Pharmacists' Knowledge and Perceptions of Emergency Contraceptive Pills in Soweto and The Johannesburg Central Business District, South Africa
Pharmacists' Knowledge and Perceptions of Emergency Contraceptive Pills in Soweto and The Johannesburg Central Business District, South Africa
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
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
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
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Acknowledgments
Charlotte Ellertson and Kate Miller provided comments on an early
draft of this article. The research was funded by the Tides Foundation.