Abstract
Background:
Unwanted pregnancy (UP) is a worldwide problem. UP mainly results from the improper or lack of use of effective contraceptive methods. Hormonal emergency contraceptive (EC) is a method of family planning that reduces UP among women in reproductive age. We assessed the knowledge and attitudes of EC among married women in the reproductive age group.Methods:
In this cross-sectional study, 225 married women aged 15 to 49 years, who were referred to hospitals in Tehran Medical Branch during 2014 and 2015, were studied. Required data were collected through interviews and a questionnaire. The Cronbach’s alpha coefficient for internal consistency was 0.85, the validity of the questionnaire was detected using content validity, and its reliability was 0.973. Data were analyzed by SPSS 14.0 statistical software. Statistical significance was set at P < 0.05.Results:
Women with a mean age of 27.3 ± 3.2 were studied. Significant statistical differences were found between the respondents’ education and awareness (P = 0.02). There was a significant relationship between knowledge and current contraceptive method, with a confidence level of 90% (P = 0.013). About 38.6% of women were aware of the general perception, whereas 61.4% were not aware of it at all. In the target group, 22.6% and 73.3% had positive and negative attitudes toward the use of EC method, respectively, and 4% were neutral on this issue.Conclusions:
UP is one of the most important problems in Iran. Increasing the quality of family plan consoling in health centers and emphasizing the advantages of EC method to promote positive attitudes among women are highly recommended. Timely prevention may decrease adverse consequences for the mother and child.Keywords
1. Background
Unwanted pregnancy (UP) is defined when a woman gets pregnant without wanting or planning for pregnancy due to improper or lack of use of contraceptive methods (1). Some studies have shown that women with UP are physically and mentally weaker and have a lower level of prenatal care than women with intentional pregnancy. In addition, these women have high-risk behaviors such as smoking, alcohol, and drug abuse (2). Previous studies in Iran have revealed that UP leads to illegal abortion, which is associated with serious complications (3). The level of knowledge in university students’ about EC is also low in Iran.
Prevention of UP has an important role in improving physical and mental health of mothers and infants. Emergency contraceptive (EC) method is a type of modern pregnancy prevention after unprotected sexual intercourse (4). EC is divided into 2 major methods including hormonal and mechanical methods. Oral contraceptive pills (OCPs) are more frequently used among women as a hormonal method and copper intrauterine devices (IUD) as a mechanical method (5). It seems that OCPs are cost- effective and safer and have an important role in preventing unintended pregnancies in both developed and developing countries (6). Yuzpe regimen is the most common method that uses 2 high-dose estrogens (HD) pills (5). Previous studies have shown that this method achieves a success rate of 80% if these pills are consumed 72 hours after unprotected intercourse (7-10). Considering the phase of uterine cycle, OCPs can prevent pregnancy by various mechanisms, such as inhibition or delay of ovulation, disruption of corpus luteum formation, increasing the thickness of endometrial, biochemical changes, and interfering with implantation of ovules in endometrial (10, 11). Despite the efforts of the international community over the past 10 years, using EC method to prevent UP has been faced with restrictions. Huge numbers of women in the low-income countries do not have any information about EC, or have a negative attitude toward it (12). In addition, many evidences demonstrate that although many women are aware of the EC method, insufficient information leads them not to use this method, especially in women with low literacy levels (4, 8, 13, 14). Regardless of physical and mental problems, UP is responsible for 5% to 10% of maternal death, placing a huge economic burden on healthcare system, especially in developing countries. Hence, awareness of EC method can significantly contribute to a decrease in the rate of UP and reduce serious health complications (15, 16). The present study aimed at evaluating the knowledge and attitude of EC among married women in the reproductive age group.
2. Methods
This cross-sectional study was performed on 225 married women, aged 15 to 45 years, who were selected through simple random sampling from 500 women who had attended the gynecology clinics of Boo-Ali and Javaheri hospitals for routine check-ups in Tehran, Iran, from November 2014 to November 2015. The ethical committee of Azad University approved the study, and written informed consent was obtained from the participants. Exclusion criteria included pregnancy, psychosomatic disorders, hypothyroidism or hyperthyroidism, diabetes, smoking, alcoholism, and kidney or liver failure. Data were collected using 2 detailed questionnaires. Demographic characteristics consisted of age, race, education, geographic region, ethnicity, marital status, number of child, history of UP, and contraceptive method. To evaluate EC awareness and attitude, we used a self-administered questionnaire that was previously translated to Farsi by Delaram (The Cronbach’s alpha coefficient for internal consistency was 0.85, the validity of the questionnaire was detected by content validity, and reliability was 0.973) (13).
The questionnaire, besides compiling a limited sociodemographic profile, asked questions with yes, no and do not know options. Knowledge of EC was assessed through 5 questions that reflected common misconceptions regarding effectiveness, availability, safety, and mechanism; attitudes were assessed through 12 questions with yes and no options that reflected common deterrents to EC use. All the participants were examined by a gynecologist, and then they were educated about the EC face-to-face at the time of recruitment. Patients completed the questionnaires. Illiterate women participated in an interview conducted by 2 experienced authors. Analysis was done using Pearson correlation coefficient and logistic regression in SPSS 14.0; significance level was set at P < 0.05.
3. Results
A total of 225 women aged 15 to 49 years, who were in reproductive age, participated in this study. The average age of women was 27.3 ± 3.2. The demographic characteristics of the participants are presented in Table 1.
Demographic Characteristics of the Population Study (N = 225)
| Characteristics | No. | Percentage, % |
|---|---|---|
| Mean age in years | 27.3 + 3.2 | |
| Occupation | ||
| Working | 34 | 15.1 |
| House wife | 191 | 84.8 |
| Education | ||
| Primary and high school educated | 115 | 51.1 |
| Bachelor of science (BS) | 72 | 32 |
| Master of science (MS) and doctorate | 38 | 16.8 |
| Age, y | ||
| 15 - 19 | 9.3% | 9.3 |
| 20 - 29 | 132 | 58.6 |
| 30 - 39 | 60 | 27.1 |
| 40 - 49 | 12 | 5.3 |
| Number of children | ||
| None | 14 | 6 |
| One or two | 145 | 64.6 |
| Three or more | 66 | 29.4 |
There were nearly equal numbers of patients with primary and high school education (51.1%) and college education (48.9%). Of the study population, 84.8% were housewives and the others were working (
The frequency distribution of current contraceptive methods and awareness is presented in Tables 2 and 3. The highest awareness (100%) was among those using contraceptive methods, whose husbands were condom users, and the lowest awareness was among those using IUD. With respect to the relationship between awareness and age between groups, the most awareness was found in those aged 20 to 29 years. Among 132 individuals of this group, 33 (34.2%) had good awareness, however, the relationship between knowledge and age of the participants was not significant (P > 0.05).
Frequency Distribution by Awareness of Using EC Pills (N = 225)
| Awareness of Using EC Pills | No. | Percentage, % |
|---|---|---|
| Various aspects of using EC pills | 73 | 32.5 |
| Number of times to take pills | 74 | 32.8 |
| Correct distance between the two dose pills | 148 | 65.7 |
| Deadline for applying EC | 141 | 62.6 |
| Number of tablets per dose | 166 | 73.7 |
Frequency Distribution by Current Contraceptive Method and Awareness (N = 225)a
| Current Method | Awareness | |
|---|---|---|
| No method | 29 (12.8) | 19 (68.9) |
| Oral contraceptive | 83 (36.8) | 52 (62.6) |
| Injectable | 35 (15.5) | 12 (34.2) |
| IUD | 44 (19.5 ) | 13 (29.5) |
| Male condom | 13 (5.7) | 13 (100) |
| Withdrawal | 21 (9.3) | 7 (33.3) |
Attitudes toward the method were predominantly negative. With respect to the attitude of women in using EC method, 19.1% agreed to use it, 75.5% disagreed, and 4.4% had no opinion about it. In case of the probability risk for fetal disability in EC method users, 79.1% expressed their disagreement in using it and 11.1% agreed. Of the participants, 47.1% agreed that they had nausea and vomiting after taking the pills, and 35.2% agreed that this method may have serious complications (negative attitude). However, 45.7% of the participants believed in using EC despite its side effects (positive attitude). The most negative attitudes were seen in the manner of 21 (9.3%) patients aged 15 to 19 years. A total of 20 (8.8%) patients had a negative attitude. There was no significant relationship (P > 0.05) between attitude and age groups. With respect to the correlation between attitude and respondents’ number of children, the most positive attitude was found among groups with 1 and 2 children in 162 members of this group, and 43 (26.5%) individuals had positive attitude, which constituted 19.1% of the total participants. However, there was no significant relationship between the attitude and the number of children of the respondents in this study. There was a correlation between awareness and education of the participants, with a confidence level of 95% (P = 0.02), meaning that women with higher education levels are more aware of the EC method. Also, there was a significant relationship between awareness and prevention of pregnancy, with a confidence level of 90% (P = 0.03). There was no significant correlation between awareness and number of children of the participants (P > 0.05). However, in 12 mothers who had no children, 9 (75%) had proper knowledge of EC method compared to those mothers with 1 and 2 and 3 and 4 children, which were 56.7% and 47%, respectively. The most common source of information of women was health professionals, so 88.4% of women’s information about EC was obtained from midwives and physicians, while this percentage by friends and acquaintances, media, and academic courses was 5.3%, 3.1%, and 2.2%, respectively.
4. Discussion
Findings of this study revealed that attitude and awareness among women using EC method, which mainly consists of combined oral contraceptive pills, was relatively low. Thus, 38.6% of women under study were aware of the method (both correct and incorrect), and about 61.4% had no knowledge about it. Our participants’ awareness was lower than what has been reported in several developed countries including Sweden, USA (Boston), and Canada (17-19) and was higher than some developing countries including India, Nigeria, Kuwait, and Kenya (20-22). These results may be due to the higher socioeconomic level of the developed countries compared to developing countries. This study suggests that the education level of women increases their awareness toward EC. In this regard, a study in South Africa, as well as another study in Honduras, found a significant relationship between level of education and awareness among women (23, 24). Garcia et al. (23) showed that age is an effective factor in determining the level of women’s awareness. In this study, age also played an important role in increasing women’s awareness. So those with the maximum amount of information, with more than 50%, were aged 20 and 29 years. The present study examined the role of health personnel, academic courses, friends, and media in educating emergency pregnancy prevention methods. In our study, a large proportion of women had been counseled about EC by health professionals, and fortunately, it shows the sufficient knowledge of healthcare providers about EC and prescribing regimes, and this result is comparable with the study of Meyer et al. (2007) (24), in which the role of clinic was low (27%).
We found an obvious gap in the role of academic courses, in which only 2.7% of women gained information and this is similar to Myre et al. (2007) (24) research in South Africa with 5%. In the study of Langille and Delaney in Canada (19), girls obtained their EC information by classmates, sexual health education classes at school, and school’s health center. These results show the role of health education classes in improving the knowledge of EC. The role of media was also less frequently in our study. However, in the study of Aneblom in Sweden (17), the greatest amount of information was obtained by media (50.1%). The tangible lack of media and educational courses in Iran is comparable with that of the developed countries. In another study conducted in the US by Aiken et al. in 2005, it was found that urban young women’s knowledge and attitudes towards EC levels was significantly increased (73%) according to the educational intervention. Some researchers have reported similar results (25, 26). In our study, the level of awareness of EC among women without children was more than those with children, which is similar to a study conducted by Noahjah et al. in Iran (27). In both studies, an inverse relationship was found between number of children and education. Thus, as the level of education was increased, the number of children was reduced, which would have been caused by more knowledge of women about EC (27). In our study, the highest level of knowledge about EC was related to women, whose husbands were using condoms, which is similar to the study conducted in Canada by Harvey (28) and in Iran by Noahjah et al. (27). The reason of higher awareness of women about EC in our study and the 2 above- mentioned studies may be due to the coadministration of condom and contraceptive pills that are recommended by many researchers. The majority (73.6%) of women had a negative attitude toward EC. In our study, 41.6% of women, with undergraduate level education and bachelor’s degree, had a positive attitude toward EC method. The positive attitude of those with master and doctoral levels was 11.7%. Thus, there was no relationship between educational levels of women and their positive attitudes toward EC method. In a study conducted in Malaysia by Najafi, despite the low information of women about the EC pills compared to women in our study, 88% of women had a more positive attitude towards the EC. More women did not have enough information about the indications for use, mechanism of action, and side effects of taking EC (29).
It is concluded that UP is an important problem in Iran. In case of timely prevention, adverse consequences for the mother and child would be during through pregnancy. Universities, schools, and media have an influential role in educating women, and in case of applying them, they would play an important role in increasing women’s awareness and creating positive attitude towards using EC method. Increasing the quality of family plan consoling in health centers and emphasizing the advantages of EC method, such as its safety and not being in contrast with religious believes, to promote positive attitudes are highly recommended. Further studies should be conducted with larger sample sizes and in various populations.
Acknowledgements
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