Mainstreaming EC in Ethiopia's Public Sector: Project Results and Implications for Scale-up

Publication date: 2009

May 2009, Volume 3, s~tpplement 1 Ethiopian Journal of Reproductive Health ORIGIONAL ARTICLE Mainstreaming EC in Ethiopia's Public Sector: Project Results c!_nd Implications for Scale-up Keesbury J1, Aytenfisu H2; Mekbib Ti, Belay T', Gaym A5, Sk.ibiak. JP6 Abstract Background: Building on nearly a decade of momentu~, the Federal Ministry of Health (FMOH), the Ethiopian S~iety of Obstetricians and ~necologists (ESOG) and Population Co'uncil (EC Afrique) launched a two-year project in 2004 to main- stream emergency contraception (EC) in the public sector. · · Objective: The project aimed at impro11ing reproducti11e health (RH) care among young women and to reduce the abortion rate by expanding access to EC in the country. Its 011erali' goal was to demonstrate the feasibility of integrating EC within the public sec- tor's broader contraceptj11e. mix. Methods: The project undertook a set of acti11ities aimed at improoing pnwider competency, increasing public demand and ensur- ing commodity security. The final eooluatio,i drew -0n seniice statistics from 33 interoention sites, and knowkdge, attitude and practice sun,eys conducted with family planning ser11ice pro11idm and clients in the health facilities in110l11ed in the project. Results: EC users were primarily unmarried women bet~n the ages of 20-24, although mak partners wae increasingly inool11ed in EC decision-making and procurement. This runs counter to predominant perceptions of EC usen as adokscent girl.s. Sexual assault was the kast commonly cited reason for EC .use, reflecting its current position as primarily a family planning method. Tek- 11ision ad11ertisements and clinic-based health education were the most commonly sited forms of communication on EC, while print · media reached the fewest respondents. Both clients and pro11iders . belie11e that pharmacy pro11ision qf EC is socially acceptable, and agree that one Birr is the optimal price for sak in the pri11ate sector. Conclusion: Scaling up_ EC mainstreaming acti11ities in Ethiopia will effecti11ely position EC as a core component in the national family planning program and post-rape care· seT11ices. Furthermore, there is need to strengthen the capacity of pro11iden so as to encourage EC users to seek HlV/STl counseling and testing ser11ices. To ensure that EC serues as a gateway to more comprehen- si11e RH care, it is critical to stress "bridging" as a key ekment of the seroices. Keywords. Emergency contraception, family planning, adolescents, kt1enorgestrel 4 'Population Council, Nairobi, '·' Ethiopian Society of Obstetricians & Gynecologislli, 'Population Council, Addis Ababa, 4Venture Strategies, Addis Ababa, 6 Reproductlve Health Supply Coalition, Brussels May 2009, Volume 3, supplement 1 Ethiopian Journal of Reproductive Health In May 2005, the FMOH, ESOG and the Population Council (EC Afrique) initiated a pilot project entitled "Mainstreaming Emergency Contraception in the Public Sector" to introduce EC into the public health system. In this project, five of the most populated regions of Ethiopia and 33 health facilities were involved. Through this pro- ject, Postinor 2 (a progesterone only drug) the first ever dedicated EC pill was introduced in Ethiopia, and the lead arti- cle in this special issue is devoted to this project (5). One of the major objectives of this project was to register this dedicated product in the country, and in 2006, Beker Pharmaceuticals and Medical Supplies received an authoriza- tion by Drug Administration and Control Agency(DACA) to import a dedicated EC product called "Postinor 2" from Gideon Rector Pharmaceuticals after passing a thorough registration process. However, chis product has not been available in the market because of its high cost. The other critical feantre of this project was to involve the Addis Ababa, Gondar and Jimma Universities in order to encourage medical sn1dents to conduct independent research on EC and thereby provide them with RH information and services to prevent unwanted pregnancy including HIV/ STis . More recently, DKT-Ethiopia has started social marketing another EC dedicated product called "Postpill", a levonorgestrd, which has become very popular among young people. DKT has trained pharmacists to enable them provide the necessary information about the drug to clients and making this drug available to those who are in need of it and thereby eliminating the need for advance prescription. At present, this dedicated product is available in most pharmacies in the country. Although DKT is doing a commendable job in the private sector, taking similar initiatives to tl1e public sector to make EC available is still a challenge that we should overcome. Finally, I would like to thank the Editorial Board members of the EJRH, the Nairobi Population Council staff for editing and suggesting valuable comments on the selected articles in this special issue. References l. WHO/HRP/ITT/99.1 World Health Organiz~tion (WHO). 1999. An assessment of Reproductive Health Needs in Ethiopia 2. Illegal and Unsafe Abortion in Ethiopia. Proceedings of the 7th Annual Conference of the Ethiopian Society of Obstetricians and Gynecologists (ESOG). May 17-18, 1999, Ghion Hotel, Addis Ababa, Ethiopia 3. Skibiak JP, Mekbib T, Getahun H. Expanding contraceptive choice in Ethiopia. Sexual Health Exchange; 2002; 2: 4-5 4. Federal Ministry of Health 2000. An Evaluation of Norplant® Insertion and Removal Services in Ethiopia. In collaboration with Population Couricil, UNFPA and WHO. 5. Keesbury J, Aytenfisu H, Mekbib T, Belay T, Gaym A, Skibiak JP. Mainstreaming Emergency Contraception in Ethiopia's Public Sector: Project Results and Implications for Scale-up. Ethiop J Rerod Health 2009; 3(1): 4-15 3 May 2009, Volume 3, supplement 1 Introduction Recognition of the need to introduce emergency contraception (EC) into the public sector began in 1997, when the National Reproductive Health (RH) Needs Assessment noted that EC could play a critical role in "limiting unwanted pregnancy, reducing the need for unsafe abortion; . lowering rates of mater- nal morbidity.aRd · . [provi.ding) a~ additional tool for rape management" (1). -Th~ Assessment also found that access to famHy planning services was limited by providers who were perceived to be "out of touch" with the needs and concerns of their young clients. In 1998, Ethiopian delegates at- tended an international conference in Malawi on EC where they developed a framework for introducing EC services in their country. This framework called for the establishment of a multi-sectoral advisory body and th~ integration of EC into 0~1going train~ ing programs and national family planning guide, lines {2). Shortly th~reafter, tl1e 1999 annual meet- ing of tl1e Etl1iopian Society of Obstetridans and Gynecologists (ESOG) endorsed EC's ability to "reduce dramatically the c~untry's soaring levels of unsafe abortion" (3). The Family Guidance Association of Ethiopia (FGAE) and the Population Council piloted. EC introduction through the coital dependent methods (CDMs) snidy in 2001. The snidy was designed to increase young people's access to CDMs by improv- ing supply at the facility level and generating demand within the community (4). Working within FGAE's national network of youth-friendly clinics, the project developed a "branded" range of post-coital metl1ods and trained providers on their provision. A single, youth-oriented graphic was included on re- packed female condoms, male condoms and vaginal foaming tablets. FGAE employed the Yuzpe regimen of EC since no dedicated EC pill existed at that time in Ethiopia. Each packet contained four tablets of high-dose, combined oral contraceptives, simple instructions (in Amharic) . on correct use, and two male condoms to encourage dual protection. Peer service providers were trained to distribute these methods. By mid- 2003, 5,000 miits of. EC had been distributed to selected FGAE youth centers nationwide. Ethiopian Journal of Reproductiv~ Health The sntdy demonstrated that. untrained health care providers had limited fam.iliarity with EC and held some misconceptions regarding its use. Most were aware that oral contraceptive pills could be used for emergency purposes, though knowledge of type, doi age and timing was low. The baseline study found that only 28% of the 1053 providers su~eyed had ever adininistered EC and aln10st half believed tts· use would lead to increased promiscuity. Less than half (44%) were aware of EC's three-day efficacy pe- riod. While the CDMs smdy demonstrated that EC could be successfully provided through . non- governmental organizations, the bulk of health care services in Ethiopia are delivered through the public sector. To ens~1re broad accessibility, tl1e Ministry of Federal Health (FMOH), ESOG and the Population Council (EC Afrique) conducted a pilot project betwe~n May 2005 and December 2006 to introduce EC into the country's public health system. This artidf; provides an overview of the project's interventions and out- comes in order to inform scaling-up of EC· services natio~wide. Interventions As identified in the CDMs study; correct knowledge of EC among Ethiopian service providers was low. To ensure quality services, the project mi.dertook efforts to train ·providers in each of the participating facilities. A total of 69 doctors and nurses were trained to provide EC during the first round of train- ing in early 2004. In late 2006, 121 providers partici- pated in a second round of training intended to pro- mote the sustainability of EC services after the pro- ject's cc:mclusion. Trainings were conducted .by members of ESQG, using a manual developed specifically for the project. This manual was drafted by a team of ten experts from. partner organizations, and was adopted at a national expert review workshop. It was based o.n materials produced by the Population Council in Bangladesh, and modified to reflect the specific 1~eeds and knowledge of Etl1i~pian s~rvice providers (5). The m~nual was pre-tested in Addis Ababa be- fore being-endorsed by the FMOH. 5 May 2009, Volurne 3, supplement 1 In addition to conducting in-service trammg, the project worked to build interest among smdents by offering small grants for degree-related research on EC. A call for proposals was issued to all medical, nursing or community health smdents at the c-0un- try's most prominent universities (Addis Ababa, Oondar and Jimma Universities) in early 2006. Smdy coordinators at each site mentored smdents in con- ducting the research and EC Afoique provided fund- ing for the field work. A total of ten projects were selected through the national competition, which examined EC in the context of social and mediqil issues such as sexual assault, pharmacy provision and adolescent access. Many of these studies are pub- lished in this volume. Under the direction -of a professional journalist, a mass media campaign was conducted throughout 2006. The campaign_ targeted opinion leaders and potential urban middle and upper class clients, and included: a one-minute informational television com• merdal on EC feamring locally popular young adult actors; an interview with the project coordinator on the regular women's television talk show, Kesetoch Adnws. The 60-minute interview, which aired in 20- minute installments for 3 consecutive weeks, focused on EC and its impact on the prevention of unsafe abortion as a way of reducing the country's high ma- ternal mortality and morbidity rates; a series of short informational news spots in leading national media e.g. Addis Admass (weekly newspaper) and Lanchi ina Lante (radio program), which highlighted the impor- tance of EC in a variety of sin1ations. In addition, the project developed a youth-oriented poster that communicated key messages about EC use and tim- ing in Amharic. To ensure continued commodity supplies, a final component of the project was the introduction and registration of a dedicated EC pill in the country. Permission to import Postinor 2 was granted by the Ethiopian Drug Administration and Control Au- thority (DACA) in August 2004 and 40,000 units were procured using funds made available by EC Af,ique. Working with the local phamuceutical com• pany Beker, ESOO and EC Afoique secured product registration based on the success of this project. In December 2006, DACA officially approved Postinor 2 for use in Ethiopia's public and private sectors. 6 Ethiopian Journal of Reproductive Health Evaluation Design and Methodology The sn1dy design involved two approaches namely: continuous monitoring of utilization data from ser- vice statistics and a post-test measurement at the end of the two year pilot phase of the project.; . Through the project, EC was provided in 33 facilities in the country's five major regions (Addis Ababa, Oromiya, Amhara, SNNPR, and Tigray) (Table l). Seven of these facilities were NGO clinics, represent- in.g areas where these NGOs dominate RH service provision. Site selection was based on criteria that included monitoring capacity and overall functional- ity, and was made in collaboration with smdy coordi- nators based in each region's medical schools. After provider training, an initial allom1ent of 10,000 units of Postinor 2 was allocated among the facilities. Product usage was monitored at each of the 33 par• ticipating hospitals and health centers, and addi- tional supplies were delivered as needed. To evaluate the impact of the project, three sets of data were collected (Table 2). First, nasic service statistics, including basic client profiles, were re• corded for every client who received Postinor 2 in each of the 33 project sites between May 2005 and December 2006. A total of 3999 cases of EC use were reported during the 20 months of ~ervice provi- sion. Second, toward the conclusion of the project period, providers were interviewed to assess their experiences with EC. Knowledge, attitudes and practice (KAP) survey was conducted with 121 providers from the five regions participating in the project in October and Novem- ber 2006. The survey was selfodministered and was completed by all providers who attended the second training exercise, and was distributed immediately before the comm~1~cement of training. The bulk of these respondents were nurses (73%)· followed by midwives (14%); only three doctors were included in the survey. May 2009, Volume 3, supplement 1 Table 1: Project sites, by region Region Addis Ababa (16 facilities) Health Facility I ilmr Anbessa Hospital Zewdiru Hospital St. Paul's Hospital Yekatit 12 Hospital Ghandi Hospitai Meshualekiya Health Center Kolfe Health Center Gulele Health Center Lideta Health Center Teklehaimanot Health Center Woreda 23 Health Center Woreda 19 Health Center Yeka Health Center FGAE Main Clinic Marie Stopes Obstetric Center Kirkos Health Center Table 2: Data Sources Ethiopian J oumal of Reproductive Health Region Health Facility Amhara Condar Hospital (5 facilities) Gondar Health Center Azeio Health Center Teda Health Center FGAE Clinic Oromiya Jimma Hospital (4 facilities) Jimma Health Center FGAE Clinic Marie Stopes Clinic Tigray Mekele Hospital (4 facilities) Mekele Health Center Kasetch Health Center Semen Healtl1 Center SNNPR Yirgalem Hospital ( 4 facilities) Awassa Health Center FGAEClinic Marie Stopes Clinic Region Number of Respondents/Cases Service Stats Provider KAP Client KAP Addis Ababa Oromiya Amhara SNNPR Tig.ray. TOTAL 2659 194 271 478 397 3999 58 22 16 14 11 121 Third, a client KAP survey was conducted in health facilities in Addis, Jimma and Awassa in the week following the p~ovider survey. A total of 768 health center clients coming for all services_ were inter• viewed by nurses who completed the EC training. No nurses were assigned to collect data from the facilities they nom1ally worked in. Respondents comprised all clients and companions, male and female, who presented at the clit1ic during the week- long data collection period. · 205 283 n/a 280 n/a 768 Interviewers were stationed throughout the facility in order to capture a diverse sample of clients. They were instructed ro approach clients only at the end of their visit, and to obtain written consent before com; mencing the interview: The survey sought general information on client contraceptive attin,des and practices as well as awareness and perceptions of EC. The sample was intended to serve as a proxy. for awareness among the segment of_ the population that is most likely to seek institutionalized health care services. 7 May 2009, Volume 3, supplement 1 The data were entered into Epi-lnfo by ESOG staff in Addis Ababa, with support from EC A[rique. Analysis was done using SPSS; a chi-square test was used to measure the strength of association in bivari• ate relationships. It is also important to point out two major limita• tions of this project evaluation. First, the absence of baseline data rule~ out th~ possibility of making pre- and post-intervention cornpaiisons. Secondly, lack of data for the control or non-intervention sites makes it difficult t~. clir~ctly attribute the outcomes noted at the end of pr!)Iect survey to the interven- tions. The service statistics provide the most compre- hensive view of the project's impact over time, but cannot account for intervening factors. The dient and provider KAP surveys evaluate the impact of provider training ancj, awareness-raising activities by examining exposure and reported behaviors, but the strength of this analysis is limited by the absence of base- line data. Results The client KAP survey found that overall knowledge and use of EC in Ethiopia remains low. Only 20% of those interviewed stated that they had ever heard of EC, and 20 (0.03%) of the 768 women and men interviewed reported that they or their partners had ever used EC. The majority of the clients (83%) also indicated that information on EC was not widely available to women in their communities. Within project sites, however, ntilization of EC steadily increased throughout the project period, with almost 600 units being distributed by the pro- ject's final month from initial non-available services (Figure 1). Ethiopian Journal of Reproductive Health Of the snidy sites were located. Overall, 67% of all EC units distributed by the project were through facilities in Addis Ababa. Client characteristics Service statistics indicated that most users (71 %) were young adults aged between 20 and 29 years ('Table 3). Almost half (47%) of the clients were aged be~een 20 and 24 years while younger adolescents (aged 19 years and below) comprised only iO%. A similar age distribution is found in the client KAP survey: of the 20 clients who reported h,wing ever used EC, 14 (70%) were between the ages of 20 and 29 years. According to service statistics, a substantial propor• tion of users (41%) were married. This proportion was even highar when disaggregated by region; in Tigray for example, 55% of the clients reported that they were married. This is similar to the pattern observed in the client KAP survey in which 11 of the 20 of those who had ever used EC identified them- selves as married (Table 3). Whereas women constinited the majority of clients (96%), some men also obtained EC for their part- ners. A total of 17 3 men accessed EC during the sntdy period, and in one region, Oromiya, nearly 22% of all EC clients were men. The client KAP survey provides further indication of male involve• ment in EC use. According to the 20 women who identified. them• selves as EC users, nearly half (45%) had talked to their partners before making the decision to use the method. Figure 1: Number of EC Units distributed in all Project Sites, May 2005- December 2006 8 700 600 500 400 300 200 100 i~~-~"P'---~r:;,.~c,.A~~--- 0 _ . N•r- " . --,N-N"••- ·•-N-•r·-· . :···-·- .-· Sourer: 1m,ice statistics -----Addis n;.:.;2.592 ---All Regic:>ns n.N• 3925 May 2009, Volume 3, supplement 1 Table 3: Characteristics of EC Clients Age category of EC clients Gender of EC clients Marital stants of EC clients Reason for EC use 10-14 15-19 20-24 25-29 30-34 35-39 40-50+ female male Married Not currently married Unprotected sex Contraceptive failure Sexual assault ·!'<41ons fur M.le among last 3 EC dientJ, IIIIU!iple r,sponm allotu,d '.:ondom breakage . . · Furthermore, almost two-thirds (61%) ·infoi;med their partners before using the method, and in all cases it was reported that their partners supported their decision. The provider KAP survey, however, also shows an unwillingness to deliver EC services to male clients. Ethiopian Journal of Reproductive Health Service Statistics Client KAP Provider KAP n•3996 N•20 n=66 1 0 n/a 19 0 n/a 47 40 n/a 24 30 n/a 7 15 n/:i 2 15 n/a 0 n/a 96' 85 n/a 4 i5 n/a 41 55 n/a 59 45 n/a 81.4 84.6 80.3* 14.2 15.4 42.4*t 4.4 0,0 37.9* In this case, providers were asked how they would respond to an unmarried ad°6lescent girl who clai~ed to have engaged in unprotected sex two· days prior and was seeking advice on how to avoid a pregnancy and that of an unmarried adolescent boy in a similar situa- tion who wanted to obtain EC pills for his girlfriend. The findings indicated that providers were · signifi- cantly more likely to report a preference to deliver EC services to adolescent girls than to adolescent boys (Table 4). Table 41 Provider attini<les toward EC and other reproductive health services to adolescents girls v. boys (n•68*t) Girl scenario Boy scenario p-value % % Provide EC 91.5 41.2 0.019 Provide FP advice 63.6 47.1 0.000 Provide STI/HlV counseling 38:1 50.0 0.000 Provide condoms 23.7 32.4 0.000 Advise against adolescent sex 11.0 13.2 0.000 Do nothing/ Refuse EC 0.0 7.4 n/a • nmltit>le """°""-' allaw.,d t On!, pro<•iden .,,ho had dispensed l:\C 111 letur one• wen, asked lhb qKDlion .SO.rce: fmJt,ider KAP . 9 May 2.009, Volume 31 supplement 1 All three data sources indicate that clients most fre- quently sought EC after engaging in "unprotected sex". Although the provider KAP allowed multiple responses, the trend across all the data sources dem- onstrates that contraceptive failure is the second most frequent reason for use, followed by sexual assault. Clinic records indicate that only 172 of the 3999 doses of EC were administered to survivors of sexual assault, while providers reported that more than one in every three clients experienced sexual assault. Reflecting patterns across the continent, the survi- vors recorded in the service statistics were young, with 52.% of all·cases being between the ages of 10 and 19 (6). Among tl1e very young adolescents (those between 10 and 14 years old), sexual assault com• prised nearly 70% of the cases. Provider Capacity The provider KAP survey was conducted immedi- ately before one-day training on EC conducted by ESOG. At that point, only one-third (33%) of all providers had received prior instruction on EC. Of these, most (85%) reported that they were trained by ESOG under the current project. The remaining providers had been trained under the FGAE project; none indicated that they learned of EC during their professional ttait,ing. The majority of providers surveyed (81%) had dis- cussed EC with their clients, and those who received training 011 EC were more likely to provide it. Ethiopian Journal of Reproductive Health In addition, the majority of trained providers shared information on EC to all likely users even if they did not request it. This is confirmed in client reports, which listed provider interaction as the second most frequent source of information on EC. Repeat use and "bridging" Data from the client KAP snrvey indicate that repeat use is not currently a problem in Ethiopia. Of the 17 clients who reported on frequency of use, the bulk (15) noted that they had only taken EC once in the past year (Table 5). Nearly half of all EC clients adopted a different or new contraceptive method following EC use, most likely because providers rou- tinely counseled them on more reliable methods. Public Awareness Although only 2.0% of resp011dents to the client KAP survey knew of EC, those who did were remarkably well-infom1ed. As indicated in Table 5, clients who were aware of the method demonstrated· levels of knowledge that rivaled, and in some cases exceeded, trained providers. All but one client correctly identitled EC as a method" for ptevehting pregnancy, and nearly 90% knew that EC should be taken within 72. hours of unprotected sex to be effective. While overall knowl- edge was high, some clients expressed concerns about the potenti:tl side-effects of using EC. Table 5: Percent distribution of EC use~'l:,y frequency of use and indicators of 'bridging' 10 Used EC only 01,ce in the past year Began using a new or different contraceptive method after EC Were provided any of the .following services alongside ECt Provided with family planning advice Referred to HIV /VCT services Reforred sexual assault survivor to police • unica pm,,ik,l 1a ~ last 3 clknrs t multipl. raporua wen, allowed in borh SKn'<JS • Client KAP n•l7 'X. 88.2 55.5 92.3 15.4 0.0 Provider KAP• n=-65 ·n/a ,,r 56.l 69.2 56.9 15,4 May 2009, Volume 3, supplement 1 Of those who feared health problems, the largest proportion (41%) believed that it could cause diffi- culties conceiving in the future. Social problems, such as increased HIV cases (61 %) and adolescent sexual activity (59%) were the most widely cited con- cerns .associated with increased EC access (Table 6). Nearly thr~uarters of the clients who knew of EC learned of the method within 1;he past year, which corresponds to the project's media outreach phase. Both clients and providers demonstrated similar exposure to the media campaign, suggesting that it reached a broad segment of the targeted urban popu; lations. The ESOG television advertisement, which was aired during popular television dramas during the weeks prior to the survey, appears to have reached the wid- est audience. Although less effective, print media was most likely to reach providers, as was the topical Kesetoch Admas television feature. More conventional channels of health communication remained key in creating awareness about EC. Nearly 80% of all pro- viders indicated that they included · EC messages in their facility's regular health education sessions. These efforts may account for the fact that nearly one-quarter of those who knew of EC r~ported that they had first heard of it from their health provider: Ethiopian Journal of Reproductive· Health Expanding access To inform future scaling-up efforts, clients and pro- viders were asked to identify the types. of clients who coula most benefit from increased access to EC. Clients were much less conservative in their percep- tions of acceptable EC · users than were providers; most clients believed that access sho~ld be extended to a wide range of women, whereas providers saw the need for greater restrictions. While no significant differences existed among trained and untrained providers, training did appear to improve percep- tions of the types of clients who should recdve EC (Table 7). Clients and providers were ~lso asked to identify the locations where they felt EC should be · made avail- able and the types of providers who should dispense it. Again, clients were more liberal in their percep• tions of acceptable access than were providers. Clients, on the other hand, supported expanded access for sexual assai1lt survivors with over · 80% mentioning emergency rooms and· nearly .40% 'indi- cating police stations. They also· supported commu- nity access through the new cadre of ·community- based health providers, health extension workers, as well as expanded adolescent access through secon- darv schools (Table 8). · Table 6: Perceived Social and Health Problems Associated with Using EC Can EC cause health problems? n= 761 What type of health problems?• n•73 difficulty conceiving causes indigestion menstrual irregularities nausea or vomiting maynotworlc Can easy access to EC cause social problems? n•768 What type of social problems!* n•88 increases HIV cases encourages adolescent sex · encourages promiscuity problem$ with family or husband •Multitu nspo,u,, allmtwl So1t1er. climt KAP sun,ey # of clients % 73 9.6 30 41.1 21 28.8 14 19.2 13 17.8 12 16.4 88 11.5 54 61.4 52 59.1 45 51.1 10 11.4 II May 2009, Volume 3, supplement 1 Providers tended to oyerwhelmingly identify conven- tional sources such as health centers, fari1ily planning clinics, and pharmacies. By the end of the project, Postinor 2 was apprnved for sale at private pharmacies. Previously, EC had only been provided at no cost in the project sites and at minimal cost in FGAE clinics. To assist pharn1acists in pricing the new product, the survey also asked respondents to identify the amount of money (in Ethiopian Birr) that they would be will- ing to pay for EC in private pharmacies. The most commonly cited price was 1 Birr. Ethiopian Journal of Reproductive Health Discussion The available data indicates that EC can be success- folly provided in Ethiopia's public sector family plan- ning facilities. It demonstrates that a latent demand for the product exists and that such demand can be met within -the context of current RH programs. With the registration of Postinor 2 in late 2006, the product is now positioned to become a core element of the country's family planning method mix and, once adequate stocks are procured, can be offered nationwide. Table 7: Percent distribution of clients and providers by perceived appropriateness of EC* 12 ·- Client Provider Indications Rape survivors Women experiencing contraceptive failure Contmindications Pregnant women Post-menopausal women Apj:,roj:niate Users Adolescents Married women Unmarried women Women who have sex infrequently •Multiple responses allowed Source: Client and provider KAP su"'eY"· n=762 Trained (%) n•36 % 96.3 97.2 80.3 89.9 l.7 8.3 2.5 36.1 76.0 63.9 77.9 72.2 71.7 61.1 72.0 50.0 Table 8: Percent distiibution of clients and providers by where they felt EC should be made available, Client and Provider KAP Surveys* Health center FP clinics Emergency Rooms (ERs) Pham1acies Community level (CBRHAs) Police ·stations Secondary schools •Multiple mporue, <ZU,,.ued Client n"764 (%) 98.0 84.6 83.9 72.3 51.1 38.1 37.2 Provider n=llJ (%) 96.5 92.0 28.3 49.6 30.1 17.0 17.9 Untrained n=75 (%) 92.0 69.3 13.3 28.0 53.3 42.7 49.3 49.3 May 2009, Volume 3, supplement 1 AcceM for sexual assault survivors While the program successfully increased access to EC in the context of family planning effo~, it was not as effective in making it available tci sexual as- sault survivors. Both clients and providers over- whelmingly identified sexual assault survivors as .ap, propriate cHents for ~C, but service st_atistics show that this population did not fully benefit fron~ the . program. · Greater access can be created by expanding the provision channels, training and equipping health care workers, in a variety of locations to deliver EC as a routine element of post-rape care. A snidy conducted by EC Afrique in Zambia, for example, found that trained police officers could effectively provide EC to survivors who presented first to a po- lice station (6). This project found that there is pub- lic support for such an approach. In Ethiopia, ESOG has developed a model of com- prehensive care thai: delivers EC as part of a one-stop shop for post-rape care in a health facility setting. These models, along with other innovative ap- proaches implemented across Africa, indicate that repositioning of EC san dramatically ~pand sexual assault survivors' access to the method. The new cadre of CBRHAs is uniquely positioned to deliver EC services to the broader population includ- ing sexual assault survivors. Located close to the community, they can he called upon to provide EC services within the 120-hour window of oppornmity, without requiring a costly and time-consuming trip to a health facility. This proximity to the community is especially valuable for sexual assault survivors who may be reluctant to seek formal health care immedi- ately after the assault. Provider training An important contribution of this project has been the development of an EC training manual specifi- cally tailored to the n'reds of Ethiopia. _The training program itself • has successfully contributed toward increased access to EC in the project sites, most lilcely by improving provider's confidence in deliver• ing the method. While the training offered by the project was strong on technical aspects, funire train• ing would benefit from an expanded emphasis on the social context of EC provision. Ethiopian Journal o( Reproductive Health EC as a hack up method In countries such as Kenya ~nd Botswana, where EC is more· widely available, concerns have emerged over its use as a regular family planning method (7). In addition, because it is less effective than other modern methods -of contraception and does not of. fer protection against HIV and other sexually trans- mitted infections (STis), the World Health Organiza, tion rec~mmends EC only for . use as a back-i1p method (8). In this study, while both clients and providers indi- cated that family planning advice was often part of EC services, only about half of all EC users actually adopted a new method. Providers . inconsistently encouraged EC users to seek HIV/ STI counseling and testing services, and referred sexi.1al assault survi- vors for appropriate care. Although the ESOG tra~- ing curriculum did not explicitly address such· "b~idging" to other services, the client and provider . KAP surveys suggest that it did take p!ace within sn1dy sites. To ensure that EC serves as a gateway to more comprehensive RH care, it is critical to stress "bridging" as a key element of the services. · An interesting outcoine of the project has been the high level of male involvement in EC. Over half of all women reported consttlting their partners before using EC while a surprisingly large ri.uri1ber of men obtained it . for their partners. However, ·providers appeared reluctant to offer EC services to this group, potentially limiting their partners' access to the method. Specific training is needed to address gen- der issues in EC provision (and in family planning in general) to encourage greater male involvement. Public _awareness CTrify 20% of the- ·men and women interviewed at health facilities had ever heard of EC, and it is likely this proportion is lower among those who do . not routinely seek health care. This indicates a clear need for increased awareness-raising activities in the country. . While clinic-level outreach will always re• main an important source of health information, ESOG's television adverts proved to be the single most effective media tool. 13 May 2009, Volume 3, supplement 1 As the government works to increase EC knowledge among the general population, such adverts strategi- cally aired during popular programming are most likely to increase the visibility of the method. Young women between the ages of 20-29, who were found to be the most frequent users of EC, should be the target of more intensive media outreach efforts. Campaigns should also stress the importance of EC as a back-up method both in and outside of mar- riage, and should include messages on 'bridging'. Condusions and Recommendations The srudy results showed that the three_ most impor- tant reasons for EC use by clients in Ethiopia are: unprotected sex, contraceptive failure, and sexual assault. · Scaling up EC mainstreaming activities in Ethiopia will effectively position EC as a core compo- nent in the national family planning programme and post-rape care services. Ethiopian Journal of Reproductive Health Evidence from the study showed that the majority o( providers inconsistently encouraged EG users to seek HlV /STI counseling and'.testin~ se~ic~;. There is need tci· ~trength~n the capacity of providers so as to encourage EC users to seek HlV /STI coun- seling arid testing .services. To ensure chat EC serves as a gateway · to m~re comprehensive reproductive healthcare, ii: is critical to stress "bridging" as a key element of the services. As a next step, it is necessary for the FMOH to build upon these successes by continuing to expand access to EC across the country. The findings of this pro- ject are intended to inform and guide this scaling-up process. Acknowledgements The authors would like to thank the Concept and Hewlett Foundations for generously supporting this work. 14 May 2009, Volunie 3, supplement 1 Ethiopian Journal of Reproductive Health References 1. Ethiopian Minis~ of Health, Family Health Department. An Assessment of Reproductive Health Needs in Ethiopia. Research on the Introduction and Transfer of Technologies for Fertility Regulation. Geneva: _WHO, Special Programme of Research, Development and Research Training in Human Reproductipn; 1999. 2. Margaret Sanger Center International. Strengthening Rq,r9(luctive Health through Emergency Contraception: tilongwe Malawi 15-18 November 1998, New York: Margaret Sanger Center International; 1999. 3. . Proceedings of the VII Annual Conference of the Ethiopian Society of Obstetricians and Gynecologists. Addis Ababa, Ethiopia; 1999. 4. Rumbold, V. and Skibiak, J. Expanding Access to Coital-dependent Methods and Dual Protection within Youth-Centered Sexual and Reproductive Healthcare Facilities in Ethiopia. Unpublished Fin_al Project Report. Nairobi: Population Council; 2006. 5. Emergency Contraceptive Pills: A Training Manual. New Delhi, India: Population Council; 2005. 6. Keesbury, J. "En1ergency Contraception for Survivors of Sexual Assault: New Windows of Opportunity in Zam- bia." Presentation to the Global Health Conference; Washington, DC; 2007. 7. Sexual and Gender-based Violence in Africa: Key Issues for Programming. Nairobi: The Population Council; 2008. 8. Medical Eligibility Criteria for-Contraceptive Use, .Third Edition, Geneva: World Health Organization; 2004. 15 May 2009, Volume 3, supplement 1 Ethiopian Journal of Reproductive Health ORIGINAL ARTICLE Knowledge, attitudes, practices and barriers to use emergency contraception among women with unsafe abortion inJimma Marie Stopes Clinic, South West Ethiopia Ante~ehAdmasu 1, Bosena Tebeje? Abstract Background: le is observed that safe and effective contraception including emergency contraception (EC) pm1ents the occurrence of unwanted pregnancy and unsafe abortion. Objective: To assess the knowledge, attitudes and practices (KAP) as well as identify barriers to the use of EC among women with unsafe abortion. Methods: This is a cross-sectional health facility based study that invol11ed women with unsafe abortion treated at ]imma Marie Stopes clinic from February 2 to March 16, 2006. Results: There were a total of 153 respondents; ·the majority, 131(85.6%) being in the age range 15-24 and single, 88 (57.5%). Only 20 (13.1%) of the total respondents had heard about EC and out of this on!:, se11en (35%) correctl:, identified 72 hours as the time limit for taking EC. T1ie most common source of information about EC were health institutions, and Marie Stopes clinic which accounted for 12 (60%) of the respondents followed b:, neighbor~od ~nd partner each accounting for three (15%). The stud:, has also rwealed that after ha11ing explained about EC, the 11ast majority respondents l30 (84.3%) had positi11e attitude towards the method and showed interest to share information about EC with their friends. Regarding use among those with prior knowledge of EC, only swen (35%) reported prwi- ous use. The most common reason given for . non-use of EC were lack of awareness about the existence of EC, 132 (86.3%); fear of side- effects, five (3 .4%) and the rest reported una11ailability of service, partner disagreement, religion and culture. Condusion: Most cases with unwanted pregnancy were young people, as they laclwl. awareness about the existence of EC. As a result, they were led .to look for termination of pregnancy as an option in aooiding unwanted pregnancy. lt is strongly recommended that IEC materials on EC targeting young people be prepared and widely disseminated. Keywords: Emergency contraception, unwanted pregnancy, unsafe abortion, KAP. i.2 Jimma University, /imma. Ethiopia 16

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