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JOURNAL OF COMMUNITY MEDICINE |
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INDIAN ASSOCIATION OF PREVENTIVE AND SOCIAL MEDICINE ORISSA CHAPTER |
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* Faculty Member, ** Principal, Regional Institute of health & Family Welfare Dhobiwan Directorate of Health Services, Kashmir Email: kadrism@gmail.com |
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Fazili Farooq, Kadri SM, B A Gash |
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Abstract
Research question: What is the knowledge of doctors of Kashmir on emergency contraception (EC)? Objective: To assess the knowledge and opinion of doctors on emergency contraction. Study design: Cross-sectional study. Setting: Regional Institute of Health and Family welfare, Kashmir. Period of study: June 2006 to May 2007. Participations: 210 Doctors from different institutions of Kashmir valley attending training at Regional Institute of Health and Family welfare, Kashmir. Result: Most of the doctors lack accurate information about various EC regimens, mechanism of action, and efficacy. Out of 210 doctors 54% of them irrespective of their experience opined that the use of EC would bring down the number of abortions and about 66% senior ones feared that the use of ECs would promote sexual irresponsibility among its users. Intrauterine pregnancy and tubal pregnancy were thought to be the most common contraindications by the doctors (59%). Conclusion: Knowledge and opinion of doctors on EC is poor. Again, keeping in mind the changing sexual behavior of the younger generation and a need, a formal training of the doctors and paramedical staff would be a right step.
Key words: Emergency contraception; emergency contraception pills, unprotected sex.
Introduction Many pregnancies are unplanned and unwanted despite the availability of wide range of contraceptive methods. Such pregnancies carry a high risk of morbidity and mortality, often due to unsafe abortion. Many of these unplanned pregnancies can be avoided using emergency contraception. Emergency contraception pills (ECP’s) are an important option for women who have recently had unprotected sex or a contraceptive accident and who do not want to become pregnant1.
Offering emergency contraception is an important way by which family planning and reproductive health programs can improve the quality of their services and better meet the unmet needs of the clients. Emergency contraception (EC) is needed because no contraceptive is 100% reliable and few people use their methods perfectly each time they have sexual intercourse.
Need of contraception has been there since time immemorial for the fertility control. Arabians started using Pebbles in the wombs of camels for the fertility control. Post coital douching is probably one of the oldest contraceptive methods used and is mentioned in the Sacred Vedas of India and Egyptian literature written about 1500BC2. Modern methods of emergency contraception started with the use of non-steroidal Estrogen-Diethylstilbestrol on rape victims3. This has been followed by Estrogen-Progesterone pills, progesterone only pills, Mefiperstone and copper IUCD’s that can be used within 72-120 hours after coitus, thus changing the terminology of post coital contraception to emergency contraception (EC). EC have now become an integral part of contraceptive services to prevent conception following an unprotected and unplanned exposure or contraceptive accidents like burst condoms, slippage of diaphragm and forgotten pills. Various studies have shown that there is a poor knowledge of doctors and users about EC, which prevents women from seeking timely help and intervention4,5,6. In view of the paucity of knowledge about EC in Kashmir Province (north India), a survey was carried out among the doctors in Kashmir to find out their knowledge and their practice about EC.
Material and Method The present study has been undertaken by conducting a KAP survey on the various aspects of emergency contraception among the doctors of various institution of Kashmir attending training programs at Regional Institute of health and Family welfare during June 2006 to May 2007. Doctors were grouped as per their of experience, group I doctors include doctors with MBBS degree and 1-5 years of experience; Group II doctors include doctors with or without MD/Diploma in Obst/gynae and with more than 5 years experience. The data were collected from 210 doctors through a structured, self-administered questionnaire to elicit information regarding their knowledge, attitude and practice of EC. Inferences have been drawn by analyzing collected data by simple classification and tabulation of reference groups.
Result A total of 210 doctors were taken up for the study; out of whom 114(54.28%) were falling in the category of group I and 123(58.57%) were male doctors.
Table I: Correct knowledge about EC
Knowledge about EC Group-I Group-II Total N = 114 n = 96 n = 210 No % No % No % Type of EC Hormonal 102 89.47 75 78.12 177 84.29 Non-Harmonal 12 10.53 21 21.88 33 15.71 EC’s indicated Routine 21 18.42 9 9.37 30 14.29 Contraception Sexual assault 51 44.74 54 56.25 105 0.00 Contraceptive 45 39.47 45 46.88 90 42.85 Accident Unprotected sex 69 60.52 48 50.00 117 55.71
Table II: Awareness about effectiveness of EC after unprotected sex, EC regimen and mechanism of action
Awareness Group-I Group-II Group-III No % No % No % Effectiveness Immediately 66 57.90 66 68.75 132 62.85 < 24 hrs. 21 18.42 18 18.75 39 18.58 Within 72 hrs. 24 21.05 12 12.50 36 17.14 > 72 hrs. 3 2.63 -- -- 3 1.42 EC regimen known 22 19.29 39 40.62 61 29.04 Mechanism of action Prevents 63 55.26 57 59.37 120 57.15 Fertilization Prevents 51 44.57 36 37.5 87 41.43 Implantation Delays ovulation 12 10.53 6 6.25 18 8.58 Causes abortion 12 10.53 6 6.25 18 8.58 Do not know 9 7.90 9 9.37 18 8.58
Table I reveals the doctor’s knowledge about emergency contraception (EC). It was observed that 84.29% were aware that EC is a hormonal method of contraception. More numbers of doctors’ in-group I (89.47%) were aware about this fact than in group II (78.12%).
While observing their knowledge about the indication of EC it was observed that unprotected sex was leading indication in Group I (60.52%) and in Group II it was sexual assault (56.25%).
Table II shows doctor’s awareness about the effectiveness of EC after unprotected sex. It was observed that 57.90% doctors’ in group I and higher percentage (68.75%) of doctors’ in group II were of the opinion that EC is most effective immediately unprotected sex. Further it was revealed that majority of doctors i.e. 39 (40.62%) with more clinical experience (group II) had an accurate knowledge about EC regimen. Only 8.58% doctors did not know the mechanism of action of EC. Similar percentage of doctors of both the category opined that common mechanisms are prevention of fertilization and implantation.
Table III Contraindications of EC usage
Contra Group-I Group-II Group-III Indication No % No % No % Intra uterine pregnancy 63 55.26 60 62.5 123 58.58 Tubal pregnancy 75 65.79 45 50.00 123 58.58 CVS disease 45 39.79 36 37.50 81 38.58 Diabetes 45 (13.15) 6 (6.25) 21 10.00
Regarding contraindications of EC different opinions were obtained (Table III) intrauterine pregnancy and tubal pregnancy was thought to be the most common contraindications by the doctors (58.58%). Cardiovascular diseases were also thought to be an important contraindication by most of the doctors almost equally in both groups (38.58%).
While analyzing the knowledge about its safety, it was revealed that most of the doctors in both the groups (42.85%) thought that EC is safe and it has no risk, and complications are little known.
While studying the impact of EC on society most of the doctors did not recommend its frequent usage in both the groups (88.58%) but few were of the opinion of its frequent usage. Almost equal number in both the groups were of the opinion that ECs will reduce abortion (54.29%).
A sizable number of senior doctors in both the groups especially group II, feared that easy availability of EC might promote sexual promiscuity and irresponsibility very much among young people (65.71%).
While analyzing the effect of EC on the usage of other contraceptives, it was revealed that 18.42% and 43.75% doctors of group I and II respectively were of the opinion that the usage of other contraceptive will be affected very much by the usage of EC. On further analysis it was observed that 44% doctors thought that there will be decreased in the condom usage very much.
Discussion Emergency contraception is an essential part of treatment for women who are victims of sexual assault. However, EC is not used or prescribed widely in most of clinical settings8,9. In a study of London Health Care Professionals it was observed that most of them lacked appropriate knowledge of prescribing EC’s6. Similarly, the use and knowledge of EC among the Americans is limited, a random telephonic survey revealed8. Study from Delhi showed that awareness of EC was high among the young interns and obstetricians that GPs, but most of them could not write a correct prescription for EC9.
Studies from other developing countries like Mexico, Kenya and Indonesia also revealed a limited knowledge of EC among Health care workers and a need was felt to educate both the public and practitioners about EC. In Kenya10 less than 50% of the service providers and 10% of the clients knew about EC, while Mexico5 although 74% of the services providers had heard about EC, fewer than 40% knew the correct dosage. A baseline survey among the health care providers and policy makers in Indonesia11 indicated that only 25% had awareness of EC and fewer than 5% of clients had ever heard the method.
Both the groups in present study had almost a correct knowledge that EC is a hormonal method but surprisingly few senior doctors were of the opinion that EC is a non-hormonal method of contraception, thus revealing the lack of knowledge among our health care providers. These findings are in consistent with the observation in a consortium on National Consensus for EC, which was held at Delhi, in 20011. Few studies from Nagpur12, Kolkata13 and Baroda14 showed lack of awareness and accurate information among the health care providers.
ECs are used in order to prevent pregnancy following unprotected intercourse within the previous 72 hours. Sexual assaults and contraceptive accidents are also included in this category9. The observations in the current study are in consistent between both groups, but it was observed that the senior doctors were of the opinion that it can be used mainly in cases of sexual assault. Thus there is a need of active reorientation of such health care providers in order to use EC in any cases of unprotected sex. Emphasize that ECs are for emergency use only. They are not recommended for routine use because of the increased possibility of failure compared to regular contraceptives and the increased incidence of side effects1. In the current study a sizeable number of junior doctors were of the opinion that ECs can be used as a routine contraception that needs to be rectified.
ECs are effective if used within a period of 72 hours and best results can be obtained if they are used immediately after unprotected sex. With the increase in time span the efficacy of ECs fall proportionately and it does not remain an effective method to prevent unwanted pregnancy1. These observations are in consistent with the opinion of doctors in the current study.
In the current study as well, both senior as well as fresher doctors lack the knowledge about EC and could not write proper EC prescription. Two EC regimens can be used; the standard regimen consists of “combined” pills containing ethinyl estradiol and levenorgestrel or comparable formulations. This regimen is known as “Yuzpe method” and has been used and widely studied since 19701. Alternate hormonal regimen consists of progestin-only pills which is equally effective as the Yuzpe regimen but has significantly lower incidence of side effects.
Treatment should not be delayed unnecessarily as efficacy may decline over time. EC pills work by interrupting a woman’s reproductive cycle. Depending on when in they cycle the pills are taken, they can stop or delay an egg from being released from the ovary or possibly, stop a fertilized egg from attaching the uterus by altering the endometrium1. EC pills also may prevent fertilization or transport of Sperm or Ova, but no data exists regarding these possible mechanisms. The misconception regarding the mechanism of EC needs to be dispelled to promote correct and timely use of EC without the fear of any legal complications, especially in countries where abortion is illegal. The dose of hormones is relatively small and pills are used for a short time, so the contraindications associated with continuous use of combined oral contraceptives and progestin only pills do not apply1. Thus because of its low risk ECs are considered safe used properly. The doctors in the present study have shared this view as well. There have been no reported deaths or serious complications involving emergency contraceptive pills in over two decades of use.
There is no evidence to suggest that knowledge of emergency contraception increases sexual activity among young people. It is felt that the need for emergency contraception pills in over two decades of use.
There is no evidence to suggest that knowledge of emergency contraception increases sexual activity among young people. It is felt that the need for emergency contraception often brings sexually active young people into family planning clinics, where they can receive other services and counseling1. However, in current study both senior and junior doctors were of the opinion that EC will increase sexual promiscuity very much, which is only theoretical, although there is scope for its further evaluation. The fear was also present among the doctors were not having this fear and claimed that EC will not effect much on other methods of contraception including that of the condom use. EC will be less effective in preventing pregnancy and more expensive than most forms of regular contraception, two additional disincentives against routine use of the method. On the other hand women and men may feel more confident about relying on condoms for birth control if emergency contraception is available as a backup, in case a condom slips or breaks. Further it will provide protection against diseases like HIV/AIDS and other STD’s1.
Conclusion Awareness of EC is poor among the doctors included in the present study. Senior and specialist doctors as well as junior doctors do not possess appropriate and details knowledge regarding different regimen, mechanism of action, and efficacy. Very few doctors prescribe EC and counsel clients for contraceptive failure. Although it is established fact that ECs will reduce the rate of abortions, its use is not so popular. Keeping in mind the changing sexual behavior of the younger generation and a need, a formal training of the doctors and paramedical staff would be a right step.
Reference 1. Consortium for emergency contraception; Emergency contraceptive pills: Medical and service Delivery guidelines May 1998. WHO special program of research, Development and Research training in Human reproduction. 2. Finch BE and Green H (1963): Contraception through ages; Charles C Thomas, Springfield Illinois. 3. Morris J.M. and Van Waganen G. (19966): Compounds interfaring with Ovum implantation and development: The role of Estrogen; Am. Jr. of Obstet. Gynecol 96(6), p 804-815. 4. Weisberg F, et al (1995): Emergency Contraception; General Practioners Knowledge, attitudes and practice in New South Wales: Med. Jr. Aust., 162, p. 136-138. 5. Langer A, Harper C., et al (1999): Emergency contraception in Mexico city: What do health care providers and potential users know and think about it? Contraception, 60(4), p. 233-241. 6. Burton R and Savage W (1990): Knowledge and use of post coital contraception: A survey among health professionals in Tower hamlets; Br. Jr. Gen. Pract., 40, p. 326-330. 7. Grossman Ra and Grossman, B.D. (1994): How frequently is emergency contraception prescribed? Fam. Plann. Perspect., 26(6), p. 270-271. |
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Emergency Contraception: Knowledge of Doctors in Kashmir Valley |
