Emergency Contraceptives: Knowledge and Practice towards Its Use among Ethiopian Female College Graduating Students

Introduction Ethiopia has a high incidence of unwanted pregnancies and incomplete and unsafe abortions, particularly among adolescents. This can be avoided by using different contraceptive methods including emergency contraceptives (EC). This study aimed to assess the knowledge and practice of EC among female college graduating students in Harar, Eastern Ethiopia. Methods Institution based cross-sectional study was conducted on 214 female students selected from two randomly selected colleges. Data was collected using a self-administered questionnaire and analyzed using SPSS for Windows version 20.1. Level of significance was taken at P <0.05. Results The mean (±SD) age of the participants was 21.06 (±2.14) years. Of the 200 (93.5%) study participants who had ever heard of ECs, 140 (70.0%) had good knowledge. Among the 214 graduating female students, 66 (33.0%) had ever used EC. Being above the age of 20 years old, father's and mother's literacy were found to be determinants of knowledge of EC. Moreover, knowledge was the only determinant factor of practice of EC. Conclusion Most of the respondents had relatively good knowledge of EC. The study revealed that female students of older age and higher educational status of parents had higher knowledge and practice of EC.


Introduction
Unintended pregnancy and unsafe abortion can be prevented by access to contraceptive methods including emergency contraceptives (EC). EC is a method used to avoid pregnancy after unprotected sexual intercourse. It is used before the potential time of implantation, unlike the regular contraceptive methods that are administered before the act [1]. EC can reduce the risk of unintended pregnancy by 75% to 99% if taken within 72 hours of sexual intercourse [2,3]. ECs are cost-effective, medically safe, and highly effective to be used for the prevention of unplanned pregnancy and subsequently avoid unsafe abortion and other consequences [4].
An estimated 80 million unintended pregnancies occurred in 2012 in the developing world, resulting in 40 million abortions and 10 million miscarriages [5]. About one-third of unintended pregnancies each year result from the incorrect use or failure of contraceptives [6]. World Health Organization (WHO) estimates that every year, nearly 5.5 million African women have unsafe abortions. Moreover, 59% of all unsafe abortions in Africa are among young women aged 15-24 years [7].
Unsafe abortion due to an unplanned pregnancy is one of the main causes of maternal morbidity and mortality in Ethiopian women [8,9]. Several studies in the country have revealed that women who tend to undergo induced abortions are below the age of 30 and above the secondary educational level [10][11][12]. Young people today start sex before marriage. Thus, they face a greater risk of unintended pregnancy [13].
Studies conducted in Ethiopia [1,[14][15][16] indicated that awareness of EC is less than 50% and utilization is below 10%. These limited studies conducted on the issue of EC in the country were mostly focused on university students, who are believed to have better overall knowledge than 2 International Journal of Reproductive Medicine college students [17]. Studies conducted in college students were not specific to their year of study, which was found to be determinant of knowledge of EC among female college students [18]. Thus, the aim of the present study was to assess determinants of knowledge and practice of ECs among female college graduating students in Harar town, eastern Ethiopia.

Study Design and Data
Collection. An institution based cross-sectional study was conducted in June 2016 among graduating female college students from selected colleges in Harar town. Sample size was determined using the simple proportion formula for cross-sectional study and taking the proportion of 21.9% for good knowledge of EC [18]. The multistage sampling techniques were used to approach the participants. Since the source population was less than 10,000, finite population correction was made, which brought the sample size to 214. Then, the sample size to each selected college and respective departments was then allocated proportionally using total number of female graduating students. Finally, the study participants were selected randomly ( Figure 1). The study was conducted by means of a self-administered questionnaire survey. The questionnaire included questions on demographic variables, sexual practice, and knowledge and practice of EC.

Data Analysis.
Following data collection, a unique code was assigned to each questionnaire. Data was then entered, cleaned, and imported to SPSS version 20.1 for analysis. Both bivariate and multivariate analysis techniques were applied to identify the factors associated with knowledge towards EC. The variables that were significant in the bivariate analysis were reexamined using stepwise binary logistic regression, to identify the significant predictors after controlling for other variables. P values less than 0.05 were considered as statistically significant.
The respondent's knowledge scores were aggregated and ranged 0-9. Based on the cumulative score, respondents who scored 5 (mean score) and above were considered to have "good knowledge", while those who scored below the mean score were considered to have "poor knowledge". Practice was determined based on every use of EC after exposure to unprotected sexual intercourse to prevent unintended pregnancy.

Ethical Consideration.
The study was carried out after obtaining ethical clearance from Institutional Ethical Clearance Board of Harar Health Science College and permission from the dean offices of selected colleges. All participants were informed about the objectives and their right to leave the study at any time they wished. A verbal consent was obtained from all participants. Confidentiality of the participants was maintained at all times. To further maintain anonymity, no forms of identifiers were in the questionnaires, as code numbers were used and only data collector and supervisor were involved in the data collection and supervision process.

Sociodemographic Characteristics.
A total of 214 female students of the graduating class participated in the study. The mean (±SD) age of the participants was 21.06 years (± 2.14). Ninety (42.1%) of them were midwifery students followed by nursing students (16.4%). As it is shown in Table 1, most of the respondents 164 (76.6%) were urban residents. Nearly three fourths (74.3%) of the respondents were unmarried. The majority (132; 61.7%) of the participants were living with their parents (Table 1).

Knowledge of Emergency Contraceptives.
Majority of the participants (93.5%) reported that they had heard about EC. Only those respondents who had heard of EC (200) were further analyzed for having knowledge and practices. The overall summary index for knowledge disclosed that 140 (70.0%) of the study participants had good knowledge about EC ( Figure 2). The main sources of information about EC were college (40.5%) followed by healthcare workers (29%) and mass media (24.5%). Most of the respondents 130 (65.0%) could identify the correct timing for administration of emergency contraceptive pills after unprotected sex. However, only 54 (27.0%) could tell the correct timing of insertion of the intrauterine contraceptive device (IUCD) ( Table 2).

Practice of Emergency Contraception and Sexual Activity.
Among female graduating college students who had ever heard of EC, almost one-third (33.0%) of them had ever used EC Pills ( Figure 2). However, none of the women had ever used IUCD. Pills missed, failed withdrawal, timing miscalculation, and condom slippage were the commonly stated reasons for using EC each accounted for 15 (22.7%), 9 (14.0%), 9 (13.6%), and 8 (12.1%), respectively. Seventyone (55.9%) of participants started sex below age of 20 years. Among the sexually active students, 30 (23.6%) had an experience of pregnancy. Unintended pregnancy were observed in 20 (15.7%) of participants (Table 3).

Determinants on Knowledge and Practice of EC.
Sociodemographic factors, age and educational status of the respondents' parents, showed a significant association with good knowledge of EC in multivariate logistic regression analysis. Females who were older (>20 years) were 6.09 times more likely to have good knowledge of EC than their younger     (Table 4).
Among variables, which showed association with bivariate logistic regression analysis, only having good knowledge of EC showed a significant association with student's ever utilization or practice of EC in multivariate analysis. Accordingly, students who had good knowledge of EC were 2.53 times more likely to practice EC than those who had poor knowledge of EC (AOR: 2.53, 95%CI: 1.29, 4.92) ( Table 5).

Discussion
Unlike other contraceptive medicines, EC is not given regularly. It is given in cases of unprotected sexual relations, which carry the risk of undesired pregnancy [16]. Awareness of the accessibility and being taken within the defined time period are necessary for appropriate and effective use of EC [19,20].
Majority (94%) of the study participants included in the study were aged 24 or below, which is considered a sexually active age group [21]. This finding is also in line with a similar study done in Nigeria [22]. The overall prevalence of awareness among the study participants was 93.5%. This finding is higher as compared to studies done in different parts of Ethiopia: Haramaya (47.6%) [14], Adama [15] (46.8%), 6 International Journal of Reproductive Medicine  Jimma (41.9%) [16], Ambo (80.7%) [17], Arba-Minch (42.5%) [18], Hosanna (45%) [23], and Debre-Markos (71.1%) [24]. However, this finding is comparable to the result of studies in Mekele (90.7%). Similar levels of awareness prevalence were also recorded in India (92.7%) [25,26]. In the present study, the major source of information about EC was college, unlike a study done in Addis Ababa [27] whereby participants relied on friends and family for knowledge of EC. Nearly three quarters (70.0%) of the respondents had good knowledge of EC in this study, which is superior to the result obtained in the studies conducted among Ethiopian colleges and university female students in Haramaya (25.7 %) [14], Arba-Minch (21.9%) [18], and Debre-Markos (62.5%) [24], Mizantepi [28] and elsewhere in India [26] and Nepal [29]. This difference might be attributed to a better free discussion on sex and sexuality among female students in Harar. However, the finding is unexpectedly lower than a study conducted among female preparatory students in Mekelle where 75.7% of the students had good knowledge of EC [25]. Moreover, in this study 130 (65%) of the participants correctly identified the time limit of EC pill use, which is superior to a study done by Abate et al., 18.5% [30]. This could be due to the high health promotion and availability of EC in pharmacies found [31] in Harar.
The finding showed that unintended pregnancies were observed in 20 (15.7%) of the respondents, which is slightly lower than study conducted in northwest Ethiopia (16.5%) [31]. However, it is much lower than the result reported in the national figure EDHS 2011 (24%) [32], and GanjoWoreda (27%) [33]. In the present study, about a third (33.0%) of the respondents had ever used EC. This finding is higher than the study conducted in Dilla (20.9%) [34]. It is also higher than EC use reported in Nigeria and India [26,35]. This may be explained by wide availability of EC in Ethiopia particularly in major cities [30] and longer college stay.
In this study, age of the student showed a statistically significant association with good knowledge of EC. In agreement with this study, multiple studies [14,24,25] have reported a significant association between older age and good knowledge of EC. However, other study done by Melkam et al. [19] reported a contrary finding. This study, furthermore, revealed that EC knowledge was significantly higher for respondents whose parents were literate compared to those with nonliterate parents. This finding is consistent with the conclusion made by different researchers [18,24], in which literacy improves one's access to information and facilitates discussion of reproductive health issues in the household.
The present study also showed that female students who had adequate knowledge of EC were more likely to use EC than their counterparts, which was in agreement with studies from Ethiopia and other countries [18,24,26,36].

Conclusion and Recommendation
In this study, respondents' knowledge of EC is found to be acceptable. This study revealed that age and parents' literacy showed statistically significant association with good knowledge of EC and in turn good knowledge of EC was the only determinant of using EC. To prevent unintended pregnancy among sexually active female college students, sexual education given at high school or counseling provided to college students is highly recommended.

Data Availability
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Ethical Approval
Ethical approval was obtained from research and ethics committee of Harar health sciences college, Harar, Ethiopia.

Consent
Since none of the respondents are below the age of 16, informed consent to participate in the study was obtained from participants themselves.

Conflicts of Interest
We declare that we have no conflicts of interest.

Authors' Contributions
Kirubel Minsamo Mishore, Abebaw Demissie Woldemariam, and Solomon Assefa Huluka conceived the study and participated in the design, data analysis, and interpretation of the result. Kirubel Minsamo Mishore was involved in data acquisition and writing of the draft manuscript as well as editing it per the suggestions of the coauthors. Abebaw Demissie Woldemariam and Solomon Assefa Huluka critically reviewed the manuscript. All authors read and approved the manuscript.