Knowledge and Parity: Perspectives of Usage of Emergency Contraceptive Pills among Women of a Rural Area of Delhi.

CONTEXT: Correct use of emergency contraceptive pills (ECPs) may prevent up to 95% of unwanted pregnancies which may significantly decrease unsafe abortions and maternal mortality. AIMS: Assessment of knowledge and use of ECPs among women and to explore factors associated with them.
MATERIALS AND METHODS: This was a facility-based cross-sectional study. Data were collected using a prestructured, pretested questionnaire from 381 reproductive age women (15-49 years) selected by systematic random sampling. Statistical Package for the Social Sciences version 16 and Epi info (version 7.0.) were used for all statistical analyses. Descriptive analysis was performed, and results were expressed in terms of frequencies and percentages. The Chi-square and Fisher's exact test were used as tests of significance in univariate analysis. Determinants of use of ECPs were identified using logistic regression.
RESULTS: Of 381 women interviewed, awareness level of ECPs (ever heard about ECPs) was found to be 34% (n = 128). Ever use of emergency contraception was reported by 38 (9.7%). Age (odds ratio [OR] = 3.02, 95% confidence interval [CI] [1.88-4.87]), education (OR = 0.086, 95% CI [0.047-0.158]), husband's education (OR = 0.11, 95% CI [0.067-0.187]), socioeconomic status (OR = 6.14, 95% CI [3.28-11.51]), and family status (OR = 2.6, 95% CI [1.59-4.24]) were found to be significantly associated with the use of emergency contraceptives.
CONCLUSIONS: The study identified that most respondents lack adequate knowledge about ECPs, and ever use of ECPs was very low. Factors that were associated with the use of ECPs were age, literacy, socioeconomic status, and knowledge about the method. Creating a sustainable awareness on ECPs and their use may serve them with power to control their parity.

INTRODUCTION

Unintended pregnancy is an important public health issue in various developed and developing countries because of its association with health, social, and economic consequences.12 Reducing the number of unintended pregnancies alone can avert 60% of maternal deaths and 57% of the child deaths.3 The WHO reports that of the 111,301 nonpregnant women who did not desire pregnancy; India contributes the largest number at 17.1%.4 Statistics for unintended pregnancy (both unwanted and mistimed) have been almost stagnant over the years in India with all three rounds of the National Family Health Surveys reporting almost the same results that about one-fourth of the pregnant women had unintended pregnancies.567 It can be blamed on low awareness as well as stronger gender-based power imbalances due to which women are unable to exercise sexual and reproductive decision-making.8

Expanding the number of modern family planning options available to women is a critical part of decreasing unintended pregnancies globally.9 Emergency contraceptive pills (ECPs) are a safe, effective, and female-controlled method of postcoital contraception.10 They provide women an important option to control their fertility even in the male-dominated society. ECPs are available as combined estrogen and progestin pills, progestin-only (levonorgestrel) pills and antiprogestin (ulipristal acetate or mifepristone) pills were made legal in India way back in 2003, and the Department of Health and Family Welfare had introduced them as E-pills in the National Family Welfare Programme during the same time with efforts to utilize them at all levels of the public health system.5 It was made available over-the-counter and included in the accredited social health activist kits to make it widely available at the community level.11

Till date, the interventions designed to increase access to ECPs have not led to decreased pregnancy rates at the population level. In order to achieve the public health benefits of widespread ECPs availability, potential users must be well informed about it. Specifically, women must know that ECPs exists, how safe and effective ECPs is as a contraceptive, what can be the possible side effects of using ECPs, what are the time limits within which it should be used to be effective, how and where it can be obtained? Without this knowledge, women will miss the opportunity to access and utilize ECPs. Till date, there are almost nil data available on exploration of knowledge and the usage of ECPs in rural women in India. Therefore, this study was needed to explore the perspective of the usage of ECPs and the important factors associated with it, so that it can help determine the best approaches to serve as a backup to other family planning methods to avoid unintended pregnancies and unsafe abortions.

Aims

This article aims to explore the knowledge and perspectives regarding the usage of ECPs in the rural reproductive age women with the following objectives:

To assess the knowledge and usage of ECPs among reproductive age group women of rural Northwest Delhi

To study the major factors associated with ECPs utilization among them.

MATERIALS AND METHODS

The cross-sectional study was carried out from March to July 2015 in one of the health centers attached to a Medical College and Teaching Hospital of Delhi which provides regular reproductive health services to the rural areas of Northwest Delhi. Literacy rate of the area was 76.05%, which is lower than the state average of 86.21%.12 Women of reproductive age group (15–49 years) both patients and attendants were included in the study. The sample size was calculated based on the data from a previous study done by Pandey et al.13 in Delhi in low-socioeconomic group women who reported knowledge of emergency contraception (EC) of 38.3%, using Epi-Info software Centers for Disease Control and Prevention (CDC), Atlanta, Georgia (United States) 95% confidence interval (CI) and 5% margin of error. The minimal sample size calculated was 363. On an average, 600 women attend the outreach center every month. Systematic sampling was used, and every third woman visiting health center was asked to participate in the study. Women were eligible if they were between the ages of 15 and 49 and ever had sexual intercourse. Women were approached to participate regardless of their reason for being at the clinic (refusals <3%). Three hundred and eighty-one women were included in the final analysis. Informed written consent was obtained from all the participants. Ethical clearance was obtained from the Institutional Ethics Committee. The study was conducted in accordance with the principles expressed in the Declaration of Helsinki. Complete confidentiality regarding patient information was maintained through all the stages of the study. We followed the Strengthening the Reporting of Observational Studies in Epidemiology guidelines thoroughly.

A predesigned, pretested, and semi-structured interview schedule was used which had both open- and closed-ended questions under following parts: (a) questions to assess sociodemographic profile of the subject; (b) questions about the menstrual and obstetric history of the women; (c) questions to assess the knowledge regarding ECs; and (d) questions to know the history of usage of ECs in the past. Knowledge about ECPs was assessed using questions of awareness about the types, the time limit for use after unprotected sex, and the dosage. Statistical Package for the Social Sciences version 20 International Business Machines Corporation, Chicago (United States) and Epi info (version 7.0.) were used for all statistical analyses. Descriptive analysis was performed and results were expressed in terms of frequencies and percentages. The Chi-square and Fisher's exact test were used as tests of significance in univariate analysis. A two-tailed P < 0.05 was considered statistically significant.

RESULTS

The sociodemographic characteristics of the women are presented in Table 1. More than one-third of the patients (38%, n = 145) were in the age group of 21–30 years, 82.2% (n = 313) of them had less than primary education, and 58% (n = 221) belonged to middle socioeconomic status as per Prasad's Classification.14 Of all, 56.4% (n = 215) of participants reported that they had completed their family and did not want any more children. An ideal number of children reported by the majority (86.3%, n = 329) was two. Twenty-three percent of participants had three or more children. Almost 14% (n = 52) of participants reported undergoing voluntary termination of pregnancy at least once in their life as the pregnancy was unintended. Only 17% (n = 63) of participants were protected from impending pregnancy last time they had sexual intercourse, either by practicing any modern method of contraception or by terminal methods.

Table 1

Demographic characteristics of the study participants (n=381)

Population features	Frequency, n (%)
Age (years)
<20	34 (9)
21-30	145 (38)
31-40	103 (27)
>40	99 (26)
Education of women
Uneducated	88 (23.2)
Just literate and primary education	225 (59)
Matriculation and senior secondary	65 (17)
Graduate and postgraduate	3 (0.8)
Education of women’s husband
Uneducated	52 (14)
Just literate and primary education	218 (57)
Matriculation and senior secondary	102 (27)
Graduate and postgraduate	9 (2)
Socioeconomic status
Upper	15 (3.9)
Middle	221 (58)
Lower	145 (38.1)
Family complete
Yes	215 (56.4)
No	166 (43.6)
Ideal number of children
1	13 (3.4)
2	329 (86.3)
>2	17 (4.5)
Gods wish	22 (5.8)
Number of living children
None	22 (5.7)
1	141 (37)
2	129 (33.9)
3 and more	89 (23.4)
History of voluntary termination of pregnancy
Once	52 (13.6)
Twice or more	35 (9.2)
None	275 (72.2)
Refused to answer	19 (5)

Of the 381 sexually active women who participated in the study, only 2.8% (n = 11) had come to the facility for family planning services specifically. Most of the participants were attending the clinic for their own medical problems (63.1%, n = 241) or accompanying their child/other relative for medical care or immunization or antenatal care services (34.1%, n = 129).

Knowledge and usage of emergency contraceptive pills

Details about women's knowledge and usage of ECPs are presented in Table 2. Overall, 34% (n = 128) of women had ever heard of ECPs when asked directly. Eleven percent (n = 42) of women spontaneously mentioned ECPs by name or description when asked if there was anything a woman could do soon after unprotected sexual intercourse (UPSI) to try to prevent pregnancy. Respondents who were aware of ECPs most commonly (73%, n = 94) reported that they had first heard about ECPs from partners, friends, or family members. Other sources of information about ECPs in women were the mass media (19%, n = 24) and clinics/health staff (6%, n = 8). Of those who were aware of ECPs, approximately 24% (n = 31) of participants said that they did not know what is the correct time interval for the use of EC after UPSI and 67.2% (n = 86) of the participants did not know the appropriate interval between UPSI and taking ECPs. Based on recent evidence, we considered this interval to be up to 72 h after sexual intercourse.10 Most of the women (63%, n = 81) thought that it can be only obtained from a pharmacy or drugstore, whereas only 7.1% (n = 9) knew that it can be obtained from a health-care worker. More than one-third of women (37%, n = 47) believed that it should not be taken without prescription. The majority (58.6%, n = 75) was in the view that the most common side effect due to ECPs is irregular menses, followed by heavy menstrual bleeding (53.9%, n = 69). Substantial percentage of women (30.5%, n = 39) were unaware about the recommended dosing of ECPs, whereas 26% (n = 33) were unaware of the appropriate gap between the doses.

Table 2

Knowledge about emergency contraception among the study participants who never heard of emergency contraception (n=128)

Variables (n=128)	n (%)
When ECP can be used
Immediately after UPSI	18 (14.1)
Within 24 h of UPSI	34 (26.6)
Within 72 h of UPSI	42 (32.8)
Anytime within a week	3 (2.3)
Do not know exactly	31 (24.2)
Place to obtain ECPs
Public health facilities	15 (11.7)
Social workers	9 (7.1)
Pharmacist/medical store	81 (63.3)
Do not know	23 (17.9)
Can one get ECPs without prescription
No	47 (36.7)
Yes	45 (35.1)
Do not know	36 (28.2)
Adverse effect of ECPs (multiple choice)
Nausea vomiting	46 (35.9)
Irregular menses	75 (58.6)
Heavy bleeding	69 (53.9)
Infertility	23 (17.9)
No idea	38 (29.7)
Recommended dose of ECPs
One tablet	26 (20.3)
Two tablet	63 (49.2)
Do not know	39 (30.5)
Interval between two doses
12 h	37 (28.9)
24 h	58 (45.3)
Do not know	33 (25.7)
Efficacy of ECs (%)
>80	37 (28.9)
>50	58 (45.3)
<50	-
Do not know	33 (25.7)

ECPs – Emergency contraceptive pills; UPSI – Unprotected sexual intercourse; ECs – Emergency contraceptions

Seventy-nine percent of women (n = 102) who were aware of ECPs, had used it; 73% (n = 65) of them had used it more than once. The main sources of the acquisition were from pharmacies (91%, n = 81). Sixty-seven percent of the women had used it within 48 h of UPSI.

Factors associated with the use of emergency contraceptive pills

Univariate logistic analysis was conducted to identify factors associated with the use of ECPs and presented in Table 3. Age of respondents was found significantly associated with the use of ECPs (odds ratio [OR] = 11.4, 95% CI [6.32, 20.9]). The likelihood of using EC increased as the education level of the study participants (OR = 11.4, 95% CI [6.32, 20.9]) as well as their husband increased (OR = 8.89, 95% CI [5.33, 14.86]). Similarly, women who belonged to lower socioeconomic status were less likely to use ECPs compared to those belonging to middle or higher (OR = 6.14, 95% CI [3.28–11.51]). Furthermore, couples were more likely to use ECPs when the family was complete (OR = 2.6, 95% CI [1.59–4.24]). Ideal numbers of children or previous abortions were not significantly associated with the usage of ECPs.

Table 3

Association of characteristics of the women with the use of emergency contraceptive pills post unprotected sexual intercourse

Demographic characteristics	Users	Nonusers	OR	95% CI
Age (years old)
<30	68 (37.9)	111 (62.1)	3.02	1.88-4.87
>30	34 (16.8)	168 (83.2)
Education
More than primary education	48 (70.6)	20 (29.4)	11.41	6.32-20.9
Primary education	54 (17.2)	259 (82.8)
Husband’s education
More than primary education	65 (58.6)	46 (41.4)	8.89	5.33-14.86
Primary education	37 (13.7)	233 (86.3)
Socioeconomic status
Upper middle	89 (37.7)	147 (62.3)	6.14	3.28-11.51
Lower	13 (8.9)	132 (91.1)
Family complete
Yes	73 (33.9)	142 (66.1)	2.6	1.59-4.24
No	29 (17.4)	137 (82.6)
Ideal number of children
<2	95 (38.4)	247 (61.6)	1.75	0.75-4.11
>2	7 (17.9)	32 (82.1)

OR – Odds ratio; CI – Confidence interval

DISCUSSION

The awareness level of ECPs among the reproductive age women in this study was found to be 34.1%. Similar findings were observed in another study in women belonging to the low-socioeconomic group in a municipal corporation hospital of an urban area of Delhi.13 However, in some previous studies in North India, rural Uttar Pradesh, and Chandigarh, the awareness level was found to be as low as 0%, 2%, and 1%, respectively.151617 Whereas, in another study from Raipur, 56% of women were aware of ECPs and 19.3% had actually used it.18 The higher awareness in this study may be attributed to the fact that it was conducted in the medical termination of pregnancy ([MTP] clinic) and all the respondents came to the clinic either for MTP or for availing family planning services. Globally, awareness about ECPs in our study was lower than that from European nations but was higher than or similar to what has been reported in developing countries such as Kenya and Nigeria.192021

In this study, majority of women (73%, n = 94) got the information about ECPs from their partners, friends, or family members which was in contrast to other studies from Bangalore and Mumbai, where majority of respondents (66.4% and 80%, respectively) gained the information from radio/television and other sources like health workers.2223 Our findings were in agreement with the results from other developing countries such as Nigeria and Ethiopia, where a good proportion of women (54% and 38%, respectively) said that they came to know about ECPs through family or friends.2425

In this study, 32.8% of the respondents had correct knowledge about timing for using ECPs which was similar (39.7%) to the study conducted in Mumbai, whereas in the studies from Nigeria and Karachi, only 6.5% and 2% of respondents, respectively, were aware of it.232426

In this study, 58.6% of women aware of ECPs feared menstrual irregularities as major adverse effect followed heavy bleeding (53.9%) and nausea and vomiting (36%). In another study from Bangalore, 74.44% of respondents reported nausea, vomiting, and pain abdomen as the major adverse effect, and only 12% complained of menstrual irregularities as the chief adverse effect.26

Another important finding of this study was that about 79% of women (n = 102) who were aware of EC had used it; 73% (n = 65) of them had used it more than once. This was remarkably higher than the 0.06% and 14.1% of the respondents, respectively, in studies from Mumbai and Bangalore.2327 The difference may be accounted for the better availability in our study participants.

The UK, National statistics revealed only 7% of the female ever used ECPs in last year.28 This can be explained by the fact that may be due to better awareness, they are using ECPs as only back up method of contraception relying more on regular methods of contraceptions.

CONCLUSIONS

Our findings suggest that there is considerable lack of knowledge about ECPs in reproductive age group women of this part of country. Most of the respondents had never heard of ECPs, and those who heard about it lacked adequate knowledge about ECP indications, usage, side effects and availability. Ever use of ECPs was also very low. Age, education, socioeconomic status, and attainment of required family size were major factors influencing usage of the ECPs. Awareness and knowledge about the ECPs promoted their use by women in the need of hour. The family welfare program should prioritize efforts to create sustainable awareness and availability on basket of choices available for contraception including ECPs. This shall certainly empower women to control their parity and hence essentially their lives.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.