Pharmacists’ Knowledge and Perceptions of Emergency

Contraceptive Pills in Soweto and the Johannesburg

Central Business District, South Africa
By Kelly Blanchard, CONTEXT: In South Africa, emergency contraceptive pills are available directly from pharmacies without a prescrip-
Teresa Harrison tion, yet few studies have assessed pharmacists’ knowledge of and attitudes toward the medication.
and Mosala Sello
METHODS: In-person interviews were conducted with 34 pharmacists practicing in Soweto and the Johannesburg
Central Business District, from February through April 2003. The pharmacists provided data on their knowledge of
Kelly Blanchard is
president, and emergency contraceptive pills and their attitudes toward providing the medication to women in specific situations.
Teresa Harrison is
project manager, Ibis RESULTS: Nearly all pharmacists sold at least one of the two types of dedicated emergency contraceptive pills avail-
Reproductive Health, able in South Africa. Although most had accurate knowledge about the method’s dosing schedule, side effects and
Cambridge, MA, mechanism(s) of action, more than half erroneously believed that repeated use posed health risks. A large majority of
USA. Mosala
Sello is a consultant pharmacists believed the pills should be available to rape victims, to single or married women and to women who had
with the Population never given birth, but almost half did not think the pills should be given to women younger than 18, and a fourth said
Council, Johannes- they would not give them to women with a late menstrual period. About one-third to half of pharmacists supported
burg, South Africa. advance provision of the medication under certain circumstances. Most were willing to display promotional materials
on emergency contraceptives in their pharmacies.

CONCLUSIONS: Interventions aimed at educating pharmacists about the benefits of emergency contraceptive pills,
especially for adolescents, are needed. Government and medical authorities should take advantage of pharmacists’
willingness to display educational materials as a way to increase women’s knowledge and use of the medication in
South Africa.
International Family Planning Perspectives, 2005, 31(4):172–178

Emergency contraceptive pills contain either progestin alone protected intercourse.8 Although recent research has shown
or a combination of estrogen and progestin in higher doses that emergency contraceptive pills are still effective when
than regular oral contraceptives. If taken within 72 hours taken up to 120 hours after unprotected intercourse,9 other
of unprotected intercourse, they can reduce a woman’s risk research has indicated that the sooner they are taken, the
of pregnancy by at least 75%.1 They are safe and effective2 better they work.10 For some women, getting a prescrip-
and, according to World Health Organization guidelines, tion and locating a provider quickly enough may be diffi-
the only contraindication to use is a confirmed pregnancy.3 cult or impossible, particularly on holidays or weekends.
The pills are not harmful to a pregnant woman or her fetus, Forty-two percent of women in the U.S. state of California
and they will not terminate a pregnancy. Women taking these and 54% in Canada who obtained the pills through phar-
pills will sometimes experience short-term nausea and vom- macy access programs purchased the method within 24
iting,4 neither of which poses a significant health risk. Even hours of contraceptive failure or unprotected intercourse,
with repeated use, women would be exposed to lower hor- indicating that pharmacy provision allows for quick access
mone levels than if they used regular birth control pills, to this time-sensitive medication.11 In four European coun-
which themselves have an excellent safety profile.5 tries where emergency contraceptive pills are available di-
Although an estimated 76 million unintended pregnan- rectly from pharmacists, women reported that such provi-
cies occur every year in developing countries,6 research on sion improved access to the method.12
the global demand and need for emergency contraceptive According to the 1998 South Africa Demographic and
pills is scant. The consequences of these pregnancies, par- Health Survey, 61% of sexually active women used a mod-
ticularly where abortion is legally restricted, may be life- ern contraceptive method, yet 53% of all births were re-
threatening.7 To lower rates of unintended pregnancy, ported as mistimed or unwanted. Seventy-eight percent of
women need better access to both regular contraceptive births to women aged 19 or younger were unplanned.13 Fur-
methods and emergency contraceptive pills. thermore, a 2004 UNAIDS/World Health Organization re-
Pharmacy provision of these pills could increase access port estimated that about one in five adults in South Africa
by eliminating the barriers associated with obtaining a pre- are infected with HIV.14 Condoms are the most effective
scription from a health care provider within 72 hours of un- method of preventing HIV and STI transmission, yet only

172 International Family Planning Perspectives

6–16% of women (depending on marital status) aged 15–49 METHODS
reported condom use at last sexual intercourse.15 The use Between February and April 2003, we conducted a census
of emergency contraceptives as a backup for condom fail- of all pharmacies in Soweto and the Johannesburg Central
ure is an important option for women, and may encourage Business District. We identified 55 pharmacies through the
safer sexual behavior. A study from Mexico showed that use local pharmacy association, telephone books and word of
of emergency contraceptives was significantly associated mouth from other pharmacists. We visited each pharmacy
with an increased probability of condom use at last sexual to determine eligibility for the study; criteria included pro-
intercourse among adolescents.16 Two U.S. studies found viding retail pharmacy services and being located in the
that women may be more inclined to use condoms if emer- study area. Fifteen pharmacies were not eligible: Twelve did
gency contraceptives are readily available.17 not exist or did not operate in the area, two were whole-
In 2000, the South Africa Medicines Control Council re- salers and did not serve the public and one was not a licensed
classified emergency contraceptive pills so that pharmacies pharmacy.
could sell them without a prescription. Two dedicated prod- At the 40 eligible pharmacies, all of which provided fam-
ucts, one a combination of estrogen and progestin (E-Gen- ily planning products, head pharmacists or pharmacy own-
C) and the other containing progestin only (NorLevo), were ers were asked if they were interested in participating in a
available in South Africa at the time of this study. Emergency study of pharmacists’ knowledge and provision of family
contraceptives are also available free of charge at public planning methods. Twelve declined to participate because
health facilities, where staff typically “make their own” by of time constraints, leaving 28 pharmacies in our sample.
providing pills from regular oral contraceptive packets. We asked them to identify all pharmacists and assistant phar-
Several studies have examined pharmacists’ knowledge macists who provided medications; in most cases, the owner
of and attitudes toward emergency contraceptives. The or head pharmacist was the only eligible respondent. When
largest survey conducted in South Africa suggested that phar- more than one individual provided services, all were invit-
macists in Durban were moderately knowledgeable about ed to participate. We interviewed 34 individuals in 28 phar-
emergency contraception.18 Most pharmacists accurately macies: two pharmacists in six stores and one in each of the
described side effects and dosing requirements, but many remaining 22 stores. One pharmacist completed only a par-
inaccurately identified contraindications and expressed con- tial interview. By law, and in practice, only registered phar-
cern about repeat use. A separate analysis using the same macists and assistant pharmacists may dispense medica-
sample revealed that pharmacists believed that greater ac- tions and counsel clients in South Africa, so we did not
cess to emergency contraceptives would promote promis- interview other staff. We visited each pharmacy an average
cuity, increase the incidence of STIs and decrease the use of four times before an interview was conducted (range, one
of barrier methods.19 However, these data were collected to six times); each interview lasted 45–60 minutes.
prior to the legalization of pharmacist provision of emer- We adapted a questionnaire used in studies of knowl-
gency contraceptives in South Africa, which likely led to edge and provision of emergency contraceptives in Mexico
increased familiarity with the medications. and Kenya.22 We chose questions that were appropriate for
Among drug store personnel in Thailand, where emer- pharmacists in South Africa, and pretested the question-
gency contraceptives are available over the counter and naire with two pharmacists working in stores outside the
where nonpharmacists are allowed to dispense medications, study area. All interviews were conducted by a trained in-
overall knowledge and provision of the method were found terviewer. The questionnaire, which included both closed-
to be poor.20 Knowledge of timing and indications for use, and open-ended questions, covered demographic charac-
as well as quality of service, were better in pharmacist-owned teristics and professional background, and knowledge of
drugstores than in stores owned by nonpharmacists. Wide- the dosing schedules, side effects, mechanisms of action,
spread misinformation about dosing among drug store per- contraindications and effectiveness of emergency contra-
sonnel was likely due in part to incorrect product leaflet ceptive pills. We elicited their opinions on supplying emer-
information. gency contraceptives (at need or in advance) to women in
A study of pharmacists in the U.S. state of Pennsylvania, specific situations—having a late menstrual period or hav-
where the method is available only by prescription, found ing been raped—or on the basis of such personal charac-
that one-third of them knew the time limit for initiating teristics as age, marital status and having had children. They
emergency contraceptive pills; almost half correctly iden- were also asked whether their pharmacy did or would be
tified nausea and vomiting as side effects, and a small pro- willing to display promotional materials for emergency con-
portion believed that the pills caused abortions.21 Multi- traceptives. Finally, we asked pharmacists about stocking
variate analysis showed that more accurate knowledge was and sales of the medication in their stores.
a strong predictor of whether pharmacists stocked emer- The data were checked for completeness and accuracy,
gency contraceptives. and then coded for analysis by the second author. We used
Our study assessed pharmacists’ knowledge and per- SPSS version 11.5 to calculate proportions. Because this
ceptions of emergency contraceptive pills in two urban areas study was designed to be a descriptive assessment of phar-
of Johannesburg two years after the method became avail- macists’ knowledge and attitudes, we did not conduct tests
able without a prescription in the nation’s pharmacies. of significance.

Volume 31, Number 4, December 2005 173

Pharmacists’ Knowledge and Perceptions of Emergency Contraceptives

TABLE 1. Number of participating pharmacists, by demo- that the pills should be taken within 72 hours of unprotected
graphic and professional characteristics, Soweto and intercourse. Most also correctly identified nausea and vom-
Johannesburg Central Business District, South Africa, 2003 iting as possible side effects, and knew that the method
Characteristic No. worked by inhibiting ovulation, fertilization or implanta-
tion. More than half of respondents mentioned pregnancy
Age
20–29 11 as a contraindication; a similar proportion considered emer-
30–39 10 gency contraceptives to be “effective,” and one-third reported
40–49 6
≥50 6 that effectiveness was 50–100%. Six in 10 respondents be-
lieved that taking the pills more than once posed health risks
Gender
Male 20
to women. Only two pharmacists incorrectly described the
Female 14 medication as an abortifacient.
Race
African 22 Perceptions of Emergency Contraceptives
White 5 In general, respondents viewed emergency contraceptive pills
Indian 4
Coloured/other 2 as an effective option for women who want to avoid unintend-
ed pregnancy. The majority of pharmacists believed the pills
Pharmacist training should be provided to women who were nulliparous, single or
Pharmacy diploma or degree 24
Pharmacist assistance course 10 married, as well as to rape victims (Table 3). Fewer than half
thought the pills were appropriate for women younger than 18,
Yrs. of pharmacist experience
1–5 11 and a quarter felt the method was appropriate for women with
6–10 8 a late menstrual period.
11–20 5 About one-third of respondents reported that they did
21–30 7
31–50 3 not offer emergency contraceptives to minors (not shown).
Several pharmacists said that use of the pills promoted
Registered with national pharmacist association
Yes 29 promiscuity and repeat use, and increased the risk of con-
No 5 tracting HIV and other STIs. One commented that the
Trained in family planning
method “encourages people not to use precautions…[and
Yes 13 to overlook] the spread of STIs like HIV/AIDS.”
No 21 Pharmacists’ attitudes regarding advance provision of
Trained in emergency contraceptives emergency contraceptives were less favorable than for gen-
Yes 16 eral provision of the medication. Nonetheless, a majority
No 18
approved of their provision to married and single women,
Note: Ns may not total 34 because of nonresponse for some items. although smaller proportions approved of advance provi-
sion to nulliparous women or women younger than 18. Re-
RESULTS spondents who disapproved of advance provision said they
Characteristics were concerned that having an advance supply would en-
The mean age of respondents was 38 (range, 22–66 years);
the majority were male (20) and African (22—Table 1). Of TABLE 2. Number of pharmacists, by source of knowledge
about emergency contraceptive pills, and by accurate
the 34 respondents, 24 were head pharmacists with a diplo- knowledge and misperceptions regarding the pills
ma or bachelor’s degree in pharmacy and 10 were assistant
pharmacists. More than half (19) had worked as a pharmacist Characteristic No.

for 10 or fewer years, and most were registered with the na- Source
University 16
tional pharmacist association. Only 13 had training in fam- Pharmacy or hospital 12
ily planning, and 16 had specific training in emergency con- Peers or workshop 4
traceptives. Of this latter group, nine had been trained during Advertisement or customers 1
Do not know 1
university studies, three had attended a session given by
the pharmaceutical society and four had attended a session Accurate knowledge
Dosing schedule 30*
organized by their employer, a pharmaceutical sales repre- Side effects 28*
sentative or the department of health. Their average fami- Mechanism(s) of action 27*
ly planning client was 30 or younger, had a secondary ed- Contraindication 19*
Effectiveness
ucation and earned less than R1,000 per month (about Effective (nonspecific) 16
US$150). 50–100% 11
Other 7

Knowledge of Emergency Contraceptives Misperceptions

Repeat use is a health risk 20*
All respondents had heard of emergency contraceptive pills; Pills act as an abortifacient 2
the majority had first learned about them at university, or
in a pharmacy or hospital (Table 2). Most pharmacists knew *One pharmacist did not respond to these questions.

174 International Family Planning Perspectives

 TABLE 3. Number of pharmacists who believed that emer- available, though not required. A large proportion of phar-
gency contraceptive pills should be provided to women macists were knowledgeable about its dosing schedule, side
with specific characteristics, by type of provision effects and mechanism(s) of action, with fewer providing
Characteristic No. correct information on contraindications and effectiveness.
General provision Limited knowledge about contraindications, however, is
Rape victim 31 not necessarily a cause for concern. Pregnancy is the only
Married 29 contraindication, and even if a pregnant woman took the
Single 25
Nulliparous 23 medication, there is no evidence to suggest it would harm
<18 yrs. old 14 her or her fetus.23 Pharmacists did not appear to restrict ac-
Late menstrual period 8
cess to the method because of misperceptions about
Advance provision contraindications.
Married 18
Nearly all pharmacists reported selling emergency con-
Single 18
Nulliparous 15 traceptives, and most attributed this decision to customer
<18 yrs. old 10 demand. The large number of customer requests reported
Note: One pharmacist did not complete this part of the interview. elsewhere in South Africa suggests that pharmacists in urban
areas perceive customer demand to be substantial.24 There
courage women to use the pills as a regular form of con- are, however, no public statistics to determine actual de-
traception and would reduce the likelihood of their using mand, and research conducted among South African women
condoms for protection against HIV and STIs. indicates that knowledge and use of emergency contra-
Nearly all of the pharmacists sold at least one of the two ceptives are limited.25 Furthermore, pharmacists’ knowl-
dedicated products available in South Africa, with two-thirds edge about the pills may play an indirect role in their like-
selling both brands (not shown). Only two respondents did lihood of stocking and selling the method. For example,
not carry either product. One did not stock the pills for re- well-informed pharmacists in the United States are more
ligious reasons, but was willing to order the method on re- likely to carry the medication.26
quest. Another did not stock or sell them because his staff All but two of the pharmacists in our study supported
was not yet trained, although he anticipated selling dedi- pharmacy provision of emergency contraceptives, and most
cated emergency contraceptive products in the near future. viewed the method as an important pregnancy prevention
Most of the pharmacists had begun selling emergency option for women. Yet despite these generally positive per-
contraceptives in the five years prior to being interviewed; ceptions, a substantial number of pharmacists did not be-
the great majority of this group reported that customer de- lieve them to be appropriate, either on demand or in ad-
mand had prompted them to stock the method (not shown). vance, for women younger than 18, and admitted denying
A few respondents said that the policy change to make the minors access to the method. Other studies have shown that
pills available in pharmacies without a prescription had en- it is not uncommon for health care providers to impose age
couraged them to start selling the medication. Only one restrictions that deny young women access to hormonal con-
pharmacist disagreed with the policy, claiming that it pro- traceptives.27 The high rate of teenage pregnancy in South
moted promiscuity and unsafe sex. Africa provides evidence that adolescents need greater ac-
cess to emergency contraceptives. Incorporating informa-
Provision of Information tion about the public health benefits, particularly for ado-
One-fifth of the pharmacists provided clients with written lescents, into pharmacists’ family planning training could
materials on emergency contraceptives, and nearly two-thirds help to change attitudes and improve the availability of these
counseled clients on pregnancy prevention (e.g., by promoting contraceptives.
condom use or a regular form of contraception—not shown). Most pharmacists in our study mistakenly believed that
Almost one-third of pharmacists offered educational mate- repeated use of emergency contraceptive pills was associ-
rials on prevention of HIV and other STIs, and more than ated with health risks. Although the available evidence in-
three-quarters reported offering HIV and STI counseling. dicates that repeated use is safe,28 this concern has been ex-
Pharmacists thought the best ways to distribute information pressed by health professionals in a wide range of settings.29
about emergency contraceptives were through media ad- Such misperceptions are one reason some pharmacists are
vertisements, patient education and pamphlets. Four out of reluctant to provide the pills to women who need them on
five were willing to display promotional materials. A few said multiple occasions. Moral objections have also been shown
that counseling clients at pharmacies and antenatal clinics to result in limited provision of emergency contraceptives.30
would be an effective means of disseminating information. However, only two respondents said they believed the pills
acted as an abortifacient, and one of them nonetheless sold
DISCUSSION the medication.
Pharmacists in Soweto and the Johannesburg Central Busi- Pharmacists also expressed concern that increased ac-
ness District were familiar with emergency contraceptive cess to the method encouraged unprotected sexual inter-
pills. Nearly half had learned about the method while at uni- course or reduced routine contraceptive use. Research in a
versity, suggesting that some formal academic training was variety of contexts has shown that expanded access does

Volume 31, Number 4, December 2005 175

Pharmacists’ Knowledge and Perceptions of Emergency Contraceptives

not increase the rate of unprotected sexual intercourse, nor in South Africa, and thereby make an invaluable contribu-
does it change sexual behavior.31 The unfounded belief that tion to public health.
greater access results in risky sexual practices could be a
barrier to pharmacists’ willingness to provide emergency REFERENCES
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23. WHO, 1998, op. cit. (see reference 3).
ron la idea de suministrar este medicamento con antelación, en
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determinadas circunstancias. La mayoría estaban dispuestos a
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knowledge, attitudes and use among public sector primary health- Conclusiones: Es necesario realizar actividades dirigidas a
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26. Bennett W et al., 2003, op. cit. (see reference 21). doras anticonceptivas de emergencia, especialmente con rela-
27. Miller K et al., eds., Clinic-Based Family Planning and Reproductive ción a las adolescentes. El gobierno y las autoridades del sector
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Contraception, 2004, 69(4):339–342.
RÉSUMÉ
Contexte: En Afrique du Sud, la contraception d’urgence est
29. Hariparsad N, 2001, op. cit. (see reference 18); Langer A et al.,
1999, op. cit. (see reference 22); Gold M, Schein A and Coupey SM, accessible directement en pharmacie, sans ordonnance. Peu
Emergency contraception: a national survey of adolescent health d’études ont cependant évalué les connaissances et les attitudes
experts, Family Planning Perspectives, 1997, 29(1):15–19; and Golden des pharmaciens à l’égard du traitement.
NH et al., Emergency contraception: pediatricians’ knowledge,
attitudes, and opinions, Pediatrics, 2001, 107(2):287–292. Méthodes: Des entrevues personnelles ont été menées avec 34
30. Golden NH et al., 2001, op. cit. (see reference 29).
pharmaciens de Soweto et du centre des affaires de Johannes-
burg, de février à fin avril 2003. Les pharmaciens ont ainsi four-
31. Glasier A and Baird D, 1998, op. cit. (see reference 8); Jackson
R et al., Advance supply of emergency contraception: effect on use ni les données relatives à leur connaissance de la contraception
and usual contraception—a randomized trial, Obstetrics & Gynecology, d’urgence et à leurs attitudes à l’égard de l’apport du traitement
2003, 102(2):8–16; Raine TR et al., Direct access to emergency con- aux femmes dans des circonstances spécifiques.
traception through pharmacies and effect on unintended pregnan-
cies and STIs, Journal of the American Medical Association, 2005, Résultats: Presque tous les pharmaciens vendaient au moins
293(1):54–62; Lovvorn A et al., Provision of emergency contraceptive un des deux produits de contraception d’urgence disponibles en
pills to spermicide users in Ghana, Contraception, 2000, 61(4): Afrique du Sud. Si la plupart avaient une connaissance correc-
287–293; and Raine T et al., Emergency contraception: advance
provision in a young, high-risk clinic population, Obstetrics & te du dosage, des effets secondaires et du ou des mécanismes d’ac-
Gynecology, 2000, 96(1):1–7. tion de la méthode, plus de la moitié pensaient erronément que
l’usage répété posait des risques pour la santé. Une grande ma-
RESUMEN jorité de pharmaciens estimaient que la contraception d’urgen-
Contexto: En Sudáfrica, las píldoras anticonceptivas de emer- ce devrait être disponible aux victimes de viol, aux femmes cé-
gencia se pueden adquirir sin receta médica directamente en las libataires ou mariées et aux femmes qui n’ont pas encore eu
farmacias; no obstante, pocos estudios han evaluado el nivel de d’enfants, mais près de la moitié ne pensaient pas qu’il devrait
conocimientos de los farmacéuticos y sus actitudes con respec- l’être aux femmes de moins de 18 ans et un quart ont déclaré
to a este medicamento. qu’ils ne le donneraient pas en cas de retard des règles. Entre
Métodos: Desde febrero hasta abril de 2003 se realizaron en- tiers environ et la moitié des pharmaciens étaient favorables à

Volume 31, Number 4, December 2005 177

Pharmacists’ Knowledge and Perceptions of Emergency Contraceptives

la fourniture anticipée du médicament dans certaines circons-

tances. La plupart étaient disposés à présenter un matériel pro-
motionnel sur la contraception d’urgence dans leur pharmacie.
Conclusions: Des interventions destinées à éduquer les phar-
maciens sur les avantages de la contraception d’urgence, pour
les adolescentes surtout, sont nécessaires. Les autorités gouver-
nementales et médicales devraient tirer parti de la disposition
des pharmaciens à présenter un matériel éducatif pour accroître
la sensibilisation et le recours des femmes au médicament en
Afrique du Sud.

Acknowledgments
Charlotte Ellertson and Kate Miller provided comments on an early
draft of this article. The research was funded by the Tides Foundation.

Author contact: [email protected]

178 International Family Planning Perspectives