only 2–3% of women in these countries report having used the method. To address the lack of data on the characteristics and motivations of users, researchers included a module on emergency contraception in a large-scale, representative household survey conducted in five cities in Kenya and six cities in Nigeria in 2010–2011. All women aged 15–49 in the selected households were eligible to participate. The individual response rate was 85% in Kenya and 95% in Nigeria. The current analyses were limited to sexually experienced women—7,785 in Kenya and 12,652 in Nigeria. The main survey included questions on social and demographic characteristics, family planning use, exposure to family planning messages and fertility intentions; the emergency contraception module added questions on knowledge, use and sources of the method. Researchers used multinomial logistic regression to examine associations between women’s emergency contraceptive use—classified as recent (past 12 months), nonrecent or never—and their social and demographic characteristics; the analyses controlled for age, education, employment status, religion, relationship status, parity, socioeconomic status and city. Descriptive analyses were stratified by marital status.
In Kenya, 54% of the women were aged 20–29 and 40% were aged 30–49; in Nigeria, 39% were aged 20–29 and 57% were aged 30–49. In both countries, more than half of the women had at least a secondary education (56% and 60%, respectively), had worked in the past 12 months (65% and 64%), were married or cohabiting (64% and 80%) and had at least one child (79% and 78%). In Kenya, nine in 10 women were Catholic or another Christian denomination and most of the remainder were Muslim; in Nigeria, half were Christian and half Muslim. The vast majority (73%) of Kenyan women resided in Nairobi, while Nigerian women were more evenly distributed among the six study cities (12–24%).
Overall, a higher proportion of women in Kenya than in Nigeria reported having heard of emergency contraceptives (58% vs. 31%). Never-married women were more likely than other women to have heard of emergency contraception, both in Kenya (65% vs. 55%) and Nigeria (50% vs. 28%). Moreover, among those who had heard of the method, never-married women were more likely than other women to know that the emergency contraceptive packets in their country contain two pills and that the method can be used up to 120 hours after sex.
Most sexually experienced women in Ken-ya (80%) and about half in Nigeria (52%) had used a modern method of contraception. In Kenya, ever-married women were more likely than their never-married counterparts to have used contraceptives (83% vs. 69%); in Nigeria, the opposite was true (49% vs. 68%). In both countries, however, emergency contraceptive use was greater among never-married than ever-married women. For example, in Kenya, never-married women were more likely than ever-married women to have used the method in the past year (13% vs. 3%) or ever (21% vs. 9%), to have used the method more than once per month in the past year (2% vs. 1%) and to consider emergency contraceptives their primary method of contraception (1.4% vs. 0.4%). Among recent users, 12% of those in Kenya and 38% of those in Nigeria considered emergency contraceptives their primary method.
Most women in Kenya (72%) and Nigeria (64%) who had used emergency contraceptives in the past year were aged 20–29. Recent and nonrecent users were more likely than never-users to have at least a secondary education (87% and 85%, respectively, vs. 52% in Kenya; 43% and 51% vs. 24% in Nigeria) but less likely to have a child (51% and 65% vs. 81% in Kenya; 52% and 64% vs. 79% in Nigeria). Moreover, in Kenya, recent and nonrecent users were disproportionately likely to have worked in the past 12 months and to be in the highest wealth quintile.
Multivariate analyses indicated that in Kenya, recent users of emergency contraceptives were more likely than never-users to be aged 20–24 than 40–49 (coefficient, 1.1), to have at least a secondary education than to have not completed primary school (1.5) and to be single (1.3) or separated or formerly married (1.4) than to be married or cohabiting. In addition, women who had recently used emergency contraceptives were less likely than never-users to have a child (–0.5) and more likely to have had multiple sex partners in the past year (0.7). Emergency contraceptive use was not associated with transactional sex or coital frequency.
In Nigeria, compared with nonusers, recent users of emergency contraceptives were more likely to be aged 20–24 or 25–29 than 40–49 (coefficients, 1.0 for each), to have a junior secondary education or more than a secondary education than a primary education (1.1 and 0.8), to be Catholic rather than Muslim (0.6) and to have never married than to be married or cohabiting (1.3). Recent users were more likely than nonrecent users to have never married than to be married or cohabiting (1.1). No associations were apparent between risky sexual behaviors and emergency contraceptive use, though an interaction analysis showed that divorced or separated women who had had multiple partners in the past year were more likely to report recent emergency contraceptive use than were those who had not had multiple partners.
The researchers acknowledge several limitations: The sexual behavior data were self-reported and therefore subject to social desirability bias; the samples were not nationally representative or even representative of all urban areas in the two countries; the data were cross-sectional; and recent use of emergency contraceptives was relatively rare. Despite these limitations, the researchers note that their findings "[deepen] our understanding of when, how and by whom emergency contraceptives are used in urban Kenya and Nigeria." They note that the study highlights "the need to adequately target information and services concerning [emergency contraceptives] to unmarried urban women, a demographic group that appears increasingly to view this method as an important element of their contraceptive toolkit." Moreover, the findings for Nigeria—particularly the relatively high proportion of women reporting that emergency contraceptives were their primary family planning method—speak to "the need for greater understanding of the dynamics of repeated use and the importance of ensuring availability and access to effective, short-term, woman-controlled barrier and hormonal methods."—L. Melhado
1. Morgan G, Keesbury J and Speizer I, Emergency contraceptive knowledge and use among urban women in Nigeria and Kenya, Studies in Family Planning, 2014, 45(1):59–72.