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Fadaei A et al., J Womens Health, Issues Care 2015, 4:2
http://dx.doi.org/10.4172/2325-9795.1000182
Journal of Women’s
Health, Issues & Care
Research Article
A SCITECHNOL JOURNAL
Knowledge, Attitude, and Practice
about Emergency Contraception
among Women in Shahriar,
Tehran, Iran
Akram Fadaei1, Ladan Haghighi2 and Marzieh Nojomi3*
1Master
of Family Medicine, Health affairs of Iran University of Medical Sciences,
Tehran, Iran
2Department of Obstetrics and Gynecology, Iran University of Medical Sciences,
Tehran, Iran
3Professor of Community Medicine, Department of Community Medicine, School
of Medicine, Preventive Medicine Research Center, Iran University of Medical
Sciences, Tehran, Iran
*Corresponding author: Marzieh Nojomi, Department of Community Medicine,
School of Medicine, Iran University of Medical Sciences, Crossroads of Hemmat
and Chamran Expressways 15875-6171, Tehran, Iran, Tel : +98 21 88602225;
Fax : +98 21 88602217; Email: [email protected]
Rec date: Jul 11, 2014, Acc date: Mar 03, 2015, Pub date: Mar 07, 2015
Abstract
Objective: The objective of current study is to determine the
knowledge, attitude, and practice of women who attended to
health care services regarding methods of emergency
contraceptive (EC) in Shahriar, Tehran, Iran.
Methods: Using a cross-sectional design over a period of three
months in 2013, data was collected. We used a convenience
method of sampling and married women of aged 15-49 years
old who attended to health care services in Shahriar were
enrolled. A self-administered and reliable (Cronbach’s
alpha=0.87) questionnaire with likert rating scale was used to
collect data.
Results: A total of 300 married women were enrolled in final
analysis. The mean age was 28.5 (± 6.7) years. Majority of
women were less than 34 years old (83%). Sixty percent of
women have ever heard about EC. Of the total, 18% of women
believed that using EC is illegal. Women who had ever taken
EC had a better knowledge about these methods. Education of
women was associated with knowledge about EC. Women who
had used EC at least once was younger than women who had
never used these methods significantly (27.5 ± 6 versus 29.2 ±
7) (P=0.04).
Conclusion: This study showed that knowledge and attitude of
studied women as a lay person about EC is almost fine and
acceptable respectively. The knowledge about various
methods of EC and golden time of using them was not satisfy.
Attitude about EC was acceptable especially for safety of these
methods. About one third of women reported ever use of these
methods.
Introduction
Unwanted pregnancy is an important issue in reproductive health
especially among young women in developing countries. Unintended
pregnancy could lead to unsafe abortion that is one of the most
important causes of maternal morbidity and mortality. Prevalence of
unwanted pregnancy in women who had attended to a general
teaching hospital in Tehran was estimated about 27% [1]. Almost 19%
of these women had a history of abortion [1]. In a population based
study in Tehran, the rate of abortion was reported 46%, in which,
about 21% was induced [2]. The history of abortion was more
prevalent in women aged 15 to 24 years versus older women [2].
Although total fertility rate in Iran is estimated 1.87 in 2012 [3], but
our country has a young population with 45% under 24 years old [4].
Therefore, control of unwanted pregnancy and abortion is an
important health issue for our policy makers. Beside the health effects
of unwanted pregnancy and abortion, and the economic implication of
this problem could be considered too.
Emergency contraception (EC) is a method to prevent pregnancy
after unprotected sex. This method could be used after a sex in which
contraception method did not work or women have used them in a
wrong way. Sometimes, this method recommended when no
contraceptive was used at all. Emergency contraception is effective just
in the first few days after coitus before the ovum is released from the
ovary and before the sperm fertilizes the ovum. There are two methods
of emergency contraception: emergency contraceptive pills (ECPs) and
copper-bearing intrauterine devices (IUDs). When inserted within five
days of unprotected intercourse, a copper-bearing IUD is the most
effective form of emergency contraception available. The emergency
contraceptive pill regimen suggested by World Health Organization is
one dose of levonorgestrel 1.5 mg, taken within five days (120 hours)
of unprotected coitus [5]. Levonorgestrel and Ethinyl Estradiol Tablets
Low dose (LD), High dose (HD), and Levonorgestrel (just progestogen
pill) are using as contraceptive pills in health care services in Iran.
It has been shown about 54% of unwanted pregnancy was occurred
in women who had used a method in a wrong way [1]. Using IUD and
contraceptive pills 72 hours after sexual intercourse could prevent
unwanted pregnancy 99% and 75-85% respectively [6-8].
The rate of unwanted pregnancy could be a criteria for not having
adequate knowledge about using contraception methods especially
emergency contraceptives. Using these methods as a second chance to
prevent pregnancy after sexual contact needs knowledge and positive
attitudes about them. A study was conducted in Shahrekord of Iran,
showed just 22% of women have adequate knowledge about these
methods [9]. There are three other studies about knowledge of using
EC in Iran in which medical science students [10], pharmacists [11]
and care providers in public health centers [12] were evaluated. We
could not find more studies about knowledge of using EC on lay
person but Shahrekord survey in Iran [9].
Therefore, the aim of current study is to evaluate the knowledge,
attitude, and practice of women who attended to health care services
in Shahriar, Tehran, Iran.
Keywords: Emergency contraception; Knowledge; Behavior;
Women; Health services
All articles published in Journal of Women’s Health, Issues & Care are the property of SciTechnol and is protected by
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Citation:
Fadaei A, Haghighi L, Nojomi M (2015) Knowledge, Attitude, and Practice about Emergency Contraception among Women in Shahriar, Tehran,
Iran. J Womens Health, Issues Care 4:2.
doi:http://dx.doi.org/10.4172/2325-9795.1000182
Material and Methods
Subjects and design
Shahriar is a city located in West of Tehran with 328,191
population. The residents of Shahriar are categorized as almost
medium/low income people. The literacy of majority of people is high
school graduated. This city has a large growth rate majority due to
immigration. Using a cross-sectional design over a period of three
months from August to November 2013 data was collected. We used a
convenience method of sampling to select eligible women for the
study. Married women aged 15-49 years old who attended to health
care services in Shahriar were enrolled. Women who had not enough
literacy to fill-out questionnaire was excluded (less than 5%).
Therefore convenience sample of 325 subjects were studied. The
device of collecting data was a structured questionnaire. Women were
asked when they were waiting for any visit in health care services. All
women signed informed consent to participate in the survey. This
study was approved by institutional review board of medical school of
Iran University of Medical Sciences.
respectively. To compare mean across two groups of demographic
variables independent sample t-test was used. Chi-square test was used
to compare categorical variables. Pearson correlation analysis was used
to assess relationship between numerical variables. Data analysis was
performed by SPSS version of 20.0 (SPSS Inc., Chicago, Ill., USA).
Significance was set at 0.05 for all analyses.
Results
Descriptive findings
Of the total attended women during study period, 60% (325
subjects) said that they ever heard about EC. This sample was enrolled
to the study. Out of 325 questionnaires, 300 completed questionnaires
were returned. Finally, 300 married women aged 15-49 years old were
analyzed (response rate of 92%). The demographic and some
reproductive variables of the respondents are shown in Table 1.
Characteristics
Number
percent
Age (n=300)
Measures and device
15-24
94
31.3
A self-administered questionnaire that was used in a national wide
survey conducted by Ethiopian Family Guidance Association (FGAE)
in 2002 [7] was applied to the subjects in current survey. We made
some modifications to the items to make them customize for using in
our subjects.
25-34
155
51.7
35-49
51
17.0
Preliminary
61
21.0
Secondary & High school
92
31.7
High school graduated
122
42.0
Academic
15
5.0
Less than 2000,000
27
9.0
2000,000 – 6000,000
223
76.3
More than 6000,000
42
14.3
Preliminary
99
33.3
Secondary & High school
102
34.2
The questionnaire was tested in a small sample of women (n=30) as
a pilot stage to test clarity and reliability of items. The Cronbach’s
alpha for knowledge and attitude domains were 0.87 and 0.82
respectively.
High school graduated
88
29.5
Academic
9
3.0
Statistical methods
None
46
15.3
Internal consistency reliability of dimensions of the questionnaire
was assessed using the Cronbach's alpha coefficient. Alpha values
equal to or greater than 0.70 were considered satisfactory. Frequency
tables and central tendency index (mean and standard deviation) were
used to describe categorical and numeric variables respectively. In
order to compare knowledge based on explanatory variables, we
scored items of knowledge as two score for correct answers and one
score for wrong answers. Then we calculated mean as average of
knowledge. Maximum and minimum scores were two and one
One or two
199
66.5
Three and more
50
16.7
Yes
152
52.2
No
139
47.7
The questionnaire in current study had five sections. The first two
parts were assessed demographic and obstetric characteristics of
women. Age, education, income and education of spouses of women
were collected as demographic variables. Obstetric/gynecologic history
was evaluated using five items included: number of children, ever
using of contraceptives method, history of unwanted pregnancy, ever
using of EC, and the source of taking knowing about EC. The staff of
health centers asked about the “ever heard of EC” at the first of
recruiting the women. If they answered “no”, they were excluded.
The third to five sections of questionnaire were evaluated
knowledge, attitude, and practice of women about EC respectively.
Knowledge about EC was evaluated through fourteen questions with
“yes” and “no” answers. Using ten and three questions attitude and
practice of women about EC were assessed respectively. A likert scale
with three points ranged from “agree/no idea/ to disagree” was used to
assess attitude.
Volume 4 • Issue 2 • 1000182
Literacy (n=290)
Income (Rials, Iranian Currency) (n=292)
Education of spouse (n=298)
Number of children (n=299)
Ever use of contraception (n=291)
Unwanted pregnancy (n=297)
• Page 2 of 5 •
Citation:
Fadaei A, Haghighi L, Nojomi M (2015) Knowledge, Attitude, and Practice about Emergency Contraception among Women in Shahriar, Tehran,
Iran. J Womens Health, Issues Care 4:2.
doi:http://dx.doi.org/10.4172/2325-9795.1000182
Table 2 illustrates the responses to items regarding knowledge
about EC. Majority of women (more than 70%) did not know EC
could be used till six and seven days after unprotected coitus. About
two third of respondents did not know that contraceptive pills could
be used as EC. This rate about using IUD as an emergency
contraceptive was 64%. Mean and standard deviation for knowledge
were 1.38 and 0.23 respectively.
Yes
66
22.2
No
231
77.7
Health care services
237
79.0
Media
27
9.0
Attitude of participated women about EC was shown in Table 3.
Other (friends, relatives,..)
36
12
Item
Num
ber
Perc
ent
Using this method is illegal
54
18.2
This method can produce problems for reproduction in future
61
20.7
Men can force women to use this method if they know about
that
54
18.2
Using this method could prevent from unwanted pregnancy
129
43.3
This method could be useful for abortion
27
9.3
Using this method maybe dangerous for women in future
83
28.2
If I know this method is safe, I’ll use it in future
122
41.4
Using this method just by physician’s prescription is possible
132
44.4
This method should not be used without consultant with
physician
140
47.3
This method is not accessible for public use
116
39.1
Source of taking information
about emergency contraception (n=300)
Table 1: Socio-demographic and reproductive characteristics of
women in Shahria
The mean age was 28.5 (± 6.7) years. Majority of women were less
than 34 years old (83%). Academic degree was just for 5% of
respondents, and about 85% had less than 6000000 Rials (Iranian
currency) per month. About 17% of women had three or more
children, and 52% had a history of taking contraceptives. The rate of
unwanted pregnancy was 22.2%. Health care services were the main
source of taking information (79%) about EC for respondents.
Item
Yes
No
Is it possible using EC after rape?
118
(40.5)
173
(59.5)
Is it possible using this method after rupture of condom?
160
(58.1)
125
(43.9)
Is it possible using this method after forgetting to take pills?
135
(47.0)
142
(53.0)
Is it possible using EC instead of an ordinary contraception
sometimes?
123
(44.2)
155
(55.8)
Is it possible using this method immediately after coitus?
136
(47.1)
153
(52.9)
Is it possible using this method until 6 days after unprotected
coitus?
94
(32.9)
192
(67.1)
Are some methods of EC useful until seven days after coitus?
40
(13.3)
240
(80.0)
Could this method prevent unwanted pregnancy up to 90%?
168
(58.9)
117
(41.1)
Is it possible using low dose pills as a method of EC?
87
(33.6)
172
(66.4)
Is it possible using high dose pills as a method of EC?
129
(45.3)
155
(54.4)
Regarding evaluation of women’s practice about EC, 33% reported
ever using of EC as a method of contraception. About 39% of these
women said that health care staff offered this method as an EC to
them. This proportion for offering from their spouse was 31%. The
reasons of using EC for more than one third of women, who had a
history of using them, were rupture of condom and forgetting to take
oral contraceptives.
Is it possible using Levonorgestrel (just progestogen pill) as an
EC?
135
(46.9)
152
(52.8)
Analytic findings
Is it possible using triphasic pills as an EC?
105
(38.0)
171
(62.0)
Knowledge
Is it possible using IUD† as an EC?
102
(35.8)
183
(64.2)
Women who had ever taken EC had a better knowledge about these
methods versus women without history of using EC significantly (1.50
± 0.19 versus 1.32 ± 0.22) (P=0.0001)
*The correct answer for all items is “yes”
†Intra uterine devices
Table 2: Knowledge about emergency contraception (EC) among
women in Shahriar.
Volume 4 • Issue 2 • 1000182
Table 3: Percentage of answers of “agree” to items of assessing attitude
about emergency contraception among women in Shahriar.
Of the total, 18% of women believed that using EC is illegal. Just 9%
of women believed this method could be used as a method for
abortion. About one third of women believed this method could be a
risk for health of them in future. Ordering of EC method just by
physicians (is not an over-the-counter drug) was belief of 44% of
women. Of the total, 39% believed that EC methods are not accessible
for public.
Women with positive history of unwanted pregnancy had a higher
score for knowledge about EC compared to women who had not a
history of unwanted pregnancy significantly (1.45 ± 0.23 versus 1.36 ±
0.23) (P=0.01). Education of women was associated with knowledge
about EC. Women with education more than preliminary had a better
• Page 3 of 5 •
Citation:
Fadaei A, Haghighi L, Nojomi M (2015) Knowledge, Attitude, and Practice about Emergency Contraception among Women in Shahriar, Tehran,
Iran. J Womens Health, Issues Care 4:2.
doi:http://dx.doi.org/10.4172/2325-9795.1000182
knowledge about EC versus women with preliminary education (1.42
± 0.24 versus 1.30 ± 0.22). This difference was significant (P=0.003).
There was an almost weak and significant correlation between age of
women and knowledge about EC (r=-0.15, P=0.01). Younger women
had a better knowledge. There was not any significant correlation
between knowledge about EC and number of children. There was not
any significant association between knowledge about EC with income
and education of women’s spouses.
Practice
Women who used EC at least once was younger significantly than
women who never used these methods (27.5 ± 6 versus 29.2 ± 7)
(P=0.04). Number of children of women who had used these methods
was less than women who had not taken EC (1.4 ± 0.98 versus 1.6 ±
1.2). This difference was not significant. There was an association
between education of women and using EC. Proportion of high school
graduated was 42.4% and 29.3% in women who had taken and had not
taken EC respectively (P=0.0.3). Women who had used at least once
EC had more monthly income compared to women who had not taken
these methods significantly (P=0.01). Sixty four percent of former
group versus 48% of later group had more than 4000,000 Rials
monthly.
Discussion
The objective of current study was to determine knowledge, believes
and practice of women regarding EC in Shahriar, Tehran. These
methods have an important role on unwanted pregnancy leading to
unsafe abortion as a main cause of maternal morbidity and mortality.
We showed 60% of women had heard about EC. About half of women
believed this method could be used to prevent unwanted pregnancy.
Younger women ever used more EC than older ones.
A study in Trinidad, Spain, has reported 63% awareness about EC
among university students [13]. This proportion in another study on
female university students in Ethiopia was 43.5% [14]. The awareness
about EC were reported more than 90% in United States of America,
and in United Kingdom [15,16]. It shows awareness about EC among
women in current study was almost high. Because, studied women in
current study were lay person with average literacy. But, majority of
mentioned studies were conducted on university or college students.
Out of women who had heard about EC, the main source of
information was health care services (79%). Media, friends, and
relatives were reported as the source of information just for 21% of
respondents. In other similar studies, the most important reported
sources were media, and friends [13,14]. This finding shows health
care services and their staffs (primary care physicians, nurses, and
other para-medical staffs) have an important role on awareness of
women in our setting. This finding has an important message, that is,
knowledge gained from a reliable source. It has been shown knowledge
gained from friends or family is often unreliable and misleading [17].
We showed the general level of knowledge about EC is satisfied.
Responses to majority of items (but one) assessing knowledge about
EC was almost correct for half of women. Because the studied women
were selected from a low educated population, this finding is
acceptable. For one item in which effectiveness of EC till seven days
after unprotected coitus was asked, the response was correct just for
13% of women. It is an expected finding, because it is a long time after
unprotected coitus, and majority of people think this method could
not act on pregnancy till seven days.
Volume 4 • Issue 2 • 1000182
The attitude of women towards EC was almost acceptable overall.
Almost 21% of women believed that the using EC could produce
reproductive problems for them. This low percent shows a positive
attitude about using EC and tell us majority of studied women
believed these methods are safe. Safety of methods of pregnancy
contraception is an important factor to promote using them. In study
on students in Trinidad about 76% of subjects thought that EC are
harmful for the body, and 31% believed that EC may effect on
pregnancy in the future [13].
Forty four percent of the women believed that EC could prevent
unwanted pregnancy. This is an important finding because could show
these women knew about using these methods in case of unprotected
coitus. Almost 9% of women thought these methods are not useful for
abortion. This finding could be addressed as a positive attitude because
actually using EC is not acceptable for abortion and using them has
time limitation.
About 44% of women believed these methods are not available
without prescription. In study of Parey et al. about 60% of subjects
knew these methods are available without prescription [13]. This
finding in current study shows women need more knowledge about
accessibility of these methods.
Strength points of current study included, studying on lay person
about EC, and addressing knowledge, attitude, and practice of women
about using EC together. We could not find similar study in our
setting. One of the limitations of current study was almost small
sample size, studying on a specific group of women versus population
based. Using such a convenient sample could limit the generalizability
of findings.
In conclusion, our study showed that knowledge of studied women
about EC is almost satisfy. The knowledge about various methods of
EC and period time of using them were not fine. Attitude about EC
was acceptable overall, specially for safety of these methods. About one
third of women were reported ever used of these methods. Ever using
of EC was associated with age and education of women. Younger and
educated ones used these methods more than versus groups.
Education of women also had a positive association with knowledge
about EC.
Acknowledgements
This study was approved and funded by Iran University of Medical
Sciences.
References
1.
2.
3.
4.
5.
6.
Nojomi M, Zeinali Z (2005) Study of unwanted pregnancy
prevalence and related factors in women referred to prenatal
clinics of Akbar-Abadi and Rasoul-e-Akram hospitals in 2002.
Iran University of Medical Sciences Journal 12: 195-200.
Nojomi M, Akbarian A, Ashory-Moghadam S (2006) Burden of
abortion: induced and spontaneous. Arch Iran Med 9: 39-45.
www.indexmundi.com/iran/total_fertility_rate.html
www.indexmundi.com/iran/demographics_profile.html
www.who.int/mediacentre/factsheets/fs244/en/
www.cecinfo.org/custom-content/uploads/2014/01/
ICEC_Medical-and-Service-Delivery-GuidelinesEnglish_June-2013.pdf
• Page 4 of 5 •
Citation:
Fadaei A, Haghighi L, Nojomi M (2015) Knowledge, Attitude, and Practice about Emergency Contraception among Women in Shahriar, Tehran,
Iran. J Womens Health, Issues Care 4:2.
doi:http://dx.doi.org/10.4172/2325-9795.1000182
7.
8.
9.
10.
11.
12.
FGAE (2002) Base line survey of the coital dependent methods
project of the Family Guidance Association of Ethiopia and
Population Council.
Friedman S, McQuaid, Grendell J (2003) Current Obstetrics &
Gynecology Diagnosis & Treatment. (9th edn), McGraw-Hill
Companies.
Delaram M (2008) Knowledge and perception of emergency
contraception of women in Shahrekord-Iran. J Fam Reprod
Health 2: 143-146.
Delaram M, Rafie H (2012) Knowledge and attitudes of
emergency contraception among medical science students.
Future of Medical Education Journal 2: 9-13.
Mostafavi SA, Sabzghabaee AM, Mirmoghtadaee P, HoseiniBiuki SM (2011) Emergency contraception and the knowledge of
community pharmacists in isfahan, iran. Int J Prev Med 2:
252-255.
Mohammad-Alizadeh-Charandabi S, Farshbaf-Khalili A,
Moeinpoor R (2011) Emergency Contraception: Providers’
Knowledge and Attitudes and Their Relationship with Users’
Knowledge and Attitudes at Public Health Centers/Posts of
Tabriz. J Caring Sci 6: 48-54.
Volume 4 • Issue 2 • 1000182
13.
14.
15.
16.
17.
Parey B, Addison L, Mark JK, Maurice B, Tripathi V, et al. (2010)
Knowledge, attitude and practice of emergency contraceptive
pills among tertiary level students in Trinidad: A cross-sectional
survey. West Indian Med J 59: 650-655.
Tamire W, Enqueselassie F (2007) Knowledge, attitude, and
practice on emergency contraceptives among female university
students in Addis Ababa, Ethiopia. Ethiop J Health Dev 21:
111-116.
Vahratian A, Patel DA, Wolff K, Xu X (2008) College students'
perceptions of emergency contraception provision. J Womens
Health (Larchmt) 17: 103-111.
Graham A, Green L, Glasier AF (1996) Teenagers' knowledge of
emergency contraception: questionnaire survey in south east
Scotland. BMJ 312: 1567-1569.
Kongnyuy EJ, Ngassa P, Fomulu N, Wiysonge CS, Kouam L, et
al. (2007) A survey of knowledge, attitudes and practice of
emergency contraception among university students in
Cameroon. BMC Emerg Med 7: 7.
• Page 5 of 5 •