Sexuality and Emergency Contraceptive Practice among Female Undergraduates in Lagos, Nigeria

Background: Young people, especially those in tertiary institutions are vulnerable to unplanned and unprotected sexual intercourse which predisposes them to unintended pregnancies and subsequently unsafe abortions. One of the key interventions for reduction of unwanted pregnancies and unsafe abortions is effective use of emergency contraceptives. Objectives: To assess the sexuality, perception, attitude towards and determinants of usage of emergency contraception among female undergraduates in Lagos, Nigeria. Methods: Cross-sectional survey conducted in June 2016 among 805 female students of the Lagos State University. Data were collected through structured self-administered questionnaire by obtaining information on demography, sexual and contraceptive history, perception, attitude towards and use of emergency contraceptives. Data obtained were analyzed using SPSS version 16. Chi-square and logistic regression models were applied to variables to test for significance that predicts the use of emergency contraceptives. Results: Of the 725 (90%) completed questionnaires, 334 (46%) of the respondents were sexually active with 115 (34%) having previous history of pregnancy. Eigh-ty-two percent of those pregnancies were unintended. Eighty-eight percent of those with unintended pregnancy had them terminated by induced abortions, 54% of which was carried out by untrained persons. Only 29% of those who had unprotected sexual intercourse used emergency contraceptives. contraceptives should be introduced in secondary schools and in general studies courses in tertiary institutions while parents and caregivers should discuss issues relating to sex and contraceptives with adolescents.


Introduction
The incidence of unwanted pregnancies leading to unsafe abortion, particularly among adolescents is very high [1] [2]. Unsafe abortion is a major public health issue because of its contribution to high rates of maternal morbidity and mortality [3]. Globally, about 46 million unwanted pregnancies are terminated every year. The annual incidence of induced abortions in Africa rose from 5.6 million to 6.4 million between 2003 and 2008 due largely to increase in the number of women of reproductive age [4] [5]. The overall incidence of induced abortion in Nigeria is 25 per 1000 women of reproductive age per year [3] [6] [7]. Approximately 610,000 abortions are performed annually in Nigeria, of which about 60% may be unsafe, thereby contributing about 20% to overall maternal deaths of 27.4% in Nigeria [8], 34.6% in Cameroon [9] and 21% in Uganda [10].
Studies have also shown that young people, particularly those in tertiary institutions are vulnerable to unplanned and unprotected sexual intercourse which predisposes them to unintended pregnancies and subsequently leading to the procurement of unsafe abortions [3] [7]. The increased proportion of induced and unsafe abortion in African countries including Nigeria can be linked to declining age of sexual debut, increasing rate of sexual activities among adolescents and low use of contraceptives among married and single women [8]. The consequences of unprotected sexual intercourse, such as unwanted pregnancies, unsafe abortion and its sequelae, cost of termination of pregnancies, emotional and long term reproductive failure can be prevented or reduced drastically by access to and use of contraceptive services, especially emergency contraceptives [3] [4]. The World Health Organization (WHO) estimated that in Africa in 2008, 14% of maternal deaths (29,000) were due to unsafe abortion. About 1.7 million women in the region were hospitalized annually for complications arising from unsafe abortion [3].
Emergency contraceptive is an intervention to prevent pregnancy following unplanned, unprotected sexual intercourse, unlike the regular methods of contraception that are taken before sexual intercourse. It has the potential, as the last resort, to prevent unwanted pregnancy and therefore help reduce unsafe abortion rate; a desirable goal especially in a country like Nigeria where abortion law is restrictive. Studies as far back as 1990 on termination of pregnancy have identified emergency contraceptive as one of the key interventions to prevent unwanted pregnancy in the United Kingdom [11]. However, use of the method is low, provision is patchy and knowledge is poor. Women are interested in preventing unintended pregnancies, hence further information and availability would help them achieve this. Knowledge of emergency contraception is crucial to its utilization [11].
Combined oral contraceptive pills (Yuzpe's) and levonorgestrel only pills (postinor) are the most common emergency contraceptive methods available in Nigeria; they are commonly available in pharmacies and can be obtained over the counter without prescription [12]. When emergency contraceptives are used within 72 hours after sexual intercourse, they have the capacity to prevent pregnancy by 75% -85% and as much as 99% with intra-uterine contraceptive device [13]. Unconventional technique of doubtful potential and efficacy are also commonly available in Nigeria. Teenage girls in Nigeria have been reported to use laxatives, quinine, menstrogen pills, and potash with unproven efficacies in prevention of unwanted pregnancy [14].
This study was designed to explore the sexuality, perception, attitude towards and utilization of emergency contraceptives among female undergraduate students in Lagos State University.

Materials and Methods
A descriptive cross-sectional study was carried out in June 2016 among Female non-medical undergraduate students of Lagos State University. The university has about 8000 female students. All the students reside off campus as there were no hostel facilities as at the time the study was conducted. Sample size was calculated using a simple proportion formula assuming the proportion of students who are aware of emergency contraceptives is 50%, adding a non-response rate of 5% and multiplying by a design effect of 2 due to multi-stage nature of sampling method, the required sample size was 805.
CALCULATION OF SAMPLE SIZE: Step 1 Step 2 when this is multiply with the design effect of 2 2 768 n × = Step 3 contingency the sample is increase by 5% to account for contingency such as non-response of recording Step 4 This is then further adjusted to the cluster of study. In this case, cluster of 7 (7 faculties) = 805 (i.e. 115 per cluster).

RESPONDENTS SELECTION
At first stage, seven faculties were randomly selected from the institution. At the second stage, seven departments were then randomly selected from these faculties where consenting individual female students had questionnaire administered to them consecutively (convenient non-probability sampling) in each of the departments. Ethical approval was obtained from the Health Research and Ethics Committee of the Lagos State University Teaching Hospital. Data was collected using structured self-administered questionnaires. The questionnaire assessed information on the socio-demographic characteristics of the respondents, knowledge and use of emergency contraceptives. Sources of information on awareness of emergency contraceptives as well as sexuality and pregnancy history were also assessed. The questionnaire was pretested among 20 students at two other departments of Lagos State University which were not selected for the main survey following which necessary modifications were made. The inclusion criteria include selection of respondents who were regular undergraduate students that consented to participate in the study. The exclusion criteria were female students of Lagos State University who were not in college of health or medical sciences related courses, not an health worker on part time basis or had ever worked in a hospital setting before. They were educated on how to fill the questionnaire after verbal consent was obtained.
Data processing and analysis were done using the SPSS version 16 (Chicago, Illinois, USA). Descriptive statistics and odds ratio were used to show associations between target variables and statistical comparison was done using Chi-square test. Results were presented using descriptive statistics, cross-tabulation and logistic regression. P-Value < 0.05 was considered statistically significant at 95 % confidence interval.

Results
Full responses were obtained from 725 questionnaires which gave a response rate of 90%. Fifty questionnaires were not returned, three had their names written on and were discarded while 27 were not completely filled.
The socio-demographic and academic characteristics of the study population were presented in Table 1. The mean age of the respondents was 20.9 years with modal range of 20 -24 years (62.9%). Participants aged 16 -24 years accounted for 93.2% (676/725) of the respondents. Most of the respondents were single at 73.1% (530/725) while 16.7% were married and others (divorcees, cohabiters, separated) constituted remaining 5.2%. Considering the religion, 69.4% (503/735) were orthodox Christians, 18.4% (133/725), were Catholics and only 12.0% were Muslims. Only 9.9% (72/725) of the respondents had delivered before. Most of the respondents were in their first year of study (37.1%) (269/725) while those in the fourth year made up (72/725) constituting the least of the smallest sample of the study population.
The sexual characteristics with various contraceptives used among respondents were shown in Table 2. Three hundred and thirty four respondents 46.1%   Majority of the respondents (62.5%) demonstrated negative attitude towards EC usage. Many of them believe that it is sinful to use emergency contraceptive, may cause infertility, birth defect, could promote promiscuity, lead to loss of confidence among partners and therefore will not recommend it to a friend or relatives, Table 5.
Logistic regression for variables showed positive predictors were increasing age and year of study, married status, history of childbearing, sexual debut, previous pregnancy, previous contraceptive use as well as knowledge of EC (P < 0.0001) while religion and ethnicity were negative predictors of usage (P > 0.05) Table 6.

Discussion
This study showed the perception attitude towards and practice of emergency contraception as well as the sexual behavior of female undergraduates in Lagos. The youths constituted majority of the respondents with predominant age  [15] and Abakaliki [18] respectively.
Respondents who were sexually exposed accounted for 46.1% which was lower than the 57%, 77%, 86% and 87% observed among similar subjects in S/Africa [19], Benin [20], Ibadan [13] and Abakalik [18] but higher than 34.5% obtained in Lagos [21]. The mean age of 17 years at coitache (sexual debut) in this study is lower than the 22 years reported by Obuehi et al., [21], also in the University of Lagos, but higher than the 16-year mean from the study by Adeneye et al. [22], in which it was observed that many of their respondents got pregnant before the age of 20 years. Unfortunately, adolescents incorrectly start sexual activity before  [23]. In Nigeria, it has been observed that unintended sexual intercourse is the leading cause of unintended pregnancy and induced abortions [24].
Steinberg and co-workers observed that adolescents who engaged in effective communication with their parents on sexuality issues are more likely than others to delay sexual intercourse [25].
In this study, 52.1% of sexually exposed respondents have ever used contraceptive before in contrast to 34.7% of the respondents among similar subjects in Ibadan [26]. It has also been observed that in spite of the high premarital sexual activity among the adolescents, their use of contraceptive is very low [27]. It is estimated that more than 60% of women with unintended pregnancies were not using any form of contraceptive [28] [29]. Some workers have observed that despite the availability of these services, their use by the youths is still poor probably due to lack of adequate information about efficacy of the methods, fear of side effects, shame, negative cultural beliefs and the judgmental attitude of service providers [30].
It is noteworthy that 82% of the respondents in this study that had ever been pregnant were not married. Sixty-three percent of pregnancies in this study were unwanted with single and married respondents accounting for 73% and 10% respectively. These pregnancies, in 54% of the cases, were terminated mostly by untrained abortionists, while 31% were self-induced using other unconventional methods. This figure was higher than 43.6%, from Ghana [31], 31.1% in southwestern Nigeria [27], 22.1% in Calabar [23] and the National average [32] of 8%. Some workers in their community survey observed that married women also experienced unwanted pregnancy, as they constituted 34.8% and 63.2% of abortion seekers in two studies respectively from southwestern Nigeria [27] [33]. The consequences of these clandestine abortions are grave and can be life-threatening, often leading to maternal death. Abortions account for 20% -40% of maternal deaths in Nigeria [7]. It has been reported that some women use abortion as a means of child spacing instead of contraception [34]. This may be as a result of low contraceptive uptake rates despite reported high contraceptive awareness and enlightenment drives [16] [34].
Emergency contraceptives are the only form of contraceptives that can be used after unprotected sexual intercourse offering a second chance to prevent unwanted pregnancy [22]. About 38% of the respondents in this study had prior awareness of emergency contraceptives, and only 29% had ever used them. This awareness was less than 86% in USA [35], 84% in Ethiopia [36], 56% in Calabar [37], 43.2% in Ghana [31] but similar to 38.1% reported in Abakaliki [18]. The concomitant use of EC by 29% among our respondents was similar to 30.7% reported by Ebuehi et al. [21] but higher than 11.5% and 10% among similar sub-Open Journal of Obstetrics and Gynecology jects in southeastern Nigeria [15] [18].
In this study, postinor was the most widely known EC (26%) followed by COCPs (23%), IUCD (10%) and other unconventional methods including menstrogen (22%), douching, herbal medicaments, potash with bitter lemon drink and the likes, accounting for the remaining methods. The 59% subjects that correctly identified conventional EC method in this study was higher than 26.4% and 36.3% reported by other workers among similar subjects [15] [21]. Major identified EC methods in this study were less than 45% postinor and 33% OCP reported by Nworah and colleagues [18]. Menstrogen, an oestrogen only pill used in the treatment of conditions related to low hormonal levels was used as emergency contraceptive in 22% respondents in contrast to 0.6% of similar subjects in other reports [18]. Its effectiveness as an emergency contraceptive requires its use in high doses [21].
The main sources of information on EC were mass media (print and electronic) in half of subjects, followed by 25% who got their information from peers (friends), 15% from health workers and other sources accounting for the remaining. This was contrary to findings of other workers that reported 20.6% & 26% for media and 32.9% & 31.4% from friends respectively [15] [18]. Obuehi 2006 reported that friends accounted for 64.9% source of information on EC [21]. The knowledge of emergency contraceptives was significantly higher among the senior students as compared to their juniors. This finding is very similar and consistent with studies in Ethiopia, Ghana, Cameroon and even in France where increasing age and year of study were find to influence the knowledge about Emergency contraception [38]. This could be due to younger subjects having less information about the proper use of EC but seems to get more Information as they advance in their studies. Raising awareness about the methods and making it both easily available and accessible will improve its use because emergency contraception are financially, psychologically and physically less burdensome than abortion.
Most respondents (62.6%) demonstrated strong negative attitudes towards emergency contraceptive, which was consistent with findings in other studies [14] [39], but however contrasted with findings in Cameroon [40]. The reasons attributed to negative attitude include the belief that it is sinful to use emergency contraceptives, may cause infertility, birth defect in case of pregnancy, promotion of sexual promiscuity, and loss of confidence among partners. Some workers have observed that lack of knowledge of EC and fear of side effects were the most frequently cited reason for not using them among similar subjects [41] [42].
Positive attitude towards EC in this study was significantly higher among or- should be made available to all females while 29.5% were willing to recommend emergency contraceptives to friends. Feleke et al. [42] also posited that women's age of 20 -24 years, urban residence, being single, being knowledgeable on emergency contraception, and having favorable attitude towards emergency contraception were significantly associated factors with the utilization of emergency contraceptives.
Positive predictors of EC usage in this study include increasing age and year of study, married status, previous childbirth, sexual debut, previous pregnancy, previous contraceptive use as well as knowledge of EC while religion and ethnicity were poor predictors. Our findings were similar to that of other workers where lack of knowledge, fear of being seen by others, and inconvenient service delivery were pointed out as the main reasons for not using emergency contraceptives [39] [41] [42]. Previous use of contraceptives, being married and age of 20 years and above were significant predictors for the use of emergency contraceptives, while poor knowledge of emergency contraceptive was a significant predictor of non-use of emergency contraceptives [38] [41] [43] [44]. This study was based on self-reported information which may be subjective to reporting errors, missed values and bias. Since the study touches on sensitive issues, the possibility of underestimation cannot be excluded, even though the respondents were anonymous. Nevertheless, it provides an insight into the sexuality, awareness and usage of EC as well as related predictors of its usage amongst female undergraduates in the Lagos State University.

Conclusions
In conclusion, the awareness of emergency contraceptive is low while its usage is even far lower, yet high rate of sexual activity and unwanted pregnancies have been reported. It is strongly recommended that information about contraceptives should be introduced in schools, as early as secondary schools and also in general studies courses in tertiary institutions. Parents and care givers should be bold and confident enough to discuss issues relating to sex, contraceptives, sexually transmitted infections and family planning with the adolescents instead of allowing them to source for information from the internet or from peer groups who may not be knowledgeable enough on such matters.
Stakeholders should ensure provision of youth-friendly sexual and reproductive health services designed to respond to and meet the health needs of these apparently sexually active young people as reflected in the Nigeria's Policy on Population for Development [45]. It is expected that this will contribute to meeting a target of the Sustainable Development Goal (SDG) 3 which aims at ensuring universal access to sexual and reproductive healthcare services, information, education, including family planning [46].

Questionnaire Preamble
We are conducting a study on sexuality and practice of emergency contraception among female undergraduates. We assure you that all your responses and result of this study will be kept strictly confidential and will be used for medical purpose only. We will appreciate it if you fill the questionnaire sincerely to the best of your knowledge.