Knowledge, Attitude and Practices of Emergency Contraception among Female Students in Preparatory School of East Shoa, Adama, Ethiopia

Background: Emergency contraception are birth control measures that, if taken after unprotected sexual intercourse, contraceptive failure, incorrect use of contraceptives or in cases of sexual assault may prevent pregnancy. Objective: The aim of the study was to assess the knowledge, attitude, and practice of female preparatory students towards emergency contraception in April, 2015. Method: The study was conducted in Adama city of Oromia region on 280 female students of Hawas preparatory school on 13 to 18 April, 2015. A cross sectional study design was conducted and Participants were selected using simple random sampling method. Data was collected by using self-administered questionnaires. Data processing and analysis: The collected data was entered into a computer and analyzed using statistical package of social science version 16.0. Result: In this study it was found that, 182 (65%) out of the study participants had a knowledge about emergency contraception most 143 (51.1%) of them reported that they know post pills and 20 (7.01%) of study participants had good knowledge about emergency contraception. Among 280 the study participants, 204 (72.9%) believe that emergency contraception is a good drug of option to prevent unwanted pregnancy and about 165 (59%) of them had positive attitude towards emergency contraceptives whereas 33 (11.78%) study participants had good practice of emergency contraception. Conclusion and recommendation: Even though this study revealed that some students` knowledge and practice towards emergency contraception was good, the improvement of female students’ knowledge about specific details of the method and timely utilization of emergency contraception is still required. Therefore Hawas Preparatory school shall better improve knowledge of emergency contraception among the students by arranging different coffee debate. Gy ne col ogy & Obetrics ISSN: 2161-0932 Gynecology & Obstetrics


Introduction
The Use of high dose post coital estrogen began in the 1960s as a treatment for rape victims. The combined estrogen-progestin (yuzpe) regimen was initially described in 1974 by Albert Yuzpe, a Canadian physician. It was soon replaced to the high-dose estrogen approach [1,2].
Modern family planning (FP) services in Ethiopia dates back to 1966, when the family guidance association of Ethiopia (FGAE) was established as non-governmental and non-profit organization to provide information, counseling and clinical services to families who voluntarily expressed their need and desire for spacing the birth of their children. The family planning service was developed and strengthened when the ministry of health integrated family planning with maternal health in 1980 [1,2].
Emergency contraception are birth control measures that, if taken after unprotected sexual intercourse, contraceptive failure, incorrect use of contraceptives or in cases of sexual assault may prevent pregnancy [3,4]. There are two methods of emergency contraception: Emergency contraception pills and Copper-bearing intrauterine devices [2]. Three types of emergency contraceptive pills are available: combined estrogen and progestin pills, progestin only pills, and ant progestin pills [5].
Emergency contraception was thought to be effective only within 72 hours, but recent studies have confirmed it is effective for up to 120 hours [5]. The copper-releasing intrauterine device (IUD) can be used safely for emergency contraception up to 5-7 days after unprotected intercourse, reducing the risk of pregnancy by over 99% [4].
It is safe with minor side effects like nausea and vomiting in case of pills and infection for IUDs if not used properly. The mechanism of actions of emergency contraceptives are: by inhibiting ovulation or preventing the implantation of fertilized egg, however will not terminate or interfere with a pregnancy once it established [6].
Despite its potential of preventing unwanted pregnancy after unprotected sex for females who don't want to get pregnant; emergency Contraception is largely underutilized worldwide and has been referred to as one of the best kept secrets in Reproductive Health (RH) [5].

Study Justification
Preparatory students are vulnerable to unprotected sexual habit because they are in a fire age. That was why we were intended to study in this area. The main purpose of this study was to assess level of knowledge, attitude and practice towards emergency contraception, and prevent and avoid unwanted pregnancy and the consequent unsafe abortion.
This study was also indirectly aimed at awareness creation on emergency contraception among female students in Hawas preparatory school. In addition, the result will help program designers to design strategies on reproductive health services.
The study was been searching for facts and information on the knowledge, attitude and practice of emergency contraceptives which was believed to be the second opportunity to prevent unintended pregnancy after unprotected sexual intercourse among female adolescents. Therefore, the findings can benefit governmental and non-governmental organization working to provide reproductive health service of these populations. Furthermore, Adama health office and non-governmental organization found around the study area and also in Ethiopia like family guidance associations which are providing emergency contraceptive service can utilize the result of this study as a base line data in planning awareness creation programs for preparatory female students.

General objective
• To assess the knowledge, attitude, and practices of emergency contraception among female students in Hawas Preparatory School from April 13 to 18, 2015.

Specific objectives
• To assess the knowledge on emergency contraception among female students in Hawas preparatory school from April 13 to 18, 2015.
• To identify the attitude towards emergency contraception among female students in Hawas preparatory school from April 13 to 18, 2015.
• To describe the practice of emergency contraception among female students in Hawas preparatory school from April 13 to 18, 2015.

Study area
The study was conducted in East Shoa Zone Oromia Region, Adama city which is 99 km away from Addis Ababa to the East. The town has 4 rural and 14 urban kebeles. The total population is estimated to be over 300,000 on the area of the city (133,600 hectares). The town is located at east Africa rift valley with 1600 meters above sea level and has a climatic condition of "quola" with annual average temperature 21 degree centigrade and 760 mm rain fall.
The health facility of the town includes 1 governmental hospital, 3 private hospitals, and 18 governmental health center. From the two governmental preparatory in the city we selected Hawas preparatory school which has a total of 886 regular female students from which we will sampled 280 students by simple random sampling.

Study period
The study was conducted from April 13 to 18, 2015.
Study design: Facility based cross sectional study design was conducted on preparatory female students to undertake this study.

Source population:
The source populations were all regular female students of Hawas preparatory school.
Study population: Regular female students of Hawas preparatory school.

Inclusion criteria
• All regular female students of Hawas preparatory school.

Exclusion criteria
• Those who were pregnant-since it was not psychologically good to ask pregnant women about use of emergency contraception.
• Blind students-because they may be unable to read selfadministered questionnaires.

Sample population
All regular female students

Sampling procedure
Study subjects were selected using simple random sampling technique.

Data collection
Data collection instruments and procedures: Data was collected using self-administered questionnaire which was partially adopted from previous study done at Mekele town that was prepared in English and we translated it into local languages Afan Oromo and Amharic. The questionnaire was modified to our situation. Five data collectors were involved during data collection process.

Data quality control technique:
The questionnaire was pretested on 5% students prior to the actual data collection in the same population outside the study area, to cross check for completeness on daily basis.

Data entry and analysis:
The collected data was entered into a computer and analyzed using SPSS version 16.0. Frequencies and percentages of different variables were determined.
Data was checked, sorted, categorized and coded. After coding the data was summarized on a master sheet and fed into the computer to make them ready for processing and analysis. Results were presented in tables and narratives. Descriptive statistics were computed to examine the independent variables on student with knowledge, attitude and practice towards emergency contraception using descriptive statistics and cross-tabulation presented using different, tables and texts.

Ethical consideration
Ethical clearance was obtained from department of Nursing and consent was asked from Hawas preparatory school director. All students who were participated on the study were asked for their willingness. Additionally, confidentiality was maintained during data collection and post.

Knowledge of study participants
In this study it has been found that out of the study participants who know 182 (65%) about emergency contraception most 143 (51.1%) of them reported that they know post pills and of this 102 (36.4%) reported that they know two types of emergency contraceptive pills whereas 29 (10.4%) know intrauterine device. More than half 196(63.2%) know condition under which emergency contraception should be used from which 72 (25.7%) said emergency contraceptive can be used if condom ruptured during intercourse and 19 (6.8%) said it can be used when there is a missed other regular contraceptive. Among those who know the correct time to take emergency contraceptives 92 (32.9%), 84 (30%) know the recommended number of dose, and 172 (61.4%) of them know how far apart emergency contraceptive pills should be taken. Among the study participants who know intrauterine device 29 (10.4%), 38 (13.6%), 75 (26.8%) reported to know correct time within which to use and effectiveness of intrauterine device to prevent unwanted pregnancy respectively.
Concerning criteria to use post pills among 280 study participants 111 (39.6%) said that, all women who did not want to get pregnant are eligible to use emergency contraceptives followed those who said it can be used by women not using regular contraception 62 (22.1%), practice sex sporadically 53 (18.9%), face condom failure 43 (15.4%), and others like who said women who missed regular contraceptives constitute the rest 11 (3.9%).
Concerning safety of emergency contraceptives 31 (11.1%) of respondents answered intrauterine device is safer, while 20 (7.1%) said combined oral contraceptive pills, 20 (7.1%) said progestin only pills and 126 (45%) of respondents said both pills and intrauterine device are safe. Among the study participants about 20 (7.01%) have had good knowledge about emergency contraception ( Table 1).

Attitude of respondents towards emergency contraception
Among 280 study participants 204 (72.9%) believe that emergency contraception is a good drug of option to prevent unwanted pregnancy and 33 (11.8%) believe that it interferes with religiosity. In our study, 178 (63.6%) agreed that emergency contraceptive can prevent is safer for the user and 148 (52.9%) of the participant were believe that emergency contraceptive can hurt the baby in case it does not work. Nearly half of the study participant 129 (46.1%) reported that emergency contraceptive is not widely accessible everywhere and the reason low provision is that lack of health care utilities 82 (29.3%), lack of wide distribution of private health centers 81 (28.9%), health care providers` discouragement 49 (17.5%) and underutilization of the available emergency contraception 57 (20.7%). Regarding the impact of increased supply of emergency contraceptives about 88 (31.4%) believed that it lead to more prevention of unwanted pregnancy while 72 (25.7%), 68 (24.3%), 52 (18.6%) believed that its failure may lead to unwanted pregnancy, adolescents may use it more than other regular contraceptives, favors sexually transmitted infections respectively. About 165 (59%) of the study subjects have had positive attitude towards emergency contraceptives ( Table 2).

Practice of emergency contraception
Among 280 sampled students about 105 (37.5%) have practiced sex out of which 24 (22.8%) have practiced sex at below the age of 18 and 63 (22.5%) of them are currently sexually active. About 73 (26.1%) study subjects have used emergency contraception and those who didn't used emergency contraception reported that their reasons for contraceptive nonuse are lack interest 90 (20%) and fear of bad side effect 29 (10.4%) ( Table 3). The mostly used emergency contraceptive pills 44 (15.7) and it has been used correctly. Most of the study subjects 95 (73.2%) who practiced sex faced problems like unwanted pregnancy 50 (47.6%), sexually transmitted infections 29 (10.4%) and others discontinued education. Out of those who faced unwanted pregnancy 4 (8%) continued pregnancy and gave birth while about 46 (92%) of them induced abortion among which 6 (13.1%) reported to induce abortion two times. Regarding future intention to use emergency contraception 135 (48.2%) of the study participants did not intended to use it in the future and their reason were bad side effect and uselessness of emergency contraception 43 (15.4%), lack of interest 54 (19.3%) and shyness to purchase 13 (4.6%). About 33 (11.78%) study participants have had good practice (answered more than 85% of practice questions) towards emergency contraception (Table 4).

Discussion
This study aimed to assess the knowledge, attitude, and practice on emergency contraceptives among female students in Hawas preparatory school. According this study 43 (15.4%) of study participants said emergency contraception is a life destroying drug and 33 (11.8%) thought as a drug which interfere with religiosity. Similarly the study carried out in Nigeria and elsewhere in Sub-Saharan Africa has shown that major obstacles to the adoption of modern contraceptive behavior include myths and misinformation or rumors, and unconfirmed information passed within social networks [7]. This shows that there is still misinformation and misconceptions towards modern contraceptive methods including emergency contraception. In this study, 50 (47.6%) of ever practiced sex 105 (37.5%) respondents reported to have the history of unwanted pregnancy and 21 (22.3%) of them induced abortion while others discontinued their academic education. According to the study conducted in Jimma at SetoSemero high school 126 (44.4%) of the respondents where experienced sex 4 (3.2%) were faced unwanted pregnancy (17). In our study the prevalence of unwanted pregnancy is higher than that of this study. This inconsistency can be related to geographical location and age difference which might had effect on use of emergency contraception after unprotected sexual intercourse to prevent unwanted pregnancy and sexual activities. The good news is that the majority of induced abortion (56%) was performed at health facilities; therefore, the  respondents did not inflict themselves to untrained abortionists that could threaten their life or darken their future chance, but some of them performed in unsafe conditions and others carried their pregnancies to term. Likewise a study conducted at Mekelle University, showed that out of 4.7% (4 students) of ever sexually active respondents reported to have the history of unwanted pregnancy and aborted at health facilities. In this study, the prevalence of unwanted pregnancy among the total study participants was 50 (17.85%) which is higher than same the study done at Mekelle University (1.1%) (16). And this may be linked to early initiation of sexual intercourse now days even at below preparatory level and more exposure to information among university students than that of preparatory school students.
Among the study participants who practiced sex 73 (69.5%) have had ever used emergency contraception. However, studies in different parts of the country show very low utilization rate (as low as 10%) of the method despite the significant proportion of youth have ever had sex in their life time [8]. This indicates the prevalence of emergency contraceptive use is higher (26.07%) in our case which may be related area of residence or gap of accessibility in different parts of the country.
The most frequently reported reasons for the non-use of the emergency contraceptive method were fear of side effect and lack of information (knowledge) while in our study the participants reported reasons like lack of interest 90 (32.1%) and bad side effect 29 (10.4%). The knowledge of overall study participants in this regard was found to be 182 (65%) as opposed to the 41% nationally and this may be due   can only obtain emergency contraception at clinic, or whith doctor's prescription [9]. This limits teen's access to emergency contraception because it can be difficult for minors to get to clinic or doctor, especially if they need parental permission, and some states allow pharmacies and hospitals the choice of whether or not to provide emergency contraception [10]. This indicates that there is still a problem related to the freedom for adolescents to get emergency contraception whenever they practiced unprotected sex and that was why the prevalence of unwanted pregnancy 50(17.85%) its consequence/unsafe abortion 34 (12.14%) is still high. This difference may be due to difference of socio cultural, social norms of the two communities [11].
In our study, the practice of emergency contraception was 73 (26.1%) which is higher than that of the finding of the study conducted at Jimma University, which showed only 11 (6.8%) were used emergency contraceptive method [9]. The reason behind this may be time gap of the studies and socio-cultural characteristics difference of the two societies [12].
About 165 (59%) of the our study subjects have had positive attitude towards emergency contraceptives whereas studies carried out at Ambo Technique College and Addis Ababa University showed that about 77.4% and only 32.3% (among those who had unprotected sexual intercourse, 75% had ever used emergency contraception) of the students have positive attitude towards emergency contraception respectively [13]. This may be the related to the experience of its bad side effect since the discrepancies may indicate that ever use of emergency contraception is associated with less positive attitude towards emergency contraception.

Conclusion
Emergency contraceptive is the only option of preventing unwanted pregnancy after unprotected sexual intercourse. More than ¼ of respondents in this study know about emergency contraceptives and had good knowledge and positive attitude; nevertheless, some respondents lack detailed information about emergency contraceptives. In this study even if 73 (69.5%) of the participants were used emergency contraception 50 (17.85%) faced unwanted pregnancy. This could be due to incorrect use of emergency contraception in appropriate dose and time. Therefore, to increase knowledge about emergency contraceptives on how to use it whenever need arise and to bring attitudinal change among female secondary school students, there should be a continuous open health education on specific information about emergency contraception [14,15].


Girls' school clubs shall work hard to create awareness on sexual activities of female students in school.
 Adama health bureau should provide different leaf lets that teach about reproductive health for student and arrange programs on regular basis to provide appropriate information concerning the use and utilization of family planning including emergency contraception.
 Government should incorporate sex education in academic learning teaching process.


Adama family planning association and youth association should cooperatively prepare posters to create awareness towards contraceptive utilization to shift short acting family planning users' action more to regular long acting family planning methods [16,17].