Assessment of Knowledge, Attitude and Utilization of Emergency Contraception Among Women of Reproductive Age in Arsi Zone, Ethiopia

Background: Unintended pregnancies, pregnancies that occur within short intervals as well as unsafe abortion could be avoided by using contraceptives. Therefore: assessment of emergency contraceptives among unmarried women is importance because of high rates of unintended sexual intercourse leading to unwanted pregnancies as well as unsafe abortion. Methods: A cross-sectional community based household survey was conducted among 965 women chosen by systematic random sampling at Arsi zone. Descriptive statistics was presented with text and frequency tables. Both bivariable and multivariable logistic regression analysis was carried out by Epi Info version 5.3.1 and exported to SPSS version 21. The association was also presented using odds ratios and 95% condence levels. P-value of < 0.05 is used to declare the signicance of association between variables. Results: From the total respondent participated in the study, 373 (38.7 %), 61.8%, and 11.2% of the total unmarried women had awareness, attitude and used emergency contraception respectively. Age, educational status, occupation, having experience of sexual intercourse and having discussion on reproductive health are signicantly associated with awareness of emergency contraception. Conclusions: There is high level of knowledge, but low utilization of emergency contraceptives among unmarried women. Therefore, there is a need to emphasize on increasing awareness and accessibly as an option with other contraceptive method to all unmarried women in the study area.


Background
Emergency contraception (EC) is de ned as contraceptive methods that reduce the chance of pregnancy following unprotected sexual intercourse ( 1 .) They are intended for use after sexual intercourse when no contraception is used, when a regular contraceptive method does not work properly, or if a woman is sexually assaulted ( 2 .) A woman can take ECPs within 72 hours or more after unprotected intercourse to reduce her risk of becoming pregnant. They contain a higher dose of the same active ingredients that regular birth control pills contain. Recent research suggests the pills are also effective, if taken within 120 hours of unprotected sexual intercourse ( 1, 2 .) Progestin pills are more effective and are associated with fewer side effects than combined emergency contraceptive pills ( 3 .) Another form of emergency contraception is the insertion of a copper Intra Uterine Device (IUD) by a trained healthcare professional ( 1,4

.)
Emergency contraception adds an important option for helping sexually active unmarried to avoid unintended pregnancy. Many unmarried women are at high risk of unintended pregnancy; they have limited knowledge of contraception and generally lack access to services or do not feel comfortable using these services ( 2 .) Nowadays, ECs have become more available in many developing countries. However, limited awareness and knowledge, as well as limited access, have hindered unmarried and young women in learning about and using ECs ( 2 .) A review of the evidence shows that adolescents' restricted access to emergency contraception is due to their lack of awareness of ECs, barriers to their use of family planning clinics, including embarrassment, lack of familiarity with the clinics, inconvenient clinic hours; fear of a pelvic examination and provider attitudes ( 5 .) According to Ethiopian Demographic Survey (EDHS) 2011, 27 % of Ethiopian women of reproductive age (15-49 years) have never been married. Among those never been married the highest proportions (77%) were between the age of 15 and 19 years. But the median age at rst intercourse for the women age 15-49 were 17.1years.The steadily decreasing age of menarche and increasing age of marriage have created a widening window of time for premarital sexual intercourse which may result in unwanted or unintended pregnancies( 2 .) Unintended pregnancies and pregnancies that occur within short intervals and abortions pose serious health risks to young women ( 6-10 .) As a consequence, most of unintended pregnancies end with induced abortion which contributes for high maternal mortality ( 11 .) Global and regional estimates of annual incidence of unsafe abortion and associated mortality in 2003 shows, the incidence rate of 14 per 1000 women aged 15-44 years which accounts for 13% of all maternal deaths worldwide. In eastern Africa the incidence estimated to be 39 per 1000 and accounts for 17% of all maternal deaths ( 11 .) By preventing pregnancy before it happens, ECs help reduce the number of unintended pregnancies, as well as the number of abortions and associated maternal mortality ( 12,13 .) Despite increase in promotional activities of modern contraceptive methods among unmarried women the utilization is relatively low. In Ethiopia current use of contraception is lower (18.7%) among all women of reproductive age group ( 14,15 .) In addition, in all reproductive age group only 52.3% of sexually active unmarried women are currently using any modern contraceptive methods ( 15 .) As it has been discussed ECs helps in reducing the risk of unintended pregnancy, its consequence unsafe abortion as well as associated maternal mortality among unmarried women which are at risk. Different institutional based studies have shown that the knowledge and utilization in relation to emergency contraception are limited among women ( 16-37 .)

Methods
Cross-sectional community based study was conducted at Arsi Zone in Oromia National Regional State about 175 kilo meters to southeast of Addis Ababa, Capital city of Ethiopia. According to the projection from 2007 census, total population of the zone estimated to be 3,202,689. Arsi Zone is currently organized in 25 administrative structures called 'woreda'. The health service coverage is 88%. The proportion of women of reproductive age group in the region is 22.1%, total fertility rate of 5.6 ( 15 .) The sample sizes were determined using single proportion formula. Assuming the proportion of unmarried women who aware of emergency contraception to be 50% since there is no study conducted at the community level, 5% marginal error, 95% con dence interval and 10% non-response rate were added.
Then multiplied by 2 for design effect due to multistage sampling and total sample size was 998.
A total of 10 rural 'kebeles' and 5 urban 'kebeles' were selected from ve 'woredas'. Based on the total population of selected woredas the sample sizes were allocated proportional to population size. Similarly, the sample sizes were distributed to kebeles according to their proportion. Then using systematic sampling the study subject was interviewed at household level using structured questionnaire. Data were collected by female nurses experienced in data collection, and checked for completeness and consistency on daily basis by the supervisors. Data were cleaned and entered to the computer using Epi Info version 5.3.1 and exported to SPSS (Statistical Package for the Social Sciences) version 21 statistical software and analysis were performed. Descriptive statistics (mean and standard deviation) was used and results were present with text and frequency tables. Both bivariable and multivariable logistic regression analysis was carried out to identify factors associated with awareness of EC among the study subject. At bivariable analysis level to select best predictor variables and those variables that are going to show signi cant association at a p-value of less than 0.20 was entered into multivariable analysis. The association of variables was also presented using odds ratios relative to the reference category and 95% con dence levels. P-value of < 0.05 is used to see the signi cance of association between dependent and independent variables.

Results
Complete responses were obtained from a total of 965 respondents yielding a response rate of 97.7%. The age of the respondent ranged from 15 to 35 years with mean age of 19.5 and standard deviation of 3.65 years. Above half of them 555(57.5%) were between the age of 15 and 19 years. Regarding residency, 586(60.7%) of the respondent were rural resident. Three hundred eighty one (39.5%) of the respondents were orthodox Christian followers (Table 1).

Conclusions
The study has shown that the knowledge of modern contraceptive was higher but the utilization is relatively low. This is an indication of signi cant risk of unwanted pregnancy and induced abortion among the sexually active unmarried women. With regard to emergency contraception the study shows low awareness and better level of positive attitude towards emergency contraception. Therefore, there is a need to develop strategies in order to raise awareness of the community about emergency contraceptive as an option with other contraceptive method. Further research of providers and male partners and follow-up stud of all females on emergency contraception provision and utilization could be important to strengthen the service.
Abbreviations AOR: Adjusted Odds Ratio COR: Crude Odds Ratio