Emergency contraception among young people in Uganda : user and provider perspectives

Background: The maternal mortality ratio for Uganda is 435/100,000 live births. Between 12-30 percent of the maternal deaths are due to induced abortions. According to the 2007 Uganda demographic and health survey (UDHS), the contraceptive prevalence rate was 24 percent and only 18 percent used modern contraceptives. The unmet need for family planning (FP) was 41 percent. Emergency contraception (EC) was officially launched in Uganda in November 1998 by the Ministry of Health with the aim of strengthening reproductive health.

Aim: This thesis explores and analyzes factors influencing accessibility, utilization and acceptability of emergency contraception among young people in Kampala, Uganda.

Materials and methods: The first phase of the study was exploratory. Four key informant interviews (KII), and seven focus group discussions (FGDs) were conducted including two male-only, two female-only and three groups with both male and female (I).The transcribed material was analyzed for latent content. In a cross sectional study at Makerere University, 379 students answered a self-administered questionnaire (II). Two-hundred forty-seven health care workers selected from 894 health units in Kampala completed a self-administered questionnaire about their knowledge and prescribing habits of EC (III).To study the acceptability of two EC Pill regimens, 337 women were enrolled in a randomized clinical trial in Kampala, Uganda. Women requesting EC pills within 72 hours after unprotected sexual intercourse received either levonorgestrel (LNG) or combined oral contraceptive pills (Yuzpe regimen). The women returned for follow up after three days and a follow-up interview was performed after one year (IV).

Results: Participants expressed ambivalence about EC pills. The method was generally recommended, but only to the right people , in this context being those aged 18 years and above (I). Less than half of the students (45.1%) had ever heard about EC Pills. The most common sources of information about EC were friends (34%) and media (24.8%). The ever pregnancy rate was 3.4 percent and 42 percent were in a steady relationship of three or more months. Among the 14.5 percent contraceptive ever users, the most common methods were condoms (48.9%) and withdrawal (23.4%). Thirty-five percent did not know when in the menstrual cycle they were likely to conceive (II). Among the HCWs, 80 percent had ever heard of EC. The Yuzpe regimen was the most commonly mentioned and prescribed method of EC. The HCWs attitudes toward EC were generally positive and it was suggested that the community should be informed and sensitized about EC. There was a significant difference between having had a family planning educational update or not in the last year and knowledge of EC (p value 0.005) (III). LNG had significantly fewer side-effects than the Yuzpe regimen (p < 0.001). There was a significant association between having worries about the method and experiencing the side-effects (p < 0.001). Both EC Pill regimens were acceptable for use by the studied women, but this could be because most (81%) were prime users of EC. The majority would recommend the EC Pill regimens for use by other clients (IV).

Conclusions: User and potential-user perceptions are crucial in the accessibility and utilization of EC Pill (I). Knowledge about EC and fertility awareness was low among the female first year university students. Friends and the media are an important source of EC information (II). Most HCWs were aware of EC, but some lacked important knowledge on its use and available methods (III). LNG is a superior option to the Yuzpe regimen, and should be promoted as the recommended EC Pill. Worries about the EC Pill, including the mechanisms of action, may influence the experience of side-effects and should be explored further (IV).

List of scientific papers

I. Byamugisha JK, Mirembe FM, Gemzell-Danielsson K, Faxelid E (2007). Faced with a double-edged risk: Ugandan university students perception of the emergency contraceptive pill. [Submitted]

II. Byamugisha JK, Mirembe FM, Faxelid E, Gemzell-Danielsson K (2006). Emergency Contraception and Fertility awareness among University Students in Kampala, Uganda. Afr Health Sci. 6(4): 194-200
https://pubmed.ncbi.nlm.nih.gov/17604507

III. Byamugisha JK, Mirembe FM, Faxelid E, Gemzell-Danielsson K (2007). Knowledge, attitudes and prescribing pattern of emergency contraceptives by health care workers in Kampala, Uganda. Acta Obstet Gynecol Scand. 86(9): 1111-6
https://pubmed.ncbi.nlm.nih.gov/17712653

IV. Byamugisha JK, Mirembe FM, Faxelid E, Tumwesigye NM, Gemzell-Danielsson K (2007). A randomized clinical trial of two emergency contraceptive pill regimens in a Ugandan population. [Submitted]