Improving reproductive health is central to achieving the Millennium Development Goals on improving maternal health, reducing child mortality and eradicating extreme poverty. This requires that women have access to safe and effective methods of fertility control. It is because of this that World Health Organization (WHO) promotes Family Planning so that women do not have to bear the burden of multiple and unwanted pregnancies [1].

Unintended pregnancy has been associated with unhealthy behaviour before, during and after pregnancy and can adversely affect pregnancy outcomes [2]. Several studies have shown that unwanted fertility has unfavourable effects on antenatal, postnatal preventive and curative care. Women who experience an unwanted pregnancy are less likely to receive care than women who had an intended pregnancy [3].

In January 2001, the Consortium on National Consensus for Emergency Contraception met in New Delhi to discuss the issues involved in the introduction of emergency contraception in India. The Consortium—consisting of the World Health Organisation (WHO), the Ministry of Health and Family Welfare, and the Indian Council of Medical Research—recommended that a dedicated product should be introduced as soon as possible with information, education, and counselling for public awareness, and relevant training for providers [4].

The Consortium agreed that ECPs should not be available over the counter at that time, but suggested that it was a possibility once widespread awareness had been established. In the wake of Consortium recommendations, manufacturing of dedicated ECPs began in India and the Drug Controller General of India granted permission that same year to launch a dedicated ECP. By 2002, dedicated ECPs were provided free of charge nationwide by the Family Welfare Programme and available by prescription in pharmacies. However, ECP use— especially among public-sector clients—was low because of a lack of awareness [4].

Government of India introduced ECP in the National Family Planning Program in 2003. Many feasibility studies were conducted by the Indian Council of Medical Research (ICMR) thereafter. In 2005, over-the-counter access was approved and pharmacies and chemist shops began selling dedicated ECPs without a prescription.

Emergency Contraception (EC) is a post-coital method of contraception that prevents pregnancy before implantation or fertilization takes place. Emergency Contraceptive Pills (ECPs) are a safe, effective form of contraception (American College of Obstetricians and Gynaecologists [ACOG], 2005) and can prevent pregnancy when taken within 120 hours of unprotected intercourse [5]. Although ECPs have been theoretically available for over 30 years, in most countries around the world they remain a relatively unknown and underused method [6].

As per a study published by the Population Council in 2005, which focussed on the utilization of ECP, highlighted that, only few people are aware of ECP as a method to prevent unwanted pregnancy after unprotected intercourse and even among thosewho are aware of ECP, very few know how to use it correctly.

In view of the above findings, this study was conceptualized with the following objectives:

• To assess the awareness of ECP among urban women

• To evaluate its utilization following its introduction in urban women

• To determine barriers to its use.

A quantitative study was carried out in urban areas of Jaipur, Rajasthan among married women in the age group of 18-44 years. Three criterions were considered for identifying respondent women – firstly, they should be fertile, secondly, they should not have got sterilized and thirdly, they should not be using an IUCD(at the time of survey).

Earlier studies on knowledge of ECP were reviewed to assess the sample size in context of the percentage of women who would have knowledge about ECP. A study in India among the women hospital workers reported that about 11.2 percent women were aware of ECP [7].

As per census 2001, the female population of Jaipur district falling in the age group of 15-44 years was 11703489. With 95 percent level of confidence (standard value of 1.96) and margin of error as 2 percent, the sample size arrived at was 789. About 10 percent of the sample size was added to the sample to account for non-response and over all a sample of 900 women was arrived at. As per census 2001, the urban population in Jaipur was 25.5 percent for urban respectively; therefore, the sample for urban area was taken to be 230.

Furthermore, multi stage systematic random sampling was adopted to select the wards, the only criteria being that the number of households should be more than 100, 15 wards were selected in all. The required households were selected to interview the women. In case, more than one eligible woman was found in the selected household, they too were interviewed which resulted in increase of sample size. After discarding the tools with inconsistent information, the sample size included 243 women.

Analysis

A quantitative schedule was developed to fulfil the above stated objectives. Descriptive and inferential statistics were used for analysis.

The level of literacy of the women was taken into consideration as literacy has a great role in opinion formation. It was seen that about 19 percent of the women were illiterate. About 59 percent studied till senior secondary, and about 22 percent of the respondents studied till graduation or more. The details of the same have been mentioned in Table 1.

Table 1: Percent women as per their literacy level.

Awareness of ECP among women

To understand the awareness that the women had in respect to all contraceptives in general and ECP in particular they were asked if they were aware of any of the contraceptives. Nearly all of the respondents were aware of Oral contraceptive pills, male condoms and female sterilization. About 96 percent of the respondents knew of male sterilization. About 97 percent of the respondents reported to have knowledge of some natural methods like mala chakra, safe period and withdrawal.

Respondents were relatively less aware of injectables as compared to other contraceptives listed before, about 85 percent of the respondents were aware of them. Astonishing as it may seem, Emergency Contraceptive Pills was the least known method, only about 62 percent of the respondents were aware of it (Table 2).

Table 2: Awareness of ECP vis-à-vis other regular methods of contraception.

The results show that the awareness with regard to ECP is low even in urban settings as compared to other contraceptives.

Utilization of ECP among women in urban areas

It came to light that most of the respondents, who were aware of ECP, came to admit it only after probing. Spontaneous response came from only about 9 percent of the respondents. ECP usage was reported by only 7 percent of the respondents, which was quite low. The data shows that almost 46 of the unwanted pregnancy ended or expected to end in births [8].

Children born as a result of an unintended pregnancy have poorer physical and mental health, poorer relationship with their mother, poorer educational attainment, lower cognitive test scores, and higher rates of adolescent delinquency [9,10].The National Campaign, 2008. In view of such findings, it can be said that the reduction of unwanted fertility is not only a key to reducing maternal and child mortality and to reaching Millennium Goals 4 and 5 but also ensuring quality of life for both the mother and the child [11]. In view of these findings, ECP could be good alternative, however only about 7 percent of the respondents used ECP (Table 3).

Table 3: Percent respondents who were aware of ECP and percent respondents who used ECP.

Barriers faced in use of ECP

In order to understand the barriers to use of ECP, the women were asked if they had ever experienced unwanted pregnancy. It was found that 30 percent of the women had at any one point of their life experienced the fear of unwanted pregnancy. Of the women who experience a fear of unwanted pregnancy only about 14 percent took ECP.

Studies in the past have found unintended pregnancy to be associated with mental peace and a possible correlation between unplanned pregnancies and depression, anxiety, and a decline in psychosocial well-being [8]. It was found that about 41 percent of the women who had a fear of unwanted pregnancy and did not take ECP got pregnant.

The women who experienced a fear of unwanted pregnancy, but did not use ECP were asked about the reasons for the same. As illustrated in Table 4, about 54 percent of the women did not take ECP due to lack of knowledge about it at the time they needed to take ECP. About 2 percent of the respondents got late in taking ECP within the stipulated 72 hours. Nearly 15 percent of the respondents did not use ECP as they thought that ECP has side effects. Around 5 percent said that their doctor had advised them against using ECP due to some medical reason.

Table 4: Percent respondents who experienced unwanted pregnancy, used ECP and reason for not using ECP.

The interesting finding of this paper is that unlike the assumption that urban women are more literate and less vulnerable to health problems, it was found that urban women were vulnerable with respect to the fear of pregnancy and the measures adopted to prevent pregnancy. As far as outcome of pregnancy is concerned, the data shows that almost 46 of the unwanted pregnancy ended or expected to end in births [12-15].

The awareness of ECP was also low as compared to other regular methods of contraception. The findings reveal that the greatest constraint on the way to use ECP is related to awareness and knowledge. Around 54 percent of the women did not use ECP at the time they needed as they were not aware about it [16-19].

Unplanned pregnancies are a major burden on individuals and the healthcare system. Whereas using contraceptives ahead of time is the ultimate goal for reducing unplanned pregnancies, the use of ECPs could provide women with an alternative means of preventing unintended pregnancy after risky behavior or barrier malfunction. While the use of ECPs could prevent 75% of unintended pregnancies unawareness and scarcity of knowledge come out to be the greatest barriers in the utilization of ECP.

To make ECP easily accessible andeffective in preventing unwanted pregnancies, it iscritical that potential users be made aware of correctuse of ECP and the sources from where it could beobtained.As long as people are not aware and don’t have complete knowledge about the emergency contraceptive pill, its use and accessibilityto potential users will remain limited.

The health system could take steps in order to help prevent unwanted pregnancies by making available IEC material of ECP in the health centres for equipping women with complete knowledge of its use and side effects. The problem of lack of knowledge of ECP should be addressed to help prevent unintended pregnancies.