1.3.09 Emergency Contraception in Africa




Wednesday, November 13, 2013


Elizabeth Westley, International Consortium for Emergency Contraception
Worknesh Kereta, Pathfinder International, Ethiopia
Emily Gold, DKT Ethiopia/ICEC,
Saiqa Mullick, Population Council
Andrew Piller, DKT Ethiopia
Tia Palermo, Stonybrook University
Martha Brady, Population Council
Sarah Rich, International Consortium for Emergency Contraception
Jennifer Bleck, University of South Florida
Ravikanthi Rapiti, Population Council
Candace Lew, Pathfinder International

Name of Preformed Panel / Nom du Panel préformé:

Emergency Contraception in Africa

Panel Overview / Description:

Panel Objectives: After attending this panel, attendees will have an understanding of the broad demographic and policy issues that impact EC access in Africa as well as how diverse strategies, including social marketing through pharmacies, youth-friendly clinic services, and sexual assault services (post-rape care) play an important role in expanding African women’s access to EC.

Description: Using several different lenses, this panel will provide a big-picture view of access to emergency contraception in Africa through a review of policies and demographic data, and will then use three country-specific presentations to highlight special approaches to providing EC, from social marketing programs that use private sector pharmacies to reach women in urban Ethiopia, to public sector clinics that offer youth-friendly services, including EC (also in Ethiopia), and, finally, to specialized post-rape care for sexual assault survivors.

Program and Policy Implications: This panel will highlight the variety of strategies needed to make a family planning technology, in this case EC, fully accessible to African women, using multiple programmatic approaches.

Panel Moderator: Martha Brady, Population Council

Presentation 1 Title / Titre de la présentation 1:

Emergency Contraception Access in Africa: Policy and Demographic Review

Presenter of Presentation 1 / Auteur de la présentation 1:

Elizabeth Westley

Presentation 1/ Présentation 1:

Background: Dedicated Emergency Contraceptive (EC) products have been available for over a decade, but access to EC for women in Africa has been uncertain.
Methods: We analyzed Demographic and Health Survey (DHS) data for 25 African countries, examining rates of EC knowledge and use and associations with a number of factors including education, wealth, and urbanicity. We also examined policies related to EC for African countries: existence of a registered product, inclusion of EC in national Essential Medicines Lists, and integration of EC into public sector services among other factors. Together, these indicators provide a broad picture of EC access in Africa.
Results: The regional mean knowledge of EC for the 25 African countries with available DHS surveys was 15.3% of all women and the mean for ever use of EC was 1.75%. These low rates of knowledge and use are contrasted with the fact that all but five African countries either have a registered product or allow importation of EC. In addition, many African countries have included EC in their essential medicines lists and integrate EC into public sector services.
Conclusions: Our results show that country-level policies are broadly favorable to EC access in many African countries, but the rates of EC knowledge – an essential part of access for this user-dependent method – remain woefully low. Demand generation strategies coupled with support and training for providers are essential to ensure that women in Africa have true access to this important second-chance method of contraception.

Presentation 2 Title / Titre de la présentation 2:

Social Marketing of Emergency Contraceptives in Ethiopia

Presenter of Presentation 2 / Auteur de la présentation 2:

Andrew Piller

Presentation 2/ Présentation 2:

Background: DKT Ethiopia, a social marketing organization operating in Ethiopia since 1990, introduced an emergency contraceptive product, Postpill, in late 2007. Postpill is a 2-tablet emergency contraceptive (each tablet contains 0.75 mg of Levonorgestrel BP). Prior to this introduction, there were no EC products available in the private sector. An initiative to introduce EC products into the public sector (from 2004-2006) had limited success.
Methods: As part of its social marketing effort, DKT Ethiopia introduced Postpill through pharmacies and drug stores throughout the country. Initially, the suggested retail price was 5 Birr (at the time, approximately US$0.36). As part of the Postpill introduction, DKT contracted with the Ethiopian Pharmaceutical Association to provide emergency contraceptive training to pharmacists throughout the country. A total of 486 pharmacy/drug store owners and employees attended these trainings. A single poster and information leaflet were developed and distributed from the time Postpill was introduced.  Following further research on distributer and user behaviors, targeted training was provided to over 800 pharmacists as well as other frontline health workers.   
Results: Since introduction, more than 4.25 million packs of Postpill have been sold to authorized outlets nationwide. Approximately one third of Postpill sales are in Addis Ababa and Postpill is most popular in urban regions. However, there are product sales in all regions. According to pharmacists, most Postpill customers are young women aged 18-25, though many known users have indicated that they first used Postpill while in high school.  
Conclusions: Postpill’s steadily increasing sales have happened despite limited promotional and educational activities. With virtually no mass media effort, ‘word-of-mouth’ communications has apparently played an important role in raising awareness of DKT’s EC product.

Presentation 3 Title / Titre de la présentation 3:

Access Granted: Using Various Approaches Improves Access to EC Information and Services Among Young Ethiopian Girls

Presenter of Presentation 3 / Auteur de la présentation 3:

Worknesh Kereta Abshiro

Presentation 3 / Présentation 3:

Background: Ethiopia, a nation of young people, has nearly 26 million adolescents and youth aged 10-24 years, constituting 30 % of the total population. Young people have serious reproductive health needs because of the biological, psychological, and social changes that occur at this time. There is also high HIV/STI prevalence and unwanted pregnancy among young people who have limited access to youth friendly RH information and services. This is evidenced by the fact that over 12% of young women aged 15-19 have begun child bearing, access to modern contraceptives is at 12% among women aged 15-24 years, and the unmet need for modern contraceptives is high among young girls at 32%.
Pathfinder International - Ethiopia continues to integrate youth-friendly services (YFS) into the public health system through the provision of family planning counseling and services, including EC. Increasing the awareness of the availability and use of EC is largely done by trained peer educators, and a dedicated EC product is leveraged from the Federal Ministry of Health (FMOH) and distributed to all YFS facilities on a quarterly base.
Methods: Pathfinder International, in collaboration with the FMOH and its partners, has integrated YFS into 165 public health facilities across six major regions:  Amhara, Oromia, Tigray, SNNP, Beneshangul, and Somali.  YFS providers and peer educators are provided with the necessary training on EC and EC is available at all YFS sites. Between 2008 and 2012, more than 8,000 peer educators were trained and integrated into existing YFS. In addition to disseminating information on RH/FP/HIV, they play a vital role in providing necessary information about and referral for EC services in their respective communities.
Results & Conclusions: The uptake of EC in YFS facilities is steadily increasing.  Diversified approaches increase the dissemination of the information among the adolescent community: using peer educators, the media, youth centers, and YFS; distributing through peer educators; making EC available over the counter through DKT’s social marketing programs  and in private clinics for free or at a cost that is affordable to young people prevents unwanted pregnancies and unsafe abortions and ultimately improves the lives of young girls.  However, there remains a need for counseling and continued education about alternatives to repeated use of EC as a regular form of birth control and the availability of other more effective methods of contraception.

Presentation 4 Title / Titre de la présentation 4:

Provision of Emergency Contraception As Part of Comprehensive Post Rape Care: Experience from South Africa

Presenter of Presentation 4 / Auteur de la présentation 4:

Ravikanthi Rapiti

Presentation 4 / Présentation 4:

Background: While post-rape care in sub-Saharan Africa is increasingly recognized as a basic human right and public health issue, the content of this care is often limited to HIV post-exposure prophylaxis, sexually transmitted infection diagnosis, and trauma counseling.  Although there is no question that these are critical elements of post-rape care, other essential components have tended to be overlooked, including prevention of pregnancy despite the probability of pregnancy following rape being much greater than that of HIV infection. In South Africa, the National Guidelines on the Management of Sexual Assault highlight the importance of the provision of EC; however, little is known about whether or how this is provided as part of comprehensive post-rape care.
Methods: Population Council, in collaboration with the National Department of Health (NDOH), conducted an assessment in 134 district hospitals and community health centres offering post-rape care in 5 provinces to learn more about the extent to which pregnancy testing and EC services are currently available within post-rape care; what gaps exist in the availability of pregnancy testing and EC services within national post-rape programs; and gaps in provider knowledge with regard to the provision of EC. Data were collected by trained staff using a structured questionnaire administered to facility heads. The questionnaire included questions on availability of guidelines, trained staff, and supplies and equipment. Routinely collected data from registers to capture M&E data on services provided to clients seeking post rape care services were also reviewed.
Results: Despite availability of guidelines and supplies, the provision of EC to eligible women and girls is low. There are large differences in how EC is issued to women and girls due to a lack of standardization on how facilities provide EC. There are uncertainties among providers about the provision of EC to adolescents, particularly on what criteria (age, menarche or breast development) to use to determine eligibility. Some providers were confused between the timing for HIV PEP and EC.  
Conclusion: First line providers of post-rape care require training and guidance to strengthen the provision of EC as part of post-rape care. There are specific difficulties regarding the provision of EC to adolescents, and these need to be highlighted clearly. There is also a need to strengthen existing M&E systems to record health outcomes of rape, including unwanted pregnancies and referrals.


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