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J Fam Plann Reprod Health Care 2011;37:89–96. doi:10.1136/jfprhc.2011.0055
Article
Abstract
Background and methodology High levels of
unplanned pregnancy among young people are
a huge public health problem in South Africa.
However, use of emergency contraception (EC)
remains low. Studies suggest that providers
constitute an important link to increasing access
to EC use. The aim of the study was to provide
greater insights into the attitudes of providers
towards EC in order to better understand factors
infl uencing uptake. The study drew upon 30 in-
depth interviews with providers at private and
public health facilities in Durban, South Africa.
Results The results of the study highlight
several barriers to the provision of EC in both
public and private health facilities. The cost
of EC products in commercial pharmacies is
likely to be a major barrier to use for many
women. In addition, providers in both public
and private facilities are often reluctant to
provide EC over the counter because they
feel that the use of EC is likely to discourage
regular use of contraception and increase the
risk of unprotected sexual intercourse and, as
a result, contribute to the spread of HIV/AIDS
in South Africa. In addition, they reported that
they do not have an opportunity to counsel
women about EC because of time constraints.
Providers in both the public and private sectors
also demonstrated a level of uncertainty
about the clinical effects of EC pills and on
the regulations surrounding their provision.
Discussion and conclusions Despite relatively
progressive legislation on EC provision and
the widespread availability of EC products in
South Africa, providers in pharmacies, family
planning clinics and public health clinics need
more training on EC provision. Interventions
should aim to educate health providers on both
the clinical and social aspects of EC provision.
Introduction
In South Africa, the level of fertility among
young women remains high. By the age of
18 years, one in five women have given
School of Development Studies,
University of KwaZulu-Natal,
Durban, South Africa
Correspondence to
Prof Pranitha Maharaj,
Associate Professor, School of
Development Studies, University
of KwaZulu-Natal, Durban 4041,
South Africa;
Maharajp7@ukzn.ac.za
Received 3 March 2010
Accepted 5 October 2010
Missing opportunities for preventing unwanted
pregnancy: a qualitative study of emergency
contraception
Pranitha Maharaj, Michael Rogan
birth, and more than 30% of women
nationally have their first child before they
attain the age of 20 years.1 2 Many births
to mothers aged less than 20 years are
unplanned and/or unwanted.2 3 Emergency
contraception (EC) is known to be highly
effective at preventing, or reducing the risk
of, an unwanted pregnancy after unpro-
tected sexual intercourse (UPSI). This
includes all cases of incorrect use, method
failure (such as condom slippage, leakage
or breakage, missing hormonal pills or an
intrauterine device expulsion) or failure to
use contraceptives, including in cases of
sexual assault.4 EC, also known as post-
coital contraception or the ‘morning-after’
pill, has been shown to be effective for up
to 120 hours (5 days) after UPSI. However,
the efficacy of the contraceptive appears
to decline with time.4 5 This makes ease of
access to EC products a critical component
of its effectiveness.
Legislation affecting access to EC is rela-
tively progressive in South Africa. Since
2000, EC products have been resched-
uled to allow for over-the-counter access
without a doctor’s prescription. There are
two dedicated EC products available on
the commercial market and, to a limited
extent, in some public sector health facili-
ties. In 1999, the first dedicated EC pill was
introduced to the South African market in
the form of an estrogen/progestogen prod-
uct. In 2001, a levonorgestrel-only EC pill
with an improved side effect profile was
made available.6 In public sector health
Key message points
▶ Demand for emergency contraception (EC) is increasing,
especially at pharmacies. However, cost remains a major
barrier to access.
▶ Providers expressed several reservations about the provision
of EC over the counter, without a prescription.
▶ There is a need for more training of providers on EC
provision.
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facilities, EC products are available at no cost to the
client and are usually provided in the form of ‘cut-up’
(i.e. repackaged) regular combined oral contraceptives
(COCs). In commercial pharmacies, the levonorgestrel-
only product (the most expensive option), the estrogen/
progestogen product (although recently discontinued)
and repackaged COCs are all available as EC options.
In the years since EC has been available over the
counter without a doctor’s prescription, several stud-
ies have begun to investigate the role of health provid-
ers in facilitating access to EC.6–8 A recent review of EC
studies in South Africa found that of the studies that
have focused on the knowledge, attitudes and prac-
tices of providers, only two have included commercial
pharmacists.9 One of these studies was conducted to
examine pharmacists’ knowledge and perceptions of
EC pills in two urban areas in South Africa 2 years
after the method became available over the counter
without a prescription.7 The other study was published
shortly after EC products were deregulated and prior
to the widespread availability of the most recent EC
product (the levonorgestrel-only pill).8
Despite the relative ease of access to EC products in
South Africa, most studies suggest that use is low.3 10 11
Increasing evidence suggests that it is not simply lack
of knowledge that results in underutilisation of EC but
also the attitudes of health providers and their reluc-
tance to provide it.6 7 A study of adolescent mothers in
South Africa found that the attitudes of providers play
a critical role in facilitating access to EC.12 Provider
knowledge and acceptance of EC constitute a crucial
link to improving access to women who need it.12 13
Some argue that the promotion of EC by health pro-
viders is likely to lead to greater client awareness of
the method and also increased availability.13 In addi-
tion, health professionals have the opportunity of
counselling EC clients on other aspects of reproduc-
tive health such as sexually transmitted infections and
HIV/AIDS.14 However, a study of two urban health
facilities in South Africa observed that the quality of
contraceptive counselling was variable and that there
appeared to be little discussion of EC.15
Given the large number of unwanted pregnancies
that occur every year in South Africa, as in many other
parts of the world, as a result of failure to use con-
traceptive methods, sexual assault and incorrect use
of barrier methods, EC has a crucial role to play in
giving women an option to avoid the negative conse-
quences of unwanted pregnancy, including the need
for an abortion.4 The available evidence suggests that
health providers may impede access to EC products.
However, qualitative work that considers the perspec-
tives of a wide range of providers is still needed, espe-
cially since there has been little work directed towards
them since the deregulation of EC products. The aim
of the study, therefore, was to investigate health pro-
vider knowledge and attitudes towards EC as a possi-
ble factor influencing uptake in South Africa.
Methods
The study drew upon qualitative data derived from
in-depth interviews with health providers. In total, 30
in-depth interviews were conducted with providers at
private clinics, commercial pharmacies, non-govern-
mental family planning clinics and public health clinics
in the city of Durban, KwaZulu-Natal, a large metro-
politan area on the east coast of South Africa.
The sampling frame was restricted to the central
district of Durban, as past studies have suggested that
EC awareness and use is considerably higher in urban
areas compared with rural areas in South Africa.6 16 As
described elsewhere,17 this site was chosen because it
serves as a major commercial centre in KwaZulu-Natal,
South Africa and has the greatest range of EC products
available. Past studies investigating EC in South Africa
have reported difficulties in identifying providers and
users of EC.10 The study area was therefore selected
to ensure a high response rate among providers of EC
since use is likely to be considerably higher in the sam-
ple area than in other parts of South Africa. As a result,
the sample may not be representative of all health pro-
viders in Durban or to the rest of KwaZulu-Natal or
South Africa in general.
In order to compile the sampling frame, a list of
all pharmacies and dispensaries registered with the
Pharmacy Council of South Africa was obtained
and contact was made with the local and provincial
health departments. The final list comprised a total
of 53 pharmacies, dispensaries and clinics contained
within the sample area. Of these facilities, only eight
were public health facilities; the remainder were com-
mercial pharmacies or private health clinics. Some of
these were excluded from the study either because
they were no longer in business (n = 8) or because
they were wholesale suppliers (n = 5) and did not pro-
vide EC pills directly to the public. In addition, four
commercial pharmacies were excluded because they
did not sell EC products and therefore did not wish to
participate in the study. The refusal rate among phar-
macists that provide EC was relatively low; only six
refusals were received and these were all due to time
constraints. In the end, interviews were conducted
with a total of 30 health providers. These comprised
20 retail pharmacists, two health workers from non-
governmental organisation-operated family planning
clinics, six nurses from public sector comprehensive
clinics, and two nurses from public sector family plan-
ning clinics.
Prior to the interviews, permission was obtained
from the relevant authorities. It was easier to gain
access to the private facilities because permission was
usually obtained from the owners or managers of the
facility. Access to the public facilities required obtain-
ing permission not only from the local and provincial
ministry of health but also the senior management at
the facility. Informed consent was obtained from all the
participating health providers prior to the interview.
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The interviews collected detailed information from
providers including their background characteristics,
knowledge of and attitudes to EC, and some of the fac-
tors facilitating and/or inhibiting use of EC among cli-
ents. All respondents were assured that their responses
would be kept strictly confidential and the study would
maintain their anonymity. An attempt was also made
to ensure maximum privacy during the interview. Each
interview lasted approximately 30–45 minutes. All the
interviews were recorded with the permission of the
respondent. Notes were also taken during the inter-
view. The recorded interviews were transcribed and
analysed using thematic analysis, which involves cat-
egorising the data according to salient themes. Themes
are defined as the recurrent ideas or topics that are
detected in the material being analysed and usually
come up on more than one occasion in a particular
set of data.18 The transcripts are used to illustrate
particular findings from the in-depth interviews with
providers.
Results
Sample description
Among the participating health providers there was a
slightly higher representation of females than males.
The average respondent was 40 years old and had
6 years of work experience in the health facility where
the interview took place. Respondents in the commer-
cial pharmacies were qualified pharmacists and health
providers in all other facilities were registered nurses.
All of the providers reported that they had heard of
EC and most (87%) had received some training on it.
In most cases (92%) the providers received informa-
tion on EC as part of their training on family planning
methods. EC is still a relatively recent component of
family planning, and as a result it may not have been a
part of the training of all providers. Some of the pro-
viders had received their training more than 10 years
ago. However, a few providers reported that they had
received training about the product at their work-
place, usually from the manufacturers of one of the
EC products.
Availability of EC
All of the providers interviewed had heard of EC or
the morning-after-pill and they were aware that it is
effective in reducing the risk of pregnancy after UPSI.
Providers seemed to have relatively good knowledge
about when to recommend EC. Most stated that
although an EC regimen may be started up to 72 hours
after UPSI, it should preferably be taken within the
first 24 hours following UPSI. Only a few providers
knew that EC may be used up to 5 days after UPSI.
Many of the interviewees also stressed that EC pills
should not be used as regular contraceptives.
“We only give them in circumstances of unprotected inter-
course if it happened within the last 72 hours. We provide
ECs in the case of rape or a burst condom. We do not
provide it if a person is not using a method of contracep-
tion and they say ‘Can you give it to me I am going to have
unprotected sex tomorrow?’ No, we do not give it in that
case.” [Commercial pharmacist]
The choice of EC products appears to be fairly lim-
ited, particularly in public sector facilities. In public
health clinics, EC is provided almost exclusively in the
form of ‘cut-up’ regular COCs. Very few public sec-
tor health providers were even aware that a dedicated
EC product was available in South Africa. In private
pharmacies, both COCs and the dedicated levonorg-
estrel-only product are available to clients. In private
facilities, providers argue that despite the improved
side effect profile of the dedicated product, there is
a higher demand for ‘cut up’ regular COCs than for
dedicated EC products. Cost is a major factor influenc-
ing choice of EC products.
“The price of the product is the main consideration at the
moment. Almost 99% of the time people have already
used the ‘cut-ups’ or their friends have used it and they
come and ask for it by name. The costs are much lower for
‘cut-ups’.” [Commercial pharmacist]
The costs of dedicated EC products are considerably
higher but they require a single dose, and according
to the providers are associated with fewer side effects.
In addition, providers in private facilities suggest that
compliance is higher with dedicated products. The use
of non-dedicated products requires the administration
of two doses within 120 hours of UPSI, with a 12-hour
interval between doses. Pharmacists observed that this
reduced the effectiveness because some clients do not
adhere to the instructions.
“People have problems with regular combined oral contra-
ceptives because there are multiple doses. Clients have to
take the second dose after 12 hours and not all of them are
compliant. We have had cases where people had lost the
second dose or the box.” [Commercial pharmacist]
Providers in public health facilities report that demand
for EC products is very low and that this is likely related
to the inability to offer walk-in EC services. In most
public facilities there is a long waiting period, which
may discourage use of EC products. Clients often have
to wait in long queues before they receive EC.
“It is very rare to find a client requesting EC. We usually
give it to the client who reports having unprotected sex:
either the condom burst or she was not using any other
contraceptive method.” [Public health provider]
Conversely, providers in private facilities report that
requests for EC are common and on the rise, especially
among young women aged between 18 and 30 years.
They noted that women are more likely to request EC
but there is also a growing demand among male part-
ners. [NB. This finding is supported by results from
South Africa’s most recent Demographic and Health
Survey, which suggests that men in the age group 15–59
years report higher levels of ‘ever use’ of emergency
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is that the demand is great among young people aged
18–25 who are relatively educated about HIV/AIDS. So
it concerns me that despite the education, there is not the
slightest fear about the possibility of contracting HIV.”
[Commercial pharmacist]
One provider at a commercial pharmacy remarked
that the facility only offered dedicated EC products
because “we try to discourage people from using it. We
use the high costs [of the dedicated product] as a means
of preventing people from using it”. Conversely, sev-
eral providers in the public sector felt that EC use was
low because the option of termination of pregnancy is
more popular, particularly among young women. As
one public health provider argued:
“I think, as I have said, they are well aware of EC now,
but I think that there are other options that they can use,
like termination. It is very rare that they think about it
now because they know that there is another option if they
do happen to fall pregnant. There is always termination.
So they do not stress about it. The teenagers especially
do not stress about it. This is why I think EC use is very
rare because abortion is one big option.” [Public health
provider]
A few providers expressed uncertainty about EC and
were not entirely comfortable with providing EC but
they felt that they were not able to change the situa-
tion. This attitude was captured by one provider in a
public facility who stated that: “At the end of the day
we are here to offer a service. The client has come for
a service and it is their right to receive it”. In South
Africa, health providers are required by legislation to
provide EC without restrictions. However, most pro-
viders in the private facilities reported that they do
not usually counsel clients about the role of EC in pre-
venting unwanted pregnancy after UPSI because of the
high client load. When clients request EC the providers
give it to them but often do not voluntarily offer them
additional information about it. However, providers
reported that it was not possible to restrict frequent
use of EC because of their high client load.
“I wish I could restrict the number of times that EC is
prescribed to an individual, but in terms of the current
circumstances it is not possible. The pharmacy is too busy
and most often we do not always remember the people
who request EC. And we often do not have time to take
down a profile.” [Commercial pharmacist]
A few providers also expressed concerns about the side
effects of EC. They felt that inappropriate or frequent
use of EC may lead to health problems. One pharmacist
incorrectly stated that multiple use of EC increases the
risk of cancer, and as a result was reluctant to provide
clients with repeat dosages. Others were concerned
about the impact of EC on hormone levels.
“If you are using EC on a continuous basis I think it poses
a health risk. I can provide counselling to a woman in one
week but in the next week she can go to another pharmacy
where the pharmacist will not know her and counsels her
contraception (1.4% of men aged 15–59 years reported
ever using EC compared with just 0.5% of women aged
15–49 years).]3 Older women are more likely to be using
a long-term contraceptive method, and according to the
providers they sometimes request EC if they experience
method failure but, in general, are not typical EC cli-
ents. As one public health provider explained:
“When you are in your 30s you are usually more mature.
You are usually more stable in your job and you know that
you cannot afford to fall pregnant because of the financial
implications. So you are either on a contraceptive already
or you have taken the necessary precautions. I think I may
see only one or two a year in that age group.” [Public
health provider]
Perceptions of EC
In general, providers, particularly in public sector
facilities, were in favour of improving the availability
of EC services and were aware of the potential benefits
of EC in preventing unplanned and often unwanted
pregnancies. However, most providers expressed mis-
givings about the use of EC. Moreover, the conditions
under which providers were willing to supply EC were
often narrowly defined, and none of the providers in
the private or public health facilities reported supply-
ing an advance dosage for clients.
“I do not have a problem with EC for the simple reason
that I would rather cope with one mistake than two. I
would rather she came here not having used a method
and wanting EC than the client having an unwanted
pregnancy; because that is likely to lead to problems.
Otherwise we are going to have mega social problems
which we are already encountering now. So to avert that
possibility I have no hesitation in providing EC.… [But]
I do not believe clients should be given an advance dose
of EC. I think they should come to the clinic when they
need it because you get an opportunity to counsel them.”
[Public health provider]
Almost one-third of providers expressed concern that
the increased availability of EC might impact negatively
on clients’ behaviour. They were particularly con-
cerned that increased accessibility of EC will lead to an
increase in risky sexual behaviour or a reduction in the
use of other (particularly barrier) methods of contra-
ception. This was especially worrying to providers in
view of the high rate of HIV/AIDS infections in South
Africa. Some providers, for example, commented:
“Obviously EC encourages risky behavior. When they come
in to request EC it is clear that they are having unpro-
tected sex, and in South Africa unprotected sex is a risk
because of the high levels of HIV infection.” [Commercial
pharmacist]
“It is good that you cannot advertise EC products. If
everybody knew that this is available you tempt them and
obviously sales will go up but there will be an increase in
sexually transmitted diseases.” [Commercial pharmacist]
“I do not feel uncomfortable giving it but it concerns me
that there is such a high demand only because of the high
levels of HIV infections. What is particularly worrying
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and clients are often not given a full range of contra-
ceptive options. In addition, EC cannot be advertised
and, according to many providers, this is a major fac-
tor that is limiting awareness of the product in both
urban and rural areas.
Many of the providers in the public health facili-
ties felt that they were ideally placed to promote EC.
However, the heavy client load and the severe short-
age of trained staff serve as an obstacle to the pro-
motion of EC. Many providers stated that the long
queues at public health facilities discourage them
from counselling clients about the risks associated
with UPSI.
“Ideally I should be going into details and saying that:
‘These are the methods that we have available. This is
what you should be on. If you have unprotected sex this is
what should be done’. However, sometimes we do not have
the time. In most cases, we do not have time to provide
detailed information and education because of staff short-
ages and increased workload.” [Public health provider]
Providers at public facilities reported that clients are
more likely to obtain EC from pharmacies than public
clinics. It is easier to obtain EC from pharmacies because
clients do not have to queue for a long period of time.
However, clients have to pay for EC products that they
obtain at pharmacies and they do not receive informa-
tion about the product. In contrast to the view that heavy
workloads and staff shortages prevent public sector
health providers from counselling EC clients, one public
health provider outlined the advantage of EC provision
in the public sector as being a source of information.
“A lot of clients will come here because they get informa-
tion from us. We counsel clients and help them make an
informed decision whereas at the pharmacies it is a matter
of ‘here is my money’ and ‘here is the product’. I think that
clients appreciate the services they receive from us. They
know that they are going to encounter side effects – they
can cope with them because we have explained the side
effects. They more or less know what to expect and are
comfortable with it.” [Public health provider]
Conversely, the consultation with the provider, partic-
ularly in pharmacies, is often very short, lasting only a
few minutes and not allowing sufficient time to counsel
clients about the benefits of EC. As a result, some pro-
viders tend to give clients a fact sheet which contains
all the relevant information about the product. On the
whole, in both the private and public sectors, providers
are faced with heavy client loads, which makes it dif-
ficult for them to give each client personal attention.
Clients rarely have an opportunity to ask any ques-
tions about their concerns. In addition, some clients
are embarrassed to be seen obtaining EC. Sometimes
the lack of privacy may affect clients’ willingness to
provide sensitive information. Other clients may listen
in on the consultation and clients in the consultation
may feel uncomfortable revealing the real reason for
visiting the clinic.
as well. The next week she can go to another pharmacy
to get her supply of EC. This can throw her whole cycle
into complete disarray and increase the risk of cancer.”
[Commercial pharmacist]
A few providers observed that they would prefer to
advocate EC rather than termination of pregnancy.
Although most providers knew that EC does not
cause abortion, a few perceived that EC may be a
form of abortion or may cause harm to a fetus if
taken too late.
“I am on the fence about it. I do it, but at the back of
my mind I am thinking ‘Is this person pregnant? I hope
that I am not causing any adverse effects to the fetus’.
However, I would rather issue EC than perform termina-
tion.” [Commercial pharmacist]
In some cases, providers also reported refusing to sup-
ply EC to clients, often as a result of uncertainty about
the age at which a client can purchase EC products
without a guardian’s consent. They reported that they
often referred young men and women to the clinic
for more effective methods of contraception. In two
cases, providers were unaware that EC could be pro-
vided without a doctor’s prescription and as a result
regularly refused provision. Perhaps the largest degree
of uncertainty among providers, however, was around
the age of clients that request EC. In fact, the majority
of providers in both the public and private health facil-
ities expressed great concern about supplying young
people, in particular, with EC. They often used age
restrictions to limit EC use among this stratum of the
population.
“I feel uncomfortable about prescribing it to a young per-
son who is under 16 years but I try to separate my per-
sonal and professional view. They need to be older than 18
for me to accept that they can make their own decision in
their own capacity. If they are younger I usually refer them
to a clinic or somebody that can give consent but most of
the time it is impossible for them to get consent, because
of stigma. Most people do not want to go to the clinic if it
is a small community. Apparently people are uncomfort-
able with the lack of privacy in these clinics and that all
people are known in these communities and they do not
want to be stigmatised.” [Commercial pharmacist]
Barriers to EC use
Despite their concerns with providing EC, health pro-
viders were able to identify a number of barriers that
EC users are likely face in South Africa. Many of the
pharmacists felt that young people do not receive suf-
ficient information about EC and contraception, more
generally, and they argued that there is a need for pro-
grammes to create greater awareness of the correct use
of EC, particularly in rural areas. Many people have
heard of EC but they lack detailed information about
the method, which is illustrated by the comment of
one provider: “Most people have heard of it but they
may not know how long after unprotected sex they
should use it”. In rural areas, access to EC is limited
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was reported to be a constraint to adequate counselling
of EC clients. Almost all providers in the pharmacies
complained of not having time to counsel EC clients
and the great majority of pharmacies did not have a
private counselling room in the facility.
Long waiting times for consultation at public clinics
is another likely reason for the low uptake of EC in
the public health sector. Long waiting times have been
shown to discourage potential clients from seeking
services.19 This is likely to be particularly important
for potential EC clients as timely access is an important
component of the treatment. Moreover, some provid-
ers may be constrained in the advice they can offer by
their lack of adequate training. As a result, they are
unable to offer clients a comprehensive range of serv-
ices. Moreover, the large client loads make it difficult
for providers to offer additional information to clients.
Under the pressure of a long queue, it is hardly surpris-
ing that most providers deal as efficiently and quickly
as possible with patients’ explicit needs before moving
to the next patient.
Both pharmacists and public health workers
expressed a number of concerns with supplying EC,
with the most common perhaps being that repeat use
of EC might be harmful to women and could discour-
age regular contraception use. This particular theme
has also been noted in the international literature on
EC despite the fact that no studies have found a direct
link between EC use and regular UPSI.20 21 Indeed,
one European study even found that EC use was the
catalyst to adopting more regular forms of contracep-
tion.22 Despite the evidence demonstrating that EC
is clinically safe, is not linked with cancer23 and has
no adverse effects, the ‘gate-keeping’ of EC products
is a relatively common practice among the providers
participating in the study. Some of the main reasons
given for limiting or restricting access to EC products
included: fears of repeat use by clients, the safety of
EC products, uncertainty regarding the regulations
surrounding EC, a feeling that EC use encourages pro-
miscuity, and a reluctance to provide EC to younger
women. The fact that age was a concern for a number
of pharmacists and public health providers, despite
the fact that the number of unplanned and sometimes
unwanted pregnancies is high among young women, is
particularly worrying.
One of the key findings of the study is that provid-
ers in pharmacies, family planning clinics and public
health clinics need more training on EC provision.
In addition to the clinical information that providers
themselves indicated that they would like to have, the
growing number of studies that have shown that EC
use does not discourage regular contraception use and
does not lead to risky sexual behaviour should also be
communicated to providers.20 22 24 The present study
found that many providers felt that EC promoted
promiscuity and UPSI. As such, many of the narra-
tives presented in this paper demonstrate the palpable
“Consultations last approximately one minute. Most [cli-
ents] do not have the time. They do not want to listen to
a whole long story. They want the stuff and they want to
leave. And some of them are embarrassed.” [Commercial
pharmacist]
Some of the providers also reported that they would
like to receive more information on EC in order to
improve the client–provider relationship. However,
providers may be constrained in the advice that they
can offer by their lack of training. Some providers had
completed their training prior to the availability of EC
products in South Africa. As a result they felt that there
was an urgent need for refresher training to update
providers on new contraceptive technologies. Some
providers also felt that they would like to receive more
information about the side effects of EC.
“As a pharmacist there is not much emphasis put on EC,
and these new contraceptive methods. I qualified before
EC was introduced. The mechanisms of it are, I would not
say sketchy, but I would like to receive more information
on it.” [Commercial pharmacist]
Discussion
As part of a larger study investigating the context of
EC provision and use in South Africa, this paper offers
several contributions to the existing literature on EC in
South Africa. First, the study is unique in that, to the
best of the authors’ knowledge, it is the only EC study
in South Africa to conduct research with commercial
pharmacists, public sector health providers, and spe-
cialised family planning providers. Second, while the
results cannot claim to be generalisable, the strength of
the paper lies in the qualitative design that offers some
valuable insights into factors influencing EC use by
drawing upon in-depth interviews with a wide range
of EC providers. Third, the study gathers recent data
from health providers in a site in which EC provision
is likely to be relatively common compared with other
parts of the country. Finally, the study offers insight
into the provision of EC nearly 10 years after both the
introduction of a dedicated EC pill in South Africa and
the passing of legislation making EC products available
without a doctor’s prescription.
There are some indications that there is an increas-
ing demand for EC, especially at private facilities.
Pharmacies remain the key access point for EC prod-
ucts and, tellingly, product price is a main consideration
for many EC clients. As in other local studies,6 10 11 EC
use in public sector clinics and facilities was found to
be very low, despite the fact that the majority of South
African women rely on the public health sector for their
contraceptive supplies. The greater accessibility of EC
at pharmacies notwithstanding, the cost of EC prod-
ucts in pharmacies is likely to be prohibitive for many
women, and the fact that some pharmacists reported
using the higher cost of the dedicated product as an
access barrier is a major concern. In both commercial
pharmacies and public health clinics, consultation time
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J Fam Plann Reprod Health Care 2011;37:89–96. doi:10.1136/jfprhc.2011.0055
Article
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Lloyd CB (ed.). Washington, DC: The National Academies
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3 Department of Health of South Africa and Macro International.
South Africa Demographic and Health Survey 2003. Pretoria,
South Africa, and Calverton, MD: Medical Research Council
and Macro International, 2003.
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6 McFadyen L, Smit J, Mqhayi MM, et al. Expanding
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Contraception Provision and Utilization at Public Sector Clinics
in South Africa. Johannesburg, South Africa: Reproductive
Health Research Unit, 2003.
7 Blanchard K, Harrison T, Sello M. Pharmacists’ knowledge and
perceptions of emergency contraceptive pills in Soweto and the
Johannesburg Central Business District, South Africa. Int Fam
Plan Perspect 2005;31:172–178.
8 Hariparsad N. Knowledge of emergency contraception among
pharmacists and doctors in Durban, South Africa.
Eur J Contracept Reprod Health Care 2001;6:21–26.
9 Maharaj P, Rogan M. Emergency contraception in South
Africa: a literature review. Eur J Contracept Reprod Health Care
2008;13:351–361.
10 Smit J, McFadyen L, Beksinska M, et al. Emergency
contraception in South Africa: knowledge, attitudes, and use
among public sector primary healthcare clients. Contraception
2001;64:333–337.
11 Myer L, Mlobeli R, Cooper D, et al. Knowledge and use of
emergency contraception among women in the Western Cape
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obstetrician-gynecologist. Obstet Gynecol 1997;89:1006–1011.
14 Harrison J, Varnam M, Cardy G. A request for the ‘morning-
after’ pill. Practitioner 1989;233:899–902.
15 Cooper D, Bracken H, Myer L, et al. Reproductive Intentions
and Choices Among HIV-infected Individuals in Cape Town,
South Africa. Policy Briefs. Cape Town, South Africa: Women’s
Health Research Unit, 2005.
16 Mqhayi MM, Smit JA, McFadyen ML, et al. Missed
opportunities: emergency contraception utilisation by young
south African women. Afr J Reprod Health 2004;8:137–144.
17 Rogan M, Nanda P, Maharaj P. Promoting and prioritizing
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uncertainty that many providers have in providing EC
to their clients, despite its recent deregulation. Some
of the reservations about EC are also related to con-
cerns about the risk of UPSI in the context of a high
HIV prevalence in KwaZulu-Natal.
It is important to note some of the limitations of this
study. The findings of the study may have limited gen-
eralisability to other populations because of the small
sample size. Moreover, the study site was specifically
chosen in order to facilitate access to health providers
where EC is most likely to be supplied. It is not unlikely
that health providers who did not participate in the
study may be less likely to provide EC. Interpretation
of the findings is also limited by provider’s self-reports.
It is also possible that social desirability may have
altered the reporting of attitudes towards EC to some
extent. As in other studies,10 providers in public health
facilities reported supplying EC only in very rare cases
and only perhaps once or twice a year. As a result,
recall bias may be a particular problem among these
health providers. In terms of the limitations associated
with interviewing commercial pharmacists, difficulties
such as a lack of privacy, frequent interruptions and
some degree of suspicion towards the research proc-
ess all may have compromised the findings to a cer-
tain degree. Some of these challenges involved with
researching EC access in pharmacies have also been
documented in the international literature.25
Overall, however, the results of the present study
suggest that much more emphasis should be placed
on obtaining provider support for EC. This is likely to
be an important lesson in other contexts where EC is
available over the counter without a prescription. The
findings presented here suggest that the availability of
dedicated EC products and access to EC pills without
a doctor’s prescription are not enough. Health provid-
ers need to be able not only to provide EC, but they
must be comfortable enough to promote the use of EC,
particularly among those at high risk of an unwanted
pregnancy. The adequate training of health care provid-
ers, both within and outside the public health sector,
is therefore an essential step in improving EC uptake.
The fact that the majority of providers in this study
expressed a strong interest in obtaining more informa-
tion about EC is encouraging in this regard.
Competing interests None.
Ethical approval Ethical approval for the study
was obtained from the university committee
at the University of KwaZulu-Natal.
Provenance and peer review Not commissioned;
externally peer reviewed.
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emergency contraception
unwanted pregnancy: a qualitative study of
Missing opportunities for preventing
Pranitha Maharaj and Michael Rogan
doi: 10.1136/jfprhc.2011.0055
2011 37: 89-96 J Fam Plann Reprod Health Care
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