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Emergency: Stigma and neglect conspire against SA women

Healthworker hostility and a lack of information are denying women access to emergency contraception, locking them into an unintended fate.

Many South African women become burdened with unintended pregnancies because they are not aware of, or can’t access, emergency contraceptives, according to Helen Rees of the Reproductive Health and HIV Institute at the University of the Witwatersrand.

Emergency contraceptives, often referred to as the morning after pill, are used after unprotected sexual intercourse (before pregnancy is established) in order to reduce the risk of pregnancy, according to the health department’s 2012 national contraception guidelines.

“Younger women and those in poorer settings are seemingly unaware of this useful technology and yet most health facilities have the products,” Rees said.

Emergency contraceptives can “be used at any time in the menstrual cycle within five days of unprotected sexual intercourse”, according to the national guidelines.

“Unprotected intercourse includes situations when a contraception method fails [for example, if a condom slips or breaks, or an intrauterine device is expelled], situations when a method was used incorrectly [such as if someone skipped their pill or went late for their injection] or not used at all.”

In addition to the morning after pill, which has to be taken within 120 hours (five days) of unprotected sex, there is another emergency contraception option available in South African public health facilities, namely the copper intrauterine device, which has to be inserted within five days after unprotected intercourse, according to the guidelines.

Challenges and barriers

Judgmental attitudes of healthcare workers towards women seeking this option are another of the barriers to the use of emergency contraceptives, said Rees.

“Provider attitude is pertinent in getting across information and raising awareness around emergency contraceptives,” she said. It was critical that the providers of emergency contraceptives be capacitated enough to dispense appropriate and adequate information on the “rescue” method.

According to Rees, “there is no database to actually provide statistics on women who have used or are using this option” but “the high teenage pregnancy and abortion rate in South Africa is a sure sign that many are not taking advantage of this method”.

During the launch of the health department’s national family planning campaign in February, Health Minister Aaron Motsoaledi said that each year about 8% of all deliveries (80 000 babies) are to young people under the age of 18 years old, but that these minors contribute to 36% of all maternal deaths.

According to a 2012 report published by the United Nations Population Fund there are 54 adolescent births (between the ages of 15 and 19) per 1 000 live births in the country, which is slightly higher than the global average of 49.

Body weight myths

South Africa, however, is not the only country that is faced with an accessibility challenge. According to a 2013 global review on emergency contraceptives in the International Journal of Gynaecology and Obstetrics, women, particularly in developing countries, had limited access to emergency contraceptives.

“The majority of women (65% of women in Latin America and 85% of women in Africa) have no knowledge of emergency contraception, profoundly hindering their ability to access this important contraceptive option,” noted the authors.

In a review of emergency contraceptives, published in July, the European Medicines Agency dispelled myths that the efficacy of these contraceptives is reduced with increased bodyweight, as stated in the product information for some pills, such as Norlevo, and said that “benefits of emergency contraceptives far outweigh the risks”.

“With side effects generally mild, the safety profile of emergency contraceptives is favourable and they can continue to be taken regardless of the woman’s body weight,” the authors state.

However, the review said that women “are reminded that emergency contraception is an occasional ‘rescue’ method, which does not work as well as regular methods of contraception, such as the pill”.

Not for long-term use

The agency also emphasises that even though the emergency contraceptives can continue to be used to prevent unintended pregnancy in women, the “promotion of family planning has immense benefits in terms of gender equality, maternal health, child survival, and preventing HIV”.

Andrea Thompson of Marie Stopes, an organisation that offers sexual and reproductive healthcare, says even though statistics are unavailable to show whether women are using emergency contraception in place of long-term alternatives in South Africa, the practice should not be encouraged.

“We prefer and encourage the use of actual contraceptive methods that are available and accessible in most health facilities across the country,” she said.

Thompson said that although there were no adverse health implications of continued use of emergency contraceptives, the practice was bound to cause setbacks to family planning interventions that have been set up to address the challenges of unintended pregnancies, unsafe abortions and particularly the transmission of sexually transmitted infections.

“The emergency contraceptives only protect against unwanted pregnancies but not against HIV and Aids. We encourage long-term contraceptive methods,” she said.

Commenting on over-use of the morning-after pill, Rees said women should instead strive to settle on a more long-term method of family planning.

Quick facts on emergency contraceptives:

  • To be used within five days (120 hours) of unprotected
  • Two available options of emergency contraceptives are being
    offered, the pill and the implant copper intrauterine device;
  • There are no age limitations;
  • There is no evidence that emergency contraceptives cause
    abortion. They have no effect on an already established pregnancy;
  • Common side effects include nausea and vomiting, occasional dizziness, headaches and fatigue as well as cycle irregularities;
  • Emergency contraceptives do not protect against sexually
    transmitted infections, including HIV; and
  • They are intended for occasional “emergency” use.

Source: The National Contraception Clinical Guidelines 2012

Phyllis Mbanje was a Bhekisisa fellow in 2014.