Representations and Uses of Emergency Contraception in West Africa. A Social Anthropological Reading of a Northern Medicinal Product

Abstract

Since the early 2000s a new form of progesterone based emergency contraception with no side effects has been on the African market, aimed at reducing contraceptive failure rates and the mortality associated with the practice of unsafe abortion. Studies of emergency contraception (EC) carried out in West Africa have only examined opinions and knowledge about EC. We hypothesized that representations and uses of this method takes place at the intersection of two dimensions: (i) a "Northern" pharmaceutical norm, and (ii) local understandings of the timing of conception. To test this hypothesis we used a discourse analysis of semi-structured interviews with 149 women and 77 with men aged between 18 and 40, of varying marital, social and professional status, resident in Dakar, Ouagadougou and Accra. The interviews were conducted in 2005-2007. EC is overwhelmingly perceived as a Northern medical treatment which encourages greater sexual freedom for women. Many respondents, both male and female, believe that EC is a "chemical" product that may cause sterility, and there is severe questioning of its supposed abortifacient character. EC is being used as recommended by the medical profession - in an occasional manner and in cases of urgent need; but it is also being used, like other post-coital methods which women have long employed, in a programmed and repeated manner. On the one hand the social issue raised by EC, namely the weakening of control by men of the sexuality and fertility of women, may be an obstacle to its diffusion. On the other hand, it may in the end be viewed as simply another post-coital method, whose use is framed by the prevailing systems of temporal representations in the three countries concerned in the study.

Full text

Representations and uses of emergency contraception in West Africa.
A social anthropological reading of a northern medicinal product
Maria Teixeira
a
, Agnès Guillaume
b
, Michèle Ferrand
c
, Agnès Adjamabgo
b
, Nathalie Bajos
a
,
d
,
*
ECAF Group
1
a
INSERM-CESP-U1018, 82 rue du Gal Leclerc, 94276 Le Kremlin Bicêtre Cedex, France
b
IRD, France
c
CNRS, France
d
INED, France
article info
Article history:
Available online 30 March 2012
Keywords:
Emergency contraception
Urban Africa
Social representation
Anthropology
Sexuality
Gender
abstract
Since the early 2000s a new form of progesterone based emergency contraception with no side effects
has been on the African market, aimed at reducing contraceptive failure rates and the mortality asso-
ciated with the practice of unsafe abortion. Studies of emergency contraception (EC) carried out in West
Africa have only examined opinions and knowledge about EC. We hypothesized that representations and
uses of this method takes place at the intersection of two dimensions: (i) a“Northern”pharmaceutical
norm, and (ii) local understandings of the timing of conception. To test this hypothesis we used
a discourse analysis of semi-structured interviews with 149 women and 77 with men aged between 18
and 40, of varying marital, social and professional status, resident in Dakar, Ouagadougou and Accra. The
interviews were conducted in 2005e2007. EC is overwhelmingly perceived as a Northern medical
treatment which encourages greater sexual freedom for women. Many respondents, both male and
female, believe that EC is a “chemical”product that may cause sterility, and there is severe questioning of
its supposed abortifacient character. EC is being used as recommended by the medical profession ein an
occasional manner and in cases of urgent need; but it is also being used, like other post-coital methods
which women have long employed, in a programmed and repeated manner. On the one hand the social
issue raised by EC, namely the weakening of control by men of the sexuality and fertility of women, may
be an obstacle to its diffusion. On the other hand, it may in the end be viewed as simply another post-
coital method, whose use is framed by the prevailing systems of temporal representations in the three
countries concerned in the study.
Published by Elsevier Ltd.
Introduction
Despite national and international policy commitments to
better access to contraception, many indicators in Sub-Saharan
Africa point to unmet contraceptive need (United Nations, 2011).
Use prevalence rates of “modern”contraceptive methods remain
low in West Africa in 2009, and there is a high incidence of recourse
to clandestine abortion which is a cause of high maternal morbidity
and mortality (WHO, 2010). Since the early 2000s a new form of
progesterone based emergency contraception (EC) has been on the
African market, aimed at reducing contraceptive failure rates and
the mortality associated with the practice of abortion. The price of
EC varies across the different sale points: from 0.5 US$ in public
sector facilities to about 5 US$ in private pharmacies. This method
offers the advantages of greater effectiveness and fewer side effects
compared with the Yuzpe method, and also of having no medical
contra-indication, which enables it to be delivered without
prescription.
There is some doubt about the potential diffusion of this
particular method of contraception, given that it may encounter the
same obstacles to its use as other methods designed by pharma-
ceutical laboratories, namely their cost, their accessibility, and
a hormonal composition whose side effects give rise to distrust
(Vitzthum & Ringheim, 2005). Some particular features of EC (the
fact that it is a post-coital form of contraception, is administered in
*Corresponding author. INED, France.Tel.: þ331 45 21 22 73;fax: þ33 1 45 21 20 75.
E-mail address: nathalie.bajos@inserm.fr (N. Bajos).
1
ECAF Group includes: Nathalie Bajos (PI), Fatima Bakass (PI Morocco), Pierrette
Koné (PI Senegal), Ivy Osei (PI Ghana), Andre Soubeiga (PI Burkina-Faso), Agnès
Adjamabgo, Michèle Ferrand, Catherine Gourbin, Agnès Guillaume, Susannah
Mayhew, Clémentine Rossier, Maria Teixeira.
Contents lists available at SciVerse ScienceDirect
Social Science & Medicine
journal homepage: www.elsevier.com/locate/socscimed
0277-9536/$ esee front matter Published by Elsevier Ltd.
doi:10.1016/j.socscimed.2012.02.038
Social Science & Medicine 75 (2012) 148e155

a single dose, and is obtainable directly from a pharmacy) could
however work in favour of its widespread adoption, if they succeed
in offering a way of overcoming the obstacles that constrain the use
of already existing contraceptive methods, by responding to the
specificities of local demand for contraception.
There are no quantitative data from representative samples
about trends in perceptions and use of EC in West Africa. Studies
have examined particular population groups: health centre clients
(Klitsch, 2002;Smit et al., 2001), students and young people (Addo
& Tagoe-Darko, 2009;Byamugisha, Mirembe, Gemzell-Danielsson,
& Faxelid, 2009;Opoku, 2010), refugee populations (Goodyear &
McGinn, 1998), family-planning providers (Creanga, Schwandt,
Danso, & Tsui, 2011;Judge, Peterman & Keesbury, 2011;Maharaj
& Rogan, 2011) or victims of violence (Dessalegn, 2008). These
studies mainly cover opinions and (more rarely) knowledge about
EC, and acknowledge that on their own they cannot report on its
use, with the exception of Opoku’s study (2010) of a non repre-
sentative sample of women aged 18 to 35 in the Kumasi metropolis
in Ghana, according to which less than 4% of them were using EC.
Studies also show that EC seems to be particularly suitable for use
in cases of sexual violence. But the available findings do not enable
us to explore more deeply either the meaning or the place of this
particular method in women’s contraceptive practice, or the
obstacles to its use. In particular these studies have scarcely, if at all,
investigated resistance to the use of a medicinal product from the
North, even though resistance to the consumption of hormonal
methods is known to be an obstacle to their acceptance (Dudgeon &
Inhorn, 2004;Vitzthum & Ringheim, 2005). Furthermore none of
these studies have explored the particular relationship with time in
which recourse to EC is necessarily embedded. The concept of
emergency is one which is fully developed in industrialised socie-
ties. But little is known about how “emergency”is understood in
the urban setting in Africa.
The aim of this article is therefore to analyse EC from a social-
eanthropological perspective, with the idea that representations
and uses of this method takes place at the intersection of two
dimensions: (i) a Northern pharmaceutical norm, and (ii) local
understandings of the timing of conception and pregnancy.
(i) While pharmaceutical products have a higher reputation for
effectiveness when they originate from industrialised coun-
tries, this remoteness of origin also induces scepticism as to
the political issues underlying the diffusion of a new product
(Nichter & Vuckovic, 1994;Van der Geest & Whyte, 2003). The
view that there is attempted control by the North over
demographic growth in the countries of the South is a widely
shared one. In this socio-political context, expressions of the
fear of possible side effects of EC on bodily health, and above
all of the risk of sterility (Cleland, 2006;Otoide, Oronsaye, &
Okonofua, 2001), can be also read as expressions of resis-
tance to such attempts to control. But beyond this issue of
normative and political imposition, there is also the central
question of the autonomy of women in terms of the
management of their own fertility. EC can be obtained without
prescription. As underlined by Van der Geest and Whyte,
a private individual treatment diminishes dependence on
biomedical practitioners, spiritual experts, and kin and the
influence of family elders, neighbours, religious leaders, and
others can be greatly reduced (Van der Geest & Whyte, 1989).
As was earlier the case in Northern countries, direct access to
EC raises issues concerning the opening up of a possibility for
women themselves to manage the reproductive consequences
of their sexuality, and so a fortiori of the possibility of a sexual
life which is less socially controlled (Adekunle, Arowojolu,
Adedimeji, & Okunlola, 2000).
(ii) Interventions to avoid pregnancy after sexual intercourse
already exist among women in Sub-Saharan Africa, such as
amulets and herbal decoctions (Agadjanian, 1998;Jinadu,
Olusi, & Ajuwon, 1997;Van de Walle & Renne, 2001). But EC
is promoted as a post-coital contraceptive method to be used
“in emergency”within a limited time span. The sooner it is
taken after non-protected intercourse, the more effective it is,
with the theoretical time limit being 120 h after intercourse
(Krishnamurti, Eggers, & Fischhoff, 2008). The idea of acting
“in emergency”may not fit with local understandings of the
timing of conception in countries where some women are
used to taking action within a few days after unprotected
sexual intercourse. The concept of kairos, seen as a “break in
the flow of time by taking action in a propitious moment”(Lovell,
2011: 257) seems to fit better into this local understanding of
timing and urgency. On the other hand, the fact that this is
a hormonal product to be taken after intercourse may give rise
to the idea that EC has an abortive effect. Although it is now
established that EC blocks or delays ovulation but does not act
once ovulation has started, and a fortiori once fertilisation has
taken place, the opponents of the method in both Northern
and Southern countries continue to argue that it is abortive in
principle (Wynn & Trussell, 2006). We may suppose that this
argument plays a role in certain representations of EC, espe-
cially in social contexts where abortion is illegal.
Methodology
The analysis is based on data collected between 2005 and 2007
during the research project “Emergency Contraception in Africa”
(ECAF) in Senegal, Burkina-Faso and Ghana, three countries where
contraceptive prevalence is low (respectively 10.5%, 8.8% and 18.7%
among married women in 2003) and unmet contraceptive needs
are high (United Nations, 2011). The overall aim of the research was
to study the possible role of EC in reducing the numbers of
unplanned pregnancies and hence abortions.
The survey was restricted to the capital city of each country
because EC has been available “over the counter”only in large urban
centres (since 2000 in Ghana, 2002 in Senegal and in Burkina).
Respondents were mainly recruited through personal acquain-
tance networks of the interviewers, using a snowball method:
people were asked to give the name of a relative whom the inter-
viewer could contact to be interviewed for a health survey. Some
respondents were also directly recruited through family-planning
clinics, in order to find people who had used EC.
A total of 149 women and 77 men aged between 18 and 40 were
recruited. They were asked to participate in an anonymous survey
covering their family and sexual life.
Sample characteristics
Since our hypothesis was that representations and uses of EC
would differ according to the social resources of women and men,
we decided to interview people with different levels of education.
Furthermore, we considered that, as for hormonal contraception,
the legitimacy of using EC would differ for women who were not
married, whose sexual life is not socially accepted. For all these
reasons, age, education and marital status quotas were fixed for
each country (see Tables 1and 2).
A semi-structured interview guide was drawn up, with the help
of which the subject’s sexual, affective, contraceptive and repro-
ductive history was re-traced, and his or her representations of
sexuality, contraception, abortion and EC were explored. For those
who had never heard about EC, the interviewer explained what EC
M. Teixeira et al. / Social Science & Medicine 75 (2012) 148e155 149

is and how it works, i.e. that EC is a hormonal product to be taken
within 3 days after sexual intercourse in order to prevent a preg-
nancy. The interview guide was pre-tested in 2005 in two pilot
surveys of 7 women and 7 men in Burkina-Faso, 9 women and 5
men in Ghana and 11 women and 7 men in Senegal. The researchers
who conducted the interviews were native to the countries con-
cerned, which enabled respondents to choose the language in
which to express themselves. Male researchers interviewed men
and female researchers women.
Analysis
Audio-taped interviews were transcribed, translated (into
English for the Ghanaian interviews and into French for the others).
All names used in this paper are pseudonyms and the data have
been decontextualised where appropriate to ensure individuals
cannot be identified. All members of the research team read the
transcripts repeatedly. Data were logged, coded and retrieved with
the aid of the qualitative data-indexing package, NVivo 7. Regular
team meetings were then held to refine the analytical codes; to
explore peoples’underlying reasoning; to discuss data on women
and men’s representations and uses of EC.
Of the 226 interviews used to study representations of EC, 40
offered the possibility of analysing use of post-coital methods of
contraception (28 women and 12 men), and of these 29 referred
particularly to use of EC (20 women and 9 men). The entire range of
verbatim transcripts (n¼226) was analysed using NVivo 7 soft-
ware. Each interview was analysed by all the 5 authors.
In all the three countries, an informed oral consent was obtained
after having read to the interviewee a consent document present-
ing the survey, the conditions under which the information was
anonymously collected, and the option not to participate.
Ethical approval was obtained in Senegal (Conseil National de
Recherche en Santé), in Ghana (Ghana Health Service Ethical
Committee) and in Burkina-Faso (Comité d’éthique pour la
Recherche en Santé).
Results
Different representations of a medical product
Analysis of the 226 interviews shows that only a minority of
the respondents had heard of EC (22 women and 7 men in
Ouagadougou, 22 women and 13 men in Accra and 16 women
and 6 men in Dakar). The interviewers explained to all those
who had never heard of EC what this product was, saying that
in cases of unprotected sexual intercourse, there is a drug the
woman can take to prevent pregnancy: the Emergency Contra-
ception. This hormonal drug has to be taken within three days
after sexual intercourse. No differences were registered between
those who had heard about EC and those to whom EC use was
explained by the interviewer.
A political northern model .
In a context of globalisation, this pill is sometimes seen as a form
of domination and interference in countries of the South by those of
the North. So Kaiser (Ghanaian man aged 33, single, primary level
of education) considers that “Whatever you do, it is God who gave it
to you and that drug was not made by the black man.”For Moussa
(Senegalese man aged 19, unmarried, secondary level of education)
the objectives of the Northern countries are clearly political: “these
methods are nothing other than a strategy of the west to compete with
African countries demographically. They are mainly made up of retired
people, youth is in a minority over there”. Political arguments of this
kind are most often advanced by men.
Influencing sexual behaviours .
The argument that there is a danger that this new method will
contribute to encouraging an unbridled sexuality is mainly
expressed by Senegalese people, both men and women. Expres-
sions such as “adopting more immoral attitudes”,“fornicating”,
“being debauched”,“only seeking pleasure”often recur in their
responses. Seydou (Senegalese man aged 24, unmarried, primary
level of education), speaks vehemently against westerners who
encourage sexual intercourse; according to him this form of
contraception is bound to “destroy our time”, it will be useful for
“street girls”“who sell themselves for sex”. Some women also
condemn the possible effects of the method on sexual activity. So
Lilian (Ghanaian woman aged 27, unmarried, educated to
secondary level) explains: “The youth. They will say that if we have
Table 2
Men’s socio demographic characteristics by capital city.
Ouagadougou
N¼27
Accra
N¼25
Dakar
N¼25
Age
18e24 5 9 5
25e29 9 7 11
30þ13 9 9
Education
None or primary 7 7 6
Secondary 11 13 12
Bac/School certificate and þ957
Current marital status
Unmarried 13 16 13
Monogamous 13 9 11
Polygamous 0 0 1
Widow/Divorced 1 0 0
No. of children
0141615
1776
2502
3011
4þ111
Ever heard of EC 7 13 6
Ever used EC (EC fail) 2 (0) 6 (0) 1 (0)
Table 1
Women’s socio demographic characteristics by capital city.
Ouagadougou
N¼50
Accra
N¼50
Dakar
N¼49
Age
18e24 25 18 21
25e29 13 10 17
30þ12 22 11
Education
None or primary 21 13 11
Secondary 22 29 25
Bac/School certificate and þ7813
Current marital status
Unmarried 21 15 30
Monogamous 22 26 14
Polygamous 5 1 2
Widow/divorced 2 8 3
No. of children
0201028
1161810
2 6 11 7
3593
4þ321
Ever heard of EC 22 22 16
Ever used EC (EC fail) 7 (0) 10 (2) 3 (0)
M. Teixeira et al. / Social Science & Medicine 75 (2012) 148e155150

this, then we can have sex anytime, if she wants something from a man
and that person demands sex she can give in and then later on she can
go and buy this drug to prevent pregnancy. That will result in an
increase in immoral behaviour”.
Other respondents, particularly in Burkina and Ghana, take
a positive view of the product, especially for unmarried people
whose sexuality is just awakening. Martial (Burkinabe man aged 24,
married, educated to secondary level) points out that when men
take their pleasure and then abandon a girl, EC will prevent her
becoming pregnant and then having to have a clandestine abortion.
Lebene (Ghanaian woman aged 33, widowed, primary education)
thinks that the EC pill “can be good for those without partners and
who cannot sit down without getting into a relationship with a man.
For example me, I don’t have a husband, if I meet somebody, today, the
way men can meet a woman and would like to sleep with her
immediately, we women too can behave the same way”.
Increasing the risk of sterility
Some people consider that EC offers an effective protection
because it is manufactured by “the Whites”, and for them this origin
is a guarantee of its quality and safety. Almost half of all respondents
are most concerned with the “chemical”(emic term) composition of
the product. The fear of becoming sterile is the most commonly
expressed apprehension about taking EC: “the uterus will be
damaged”,“the vagina will shrink”,“the tubes will be affected”,“the
female apparatus”or “something in the body”will be destroyed, or
the EC “may not dissolve and may accumulate in the stomach”.In
some cultures people believe that God decides to grant each woman
a certain number of children, and that when a woman takes
contraception she is wasting the children God has put in her womb.
On seeing her do this, God may decide to take them awayfrom her to
put them into the womb of another woman who is more inclined to
procreate. Patenema (Burkinabe man aged 27, unmarried, primary
education) expresses this clearly: “God may make it so that, if she
refuses the pregnancy, he takes her fertility and gives it to another
woman so that she can have the baby. You avoided giving birth, so he
left you where you were, took away all the children who were in your
womb and gave them to someone else who wanted them”.
But the overall picture is that this form of contraception is less
feared than daily hormonal contraception, because the fact that it is
taken only occasionally implies that its health impact is less. A few
people, such as Jasmina (woman from Burkina aged 24, married,
with primary education) even think that there is no danger: “It’s
good because, if it doesn’t damage the tubes, that makes it better.
Because you are not taking it all the time. If I know it can’tdoany
harm, that makes it better. If it’s just taking one at a time, sometimes
but not every day, that’s good”.
EC and the process of conception
The timing within which the act of emergency contraception
takes place raises questions for our respondents. Does the product
prevent conception by acting before it takes place, or is it rather
that it interrupts pregnancy by acting on the conception process
itself? Some respondents spontaneously say that its mode of
operation is abortive, while conversely others, mainly women, view
it as exactly the opposite, enabling abortion to be avoided. No
differences in this respect were observed between countries.
Micheline (Burkinabe woman aged 23, unmarried, primary
education) believes that at the moment when the EC is taken “it is
still just blood”. For Katy (Senegalese woman, aged 34, single, higher
education) when one takes EC “in some way the process hasn’tyet
started, or if it has started, you know, you can say it’s within the first 72
hours. So it’s, you can say it isn’t yet an abortion”.
Other accounts allow doubts and questions to surface. Mathieu
(Burkinabe man aged 29, unmarried, higher education), wonders
about the exact moment when the gametes are joined and about
the exact mechanism of EC: “as soon as they meet, there may be the
beginnings of formation, I am not sure. Does this pill not act on the
conception at its very beginning; anyway when is the moment when
conception starts? I think it is as soon as the two gametes meet, and it’s
not 72 h later that the two cells encounter each other. I have the feeling
that this kind of contraception is really like.it’s like an abortion”.
The very fact that the intervention takes place after the sexual act
explains how others such as Karlos (Ghanaian man aged 21,
unmarried, higher education) assimilates taking EC to having an
abortion because “even if it hasn’t developed, but the process of
formation has begun”. Some respondents reject the product outright
because they consider it abortive. So Maminatou (Senegalese
woman aged 21, unmarried, higher education) says that after 5 days
the embryo begins to take shape, and so this is an “effectiveabortion”.
Representations of the moment of conception and of the mode
of action of EC determine the acceptance or rejection of this method
and the recognition of its effectiveness. This is the case for Odele
(Ghanaian woman aged 24, unmarried, secondary education), for
whom “when you have sex, the same moment you have sex and
sperms are released they fertilize the eggs immediately and you cannot
destroy them within those three days, because conception has taken
place already”, which also leads her to doubt the efficacy of the
method.
These different sets of opinions are usually internally consistent
and appeared to be gender specific, since women are more likely to
consider that EC helps in preventing abortion. Those who believe
that EC is abortive are usually those who also base their rejection of
it on the feeling that its diffusion carries the risk of subverting
sexual morality, and who are opposed to values coming from the
North. Conversely, those who have more liberal opinions about
sexual behaviour, and who are not opposed to changes in values,
accept EC and do not assimilate it closely or at all to an act of
abortion; they see it as a possible way of saving lives, especially
among young people whose sexuality is nascent. Mistrust about the
hormonal content of the product is outweighed by the less
damaging effects on health which are presumed to follow a less
frequent ingestion of hormones compared to the daily pill.
Temporal variety in post-coital contraceptive methods used in Africa
28 women and 12 men spontaneously referred to post-coital
methods of some kind. EC is indeed a new method which takes
its place in a landscape of diverse post-coital contraceptive prac-
tices: drinks manufactured by the food industry (soda, beer), coffee,
decoctions of local plants, pharmaceutical products (antibiotics,
Nivaquine, Paracetamol, pessaries), body positions, post-coital
baths. These methods are used immediately after sex, but also the
following day, some days later, or even up to a week before the
expected date of the monthly period, which seems to be the final
end date. The time span for these post-coital contraceptive prac-
tices is limited, but is definitely longer than that of EC.
No differences in these respects were registered between
countries either for men or for women.
Just after sex or the following day
Two women and the partner of a third one in our sample
reported trying, just after having sex, to evacuate the sperm
introduced into the uterus. Others like Jamie (Burkinabe woman
aged 37, in a polygynous marriage, higher level of education)
prepare a decoction which she drinks immediately, and which she
says has no abortive effect: “It isn’t a pregnancy. After having sex you
get up in the morning, you purge yourself and you are clean [.]for
M. Teixeira et al. / Social Science & Medicine 75 (2012) 148e155 151

example today..I had sex last night, so I get up in the morning and go
to the market, I buy my leaves. It’s not expensive, 25 francs a time, I
crush them well, with warm water and a couple of small peppers, and
then I purge myself”.
These methods which aim to evacuate the sperm mechanically
or to render it ineffective are taken, very logically, just after sex;
women use them without evoking the concept of emergency in
their descriptions.
Other methods described involve products of the food industry
diverted from their primary purpose, such as coca-cola, or heated
beer, sometimes with added sugar. Women who use these methods
(2 in our sample) are not necessarily completely opposed to
Western academic medicine. Some use medical products, reinter-
preting the dosages of pharmaceutical substances. Lotus (Ghanaian
woman aged 34, in a couple but unmarried, secondary education)
who knows the rhythm method, takes antibiotics as a contracep-
tive. She was introduced to this self-medication by a friend who
explained to her that antibiotics render sperm ineffective and kill
germs. She takes two capsules before having sex, or if she forgets to
do this she takes four afterwards; but this method failed for her:
“when I made love with this man, I didn’t, so I say I will take the
ampicillin [antibiotic] too, I tried it but it didn’t work.”
One week after sex, or one week before the menstrual period
For two women, i ntervention to avoid pre gnancy can be made wit hin
a longer time interval. Lebene (Ghanaian woman aged 33, a widow
formerly in a polygynous marriage, primaryeducation) consumes a high
dose of caffeine every day for a week. She begins to drink this three or
four days after sex. No notion of emergency is involved.
Certain native plants are known for their contraceptive qualities.
At the end of the month, one week before the expected date of her
menstrual period, Luvena (Ghanaian divorced woman aged 28,
without formal education), takes plant based mixtures to avoid
becoming pregnant. She denies that she has used it for abortion
purposes. “Since I matured I have always used that herb. I go to pick
and prepare soup with it, when I eat it, within two days the blood will
come. I have never taken traditional herbal medicine with the sole
intention of terminating a pregnancy, no, I have never done that.”
Luvena’s case is particularly striking. Without any hurry, panic,
fear or apprehension, she waits after having sex until a week before
the expected date of her period, and then drinks a concoction to
render the whole of the last month’s sexual relations safe.
In this varied post-coital contraceptive landscape, EC thus
presents itself as the sole medical contraceptive means which
explicitly has to be taken just after having sex, and furthermore in
a context which is recognised as one of emergency.
The specificity of EC as a post ecoital method
Analysis of the conditions of EC use has been performed for 20
women and 9 men. Almost of the EC users were aware of the fertile
period, had also a higher level of education than the other
respondents and were single.
Emergency use
Occasional use in emergency is common in the accounts
recorded. This often occurs as a result of a burst condom during the
fertile period, or as a result of errors in calculating the cycle, such as
in the case of Paouni (Burkinabe man aged 26, unmarried, higher
education).
The feeling of urgency arises and is expressed in the anxiety
which is felt: “when I realised that it was a risky period, I did not sleep
all night”. Others like Ledem (Ghanaian woman aged 22, unmarried,
higher education), went on a journey and forgot to take their daily
pills with them, and used EC to remedy unprotected sex which
occurred during the trip. Here use of EC was specific to the occasion,
and the method was used with a feeling of urgency, to overcome
a single and not-to-be repeated mistake.
Other respondents were particularly careful and used several
different forms of protection. Sara (Senegalese man aged 34,
married, secondary educated) had sex with his girl friend on a date
which was in the fertile period. Although they used a condom he
knew that this method was not 100% safe, and this led him to give
his partner EC to “feel safe”.Such a situation can indeed be seen as
intermediate between “Emergency used”and “Planned used”.
Planned use
Equally, the interviews also show that EC is often used outside
the circumstances foreseen for it (7 women out of 20 and 2 men out
of 9). Some women combine EC with the rhythm method, in the
same way as others combine their cycle with withdrawal or with
the use of a condom, with a view to not compromising their future
fertility through the use of a hormonal contraceptive on a daily or
a long term basis, as with pills, injections or implants. But some-
times there is a shift in which taking EC becomes less and less
sporadic and more and more regular, to the point at which it
becomes continuous, as was the case for Lolo, a young Ghanaian
student aged 22, unmarried with a higher education level. After
taking an HIV test, she and her partner decided to stop using
condoms. From then on, she took EC regularly each week like
a regular contraceptive, and she stressed its advantages when
compared with the daily pill which she might easily forget to take.
The method “is very convenient, it is easy to take, is not too much of
drugs. If you are the type who doesn’t like to take medicine, it is not the
type which you have to take every day; it is only two pills.”Emergency
is not an appropriate concept to refer to in describing this use of the
EC pill. In fact Lolo, as she says herself, has taken EC an incalculable
number of times; when she stocks up she buys five boxes at a time.
Love (Ghanaian woman aged 30, married, higher education)
points out that the fact of being “free with no any medicine in your
blood”when this is not necessary, in other words when one is not
having sex, outweighs the lesser efficacy of the method. Cited in
favour of EC are the facts that the contraceptive does not remain
long in the body, it “is not a long term contraceptive”, and that it is
not taken continuously, which also enables one to remain fertile
once the critical phase has passed.
Men’s accounts also reveal planned use of EC taken systemati-
cally after each intercourse, as is the case for Kamil (Ghanaian man
aged 31, unmarried, secondary education). Jack (Ghanaian man aged
27, unmarried, secondary education) for his part, has used EC only
twice, when he has had sex with his partner at the time of ovulation;
but he suggests that it is possible to cover several instances of
intercourse taking place over two days by taking EC before the third
day. The interviewer asked: “So if I sleep with somebody today..?”
and before he could finish Jack replied: “Today! you can continue
tomorrow and then the third day, if you give her this it’s going to work
alright”. It is also true that this pill is relatively costly for Jack, and
that the idea of protecting three days of sex with a single dose of EC
is financially a good one from his point of view.
Finally there is another configuration of circumstances which
favours taking EC and which comes out in three interviews. This
concerns conflictual situations between partners around the desire
to have a child. Taking EC then becomes clearly a part of power
strategies and counter-strategies deployed by women against those
of their partner. Thus Magali (Burkinabe woman aged 27, unmar-
ried, secondary education) has a partner who, to bind her to him,
tries to make her pregnant by piercing the condoms or by waking
up in the middle of the night to have unprotected sex, with the
pretext that he cannot find a condom. The following morning,
whether she is in her ovulation phase or not, Magali takes EC
M. Teixeira et al. / Social Science & Medicine 75 (2012) 148e155152

without revealing this to her partner, because she does not want to
run any risks. For Josée (Burkinabe woman aged 20, engaged to be
married and living in a couple, secondary education), the situation
is reversed. Her partner does not want to have a child, but she
wants to become a mother and so not to take EC. Every time they
have sex at a time her partner identifies as being during the fertile
part of her cycle, he buys EC for her; but what he does not know is
that Josée takes it home without taking it. She achieves her goal,
becomes pregnant, refuses to have an abortion, leaves her partner
and carries the pregnancy to term.
Thus EC is essentially taken according to the norms prescribed
by the health establishment; however, we can see that the specific
context of West Africa (where long-standing post-coital methods
exist which involve the notion of urgency hardly or not at all), and
the fear of using hormonal products on a long term basis, may bring
about a different pattern of usage of EC. Its use may become regular
and non-urgent, and may replace contraception used pre-coitally
or during the act, or may be mobilised as part of female counter-
strategies of power.
Discussion
As in any qualitative survey, the data collected from semi-
structured interviews cannot support an extrapolation of findings
to the entire population, since the people who participated in the
survey are not a representative sample of the population concerned
(Thompson & Collins, 2002). But it is still true that the diversity of
social characteristics of the women and men encountered in this
survey enables us to shed light on the diversity of representations
of EC and of the social rationales which underpin its use. The
analyses of the conditions of EC use are also limited because of the
small number of cases of use of EC which were encountered.
Nevertheless this fact in itself is a finding which highlights the low
rate of use of this method in West Africa, even in urban settings.
Finally, we may think that some women who have had pre-marital
sex, and are more likely to use EC, may have refused to participate
in the survey.
EC made its appearance in industrialised countries, where
different forms of contraception, pre-coital or barrier methods, are
very widespread, and where the idea of women’s control of fertility
is largely accepted. Here EC finds its place as a new form of
contraception to be taken in emergency and in exceptional
circumstances, to recover from a mistake or an oversight which
might lead to an unintended pregnancy. This pill is presented by
the medical establishment as being not an abortifacient but
a timely and occasional means of significantly reducing the prob-
ability of an unforeseen pregnancy. In Sub-Saharan Africa the
situation appears quite different; here EC enters a context inwhich
pre-coital contraception is little used (United Nations, 2011), but
where the idea already exists of acting upon the possible conse-
quences of sexual intercourse after it has occurred (Agadjanian,
1998;Jinadu et al., 1997), through recourse to methods either
ancient (using plants or mechanical interventions) or more recent
(through self-medication) as is shown in our results.
Representations of EC, as we have seen, do not spontaneously
refer to the notion of emergency, although this might be thought to
be one of its distinguishing features. Rather it is the issue of control
of women’s sexuality which appears to structure these represen-
tations, as the oral testimony collected tends to show.
EC and social control
As underlined by Desclaux et al., negative perceptions of
medicines connected to their toxicity, their aggressiveness and
their side effects are also an expression of political positions
(Desclaux & Lévy, 2003). In the case of EC we find the same fears as
those expressed towards medicalised contraceptionin general, that
of the control by the West over demographic growth in the coun-
tries of the South. In particular, we have seen how the risk of side
effects to bodily health, and above all the risk of sterility, appear to
be central to these representations, as shown by Otoide (2001) and
Bankole (2006). Beyond these health dimensions we may
hypothesise, in line with Tabet (1998), that it is around the issue of
women’sautonomy in decision making as regards their sexuality
and their fertility that resistance to the diffusion of hormonal
contraception crystallises.
One of the specific characteristics of EC is its direct availability at
pharmacies without medical prescription. Making the product
available through these outlets enables an escape not only from the
obstacles of one’s social circle ethe partner or the family ebut also
those of the medical establishment. This is an important feature, to
judge by other examples from West Africa, where it has been
shown that the success of certain pharmaceutical products comes
from the fact that they enable some of the social controls to which
individuals are subject to be short-circuited, so that their private or
even secret use contributes to autonomy in life and treatment
choices (Desclaux & Lévy, 2003).
Another specificity of EC is to do with its episodic and discreet
use, which more easily allows the existence of one’s sexual life to
remain hidden. This can be an especially important issue in Sub-
Saharan African countries experiencing the development of a pre-
marital sexuality for young people (Bledsoe & Cohen, 1993),
which is often clandestine and not approved by the society of their
elders (Mensch, Grant, & Blanc, 2006). They can obtain EC in an
anonymous manner which preserves their intimacy and privacy
(Van der Geest & Whyte, 2003). Indeed, we found that EC was
mainly used by unmarried people in the three countries. Further-
more, the opinion that EC may lead to an unbridled sexuality is
mainly expressed by women and men in Senegal, where pre-
marital sex is particularly socially stigmatized. Behind condemna-
tion of the use of EC can be detected a rejection of greater sexual
freedom, especially in terms of religious morality and social
constraints. There are plenty of opponents of any development of
sexual mores which goes against both religious convictions and
male control over descendants (Bajos & Ferrand, 2004;Byamugisha
et al., 2009;Héritier, 1999;Mqhayi et al., 2004). Our interviews
showed that the fear of sexual licence through the growth of pre-
marital, adulterous or paid sex weighs heavily on the image of
those likely to use this method. Behind this stigmatisation, what is
being aimed at is the possibility for women of enjoying greater
freedom to avoid an imposed pregnancy, or to discreetly entrap
a partner. Indeed, as some of our interviews show, we may think
that EC may also turn out to be an instrument of resistance and of
countervailing power, which women can use against their elders or
against their partners where there is disharmony between them, in
other words wherever there is disagreement over a sexual act, an
instance of contraception, or an intention to have a child or contract
a marriage, situations that are far from rare occurrences (Kaggwa,
Diop, & Storey, 2008;Kulczycki, 2008).
Finally, the social representations of EC seem to reveal the
strength of the social control over women’s sexuality. As we
have seen, these representations are gendered in two ways. First,
males were more likely to report opinions concerning the risk of
women’s sexuality becoming unbridled, while women more
often referred to the issue of health side effects and especially
the risk of sterility. Second, these opinions almost systematically
refer to women’s sexuality becoming out of control but refer
very rarely to men’s sexual life. The same kinds of arguments
were heard in the past about the diffusion of the hormonal pill
(Bajos & Ferrand, 2004).
M. Teixeira et al. / Social Science & Medicine 75 (2012) 148e155 153

EC and the process of conception
It is difficult to determine the moment at which the procreative
process, invisible at the outset of gestation, begins. So temporal
representations of the prevention of unwanted pregnancy may differ,
all the more so because the event which sets off the process, an act of
sexual intercourse without contraception or protection, has a random
reproductive effectiveness which may appear to be a matter of chance
or of the intervention of an invisible power external to the couple
(Godelier,1998).For some people, as soon as the sex act has taken place,
the process of gestation begins, so to interrupt it would immediately be
a kind of premature abortion. But others believe, as we have seen, that
intervening shortly before the expected date of the next period is a kind
of contraceptive approach. The dividing line between contraceptive
and abortive actions is not easily drawn. This ambivalence is all the
stronger because many post-coital contraceptive techniques practised
in Africa (such as decoctions of local plants, use of antibiotics) are
similar to those employed by women to induced abortions (Guillaume,
2006;Riddle,1997). In anycase, our results show that it is important for
policy makers to take into account representations that the women and
the men have of the abortive character of emergency contraception.
Where contraception is pre-coital there is a disjunction between
the sexual activity and the contraceptive action; they are inde-
pendent of each other. By contrast EC is a form of contraception
linked to the sexual act which takes place in relation to an irregu-
larly occurring event. Use of EC can be unforeseeable when the
sexual act is unexpected, but can also take a foreseeable form when
the act is expected or even planned. Here sexual activity and
contraceptive action are dependent on each other. While the
distant future, being abstract, does not necessarily induce an atti-
tude of prevention, the near future on the other hand loses its
hypothetical aspect; the imminence of the event makes it concrete,
which encourages reaction.
Afirst use of EC will more frequently be carried out in panic and
urgency; but for later uses, if there are such, the partners will be in
a situation they already know. A shift takes place and there is
a delay in relation to the event. In the end, why not plan to take it,
either just afterwards or even three days later? So sex which is
protected after the event is not experienced as unprotected; it will
become protected retroactively.
The idea of ordinary preventive post-coital contraception is
therefore already present among those who use EC in a regular and
planned way after sex; whereas when it is used in a one-off way
and in haste following a failure in use of a pre-coital or a barrier
method, this is an emergency preventive contraceptive reaction.
The process, the intentionality and the frequency are all differentin
these two cases. Such results underline that the notions of urgency
and contraceptive failure are not necessarily the same in people’s
representations.
Where a health professional sees what is essentially non-
protected sex, regular users of EC see these methods as preventive
in the sense that they take effect before the detected appearance of
pregnancy. This shows consumers’creativity and adaptation to
biomedical understandings of emergency contraception.
In this context, EC has a place as an ordinary post-coital form of
contraception used in a repeated manner, in addition to its role as
a method to be used exceptionally in emergency cases.
The development of greater individualisation in sexual behaviours,
and of a private life which is at least partly detached from the family,
social, medical or religious group, has tobe seen alongside the diversity
of contraceptive repre sentations and practices. Th ere cent introduction
of EC into an urban African setting which is in rapid transformation
enables us to look closely at a society where multiple values and
practices, with their roots in dynamic social change, exist alongside
each other and associate with or oppose each other. On one side, the
issue of lessening control over the sexuality and fertility of women by
men, which EC represents, is a brake on its spread. On the other hand,
EC is no more than another post-coital method whose use fits easily
into the prevalent systems of temporal representations in the three
countries studied. Finally, as the concept of emergency is hardly ever
used spontaneously by the interviewees, and in order to fitinwithlocal
contraceptive landscapes in which post-coital contraceptive is already
practiced, we may wonder if the name “emergency contraception”
should not be changed.
Acknowledgements
The Survey was funded by the Commission of the European
Communities (Contract no.: 510 956). The authors thank all the
persons who participated in the survey and Duncan Fulton for his
help in editing the text.
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