Awareness and usage of emergency contraception among teenagers seeking abortion: A Shanghai survey☆

1. Background 

With the development of the economy and society China, social norms and values related to sexual behavior and marriage have changed dramatically. Because of better nutrition and health status, the average age of pubertal maturity and first sexual intercourse has gradually declined and the sexual activity rate is rising among adolescents [1]. Typically, adolescent sexuality is characterized by unstable relationships, unplanned sexual intercourse, no contraceptive planning, and a high risk of unwanted pregnancy.

Emergency contraception (EC) is defined as the use of a drug or device as an emergency measure to prevent pregnancy after unprotected intercourse or contraception failure [2]. If used promptly, EC can prevent 70% of unintended pregnancies [3], but potential users must know about it and know how to use it correctly. EC in this article refers to EC pills, because IUD insertion is not routinely used in adolescents in China. In China, levonorgestrel EC products were being dispensed by pharmacies without a prescription as early as 1998, and mifepristone products containing 10mg or 25mg in 2001. Moreover, EC pills are cheap, widely available, and accessible to adolescents. There is no law restricting the sale of EC pills to adolescents of a particular minimum age. Condoms, oral contraception, and spermicides are also available over the counter (OTC) in pharmacies. But family planning technical services are strictly restricted to government hospitals and family planning service stations.

Teenage pregnancies have become a new phenomenon in China’s big cities over the last decade, but regular contraceptive use among pregnant girls prior to the unwanted pregnancy is only 2.6% [4]. According to our experience there are about 6000 cases of adolescent abortion every year in Shanghai, and this incidence tends to be under-reported. We report a questionnaire survey of the awareness and usage of EC pills among a representative sample of adolescents with an unwanted pregnancy who requested an abortion in Shanghai.

2. Materials and methods 

All pregnant teenagers between the ages of 10 and 19 years requesting a termination of pregnancy between the beginning of January 2005 and the end of June 2005 at the outpatient clinic or inpatient wards in three district hospitals, one municipal MCH hospital, one OB/GYN hospital, and one general hospital in Shanghai, were recruited. Six hundred girls were interviewed anonymously before the abortion was performed; nine refused to answer the questions. The response rate was 98.5%.

We obtained approval for our study from the International Peace MCH Hospital Ethics Committee. Six doctors from the six hospitals who work at the family planning clinic counseling room had training on how to conduct the interview before the survey. Doctors obtained an informed consent signature from the pregnant girls immediately before the interview started. The teenagers were informed about the purpose of the study, and were told they could stop the interview at any time. Each interview lasted about 30min. Questionnaires with an envelope were distributed to the girls. They filled in the questionnaire by themselves in a private room at the family planning outpatient clinic or inpatient ward; then they sealed the envelope and put it in a box. Most of the girls were unaccompanied. Less than 5% of them answered the questions in the presence of peers or their boyfriend.

SPSS 10.0 software was used for statistical analysis. Chi-squared and Fisher’s exact test were used to compare past contraceptive use and awareness of EC.

3. Results 

Table 1 shows the characteristics of the population. All our participants have a high school or university educational background. One hundred percent of the pregnancies were unintended. Among the participants, 49.1% (290/591) had previously experienced contraception failure (burst condom or failure to withdraw), 99.3% (587/591) had already had sex with no contraception in the past, and 92.6% (547/591) reported being “worried” about pregnancy after unprotected intercourse. When asked whether they knew something could be done within a few days after unprotected sex to prevent subsequent pregnancy, 51.6% (305/591) of them said yes. From our qualitative in-depth interview before this study, we obtained information on all kinds of contraception that teenagers tend to use. Methods already used were EC in 36.1% (110/305), urinating in 32.1% (98/305), showering/bathing in 15.4% (47/305), vaginal douching in 10.5% (32/305), and jumping up and down in 5.9% (18/305). These “mythical” methods were used straight after intercourse; therefore, we categorized them as back-up methods.

Table 1. Study group characteristics

		Age	Age of sexual debut
	Mean and S.D.	17.86±0.99	16.92±1.37
	Minimum	13.5	13.0
	Maximum	19	18.8

	Frequency of sexual intercourse (%)
	<1/week	47.7
	1–2/week	35.5
	>2/week	16.8
	Most frequent contraception used after first intercourse (%)
	Condom	27.7
	Rhythm	8.8
	Withdrawal	6.9
	Oral contraception	5.4
	Spermicide	0.3
	Others	1.7
	Never use any contraception	49.1

Table 2 shows the awareness and knowledge regarding EC pills among pregnant teenagers. Among those who had heard about EC, only 101 (35.8%) knew the correct time-frame for proper EC use, which is 72h for EC products in China. Table 3 describes participants’ previous usage and ways of acquiring EC pills. Among those who had actually already used EC, there were still 42 (33.9%) who were unaware of how many hours after unprotected intercourse EC should be used for maximum efficacy. Table 4 shows the impact of previous knowledge of EC pills on past contraceptive use.

Table 2. Awareness of EC pills among pregnant teenagers

	Total subjects	Have heard of EC		Source of information		Know time limit of EC
	591	Yes	282 (47.7%)	Peers and boyfriends	169 (59.9%)	Yes	101 (35.8%)
				Magazines and newspapers	60 (21.3%)
				TV and radio	19 (6.7%)
				Internet	18 (6.4%)
				Health professionals	6 (2.1%)	No	181 (64.2%)
				Parents	3 (1.1%)
				Others	3 (1.1%)
				Could not recall	4 (1.4%)
		No	309 (52.3%)

Table 3. Previous usage and ways of acquisition of EC pills among pregnant teenagers

	Have heard of EC	Have used EC		Frequency of use of EC pills within 6 months before pregnancy		Route of getting EC pills		Know time limit of EC
	282	Yes	124 (44.0%)	None	9 (7.2%)	Pharmacy	114 (91.9%)	Yes	82 (66.1%)
				Once	41 (33.1%)
				Twice	30 (24.2%)	Peers	3 (2.4%)
				Three times	14 (11.3%)
				Four times	10 (8.1%)	Illegal clinic	5 (4.0%)	No	42 (33.9%)
				Five times	4 (3.2%)
				Could not remember	16 (12.9%)	Health professional	2 (1.6%)
		No	158 (56.0%)

Table 4. Impact of previous knowledge of EC pills on past contraceptive use

		Have heard of EC		P value
		Yes	No
	Contraceptive behavior
	Never used any contraceptive method	97 (33.4%)	193 (66.6%)	0.000a
	Already used a contraception	185 (61.5%)	116 (38.5%)
	Contraceptive methods
	Most frequently used contraception within last 6–12 months
	Condom	98 (59.8%)	66 (40.2%)	0.530b
	Oral contraception	24 (75.0%)	8 (25.0%)
	Spermicide	1 (50.0%)	1 (50.0%)
	Withdrawal	27 (65.9%)	14 (34.1%)
	Rhythm	29 (55.8%)	23 (44.2%)
	Others	6 (60.0%)	4 (40.0%)

a Chi square. b Fisher exact test.

Within the current pregnancy cycle, 540 participants (91.4%) used no contraception, 51 (8.6%) experienced contraception failure, and only 49 (8.3%) actually used EC to try to prevent pregnancy after intercourse. The other 542 girls listed the reasons why they did not use EC as follows: 57.0% did not know about EC, 34.7% did not think they were at risk of getting pregnant, 2.8% did not know how to use EC, 2.0% were worried about the side effects of EC, 1.5% were worried about being seen by adults at the pharmacy, 1.1% did not know where to get EC, 0.6% were worried about the judgmental attitudes of health professionals, and 0.3% had other reasons. Among those 49 girls who used EC to prevent pregnancy, 81.6% of the failure can be considered to be attributable to user error or imperfect use, such as having intercourse more than once or taking more than one dose of EC pills within 1 month, while method failure attributable to the inherent inadequacy of the method itself was considered to have occurred in 18.4%.

After the interviewer had explained to them how to correctly use EC, 89.7% (530/591) of the girls said they would be willing to use EC when confronted with the same situation in the future; among them 75.7% (401/530) planned to get it OTC from a pharmacy, 23.4% (124/530) from the doctor, 0.9% (5/530) from an illegal clinic, and 10.3% (61/591) were still unwilling to use EC in the future because in 59.0% of cases (36/61) they were worried about the side effects or in 18.0% (11/61) they were worried about the high failure rate, in 3.3% (2/61) they were unwilling to face doctors, in 3.3% (2/61) taking EC was too troublesome, in 1.6% (1/61) obtaining EC was too difficult, and in 14.8% (9/61) they underestimated the risk of getting pregnant.

4. Discussion 

The six hospitals in which we chose to conduct the survey were in 6 of the 20 districts of Shanghai, and they were different kinds and levels of hospitals.

The rate of abortion among pregnant teenagers in China is high; however, no research documenting its magnitude has been published to date. Several reasons might explain this. First, China’s policy set the legal age of marriage for women at 20 years and the national family planning policy that encourages one couple to have one child after marriage. These might discourage teenagers from carrying unwanted pregnancies to term. Second, sexual activity among unmarried teenagers is high, although being a teenage mother is not socially acceptable in China. Third, in China, unlike in western countries, there is no social welfare system to support the teenage mother and her child. Xu et al. [4] published in 2005 one of the first papers about teenage pregnancy in China. The age and age at first sexual intercourse of the participants are similar in the two studies. The study sample is likely to be representative of pregnant teenagers in Shanghai.

The results of our study improve the understanding of adolescent knowledge and use of EC, and thus can help inform interventions to improve uptake of contraception. However, our study has several limitations. There is a possibility of recall bias due to the cross-sectional nature of the study. Although the response rate is very high, the sensitive nature of the questions may have introduced reporting bias. These potential biases, along with the distinct population in which the study was conducted, may limit the generalization of our findings to adolescent EC users elsewhere.

When adolescents become sexually active, multiple strategies are necessary to encourage them to avoid sexually transmitted infections and unintended pregnancy. The traditional approach to unintended pregnancy in China has been primary prevention (contraception), backed up by secondary prevention (induced abortion). However, until recently, contraception meant only regular contraception and some degree of anticipation on the part of the woman. The definition of the primary prevention of unintended pregnancy could and should now be expanded to include post hoc contraception as well [5]. Some healthcare providers have concerns about the use of EC, fearing that it may actually lead to an increase in unprotected intercourse and less frequent use of reliable contraceptive methods, which could subsequently contribute to higher rates of sexually transmitted infections (STIs) and unwanted pregnancies [6]. However, EC use has no adverse effects on condom use, but is rather associated with an increased probability of condom use and an increased perceived capacity to negotiate condom use [7]. A recent study reported that the advance provision of EC pills to adolescents was not associated with more unprotected intercourse or less condom or hormonal contraceptive use [8]. Our study also shows that girls who were aware of EC were more likely to use a contraceptive method, and less likely to have sex without any contraception, although they did not use unreliable contraceptive methods more frequently.

Because the sexual activity of adolescents is usually unplanned, the rate of contraception use is rather low among this population. EC is the only method that can be used to prevent pregnancy after unprotected sexual intercourse or contraceptive failure. However, the present results show that the awareness of EC is poor among adolescents compared with adult women in Shanghai. A study conducted in 2005 in Shanghai showed that awareness among women of childbearing age was as high as 90.29% [9]. Having heard of EC, however, does not necessarily imply sufficient knowledge, such as indications for use, efficacy, safety, common side effects, correct time frame for use, or where and how to obtain the products. In our study, only 17.0% (101/591) of all participants correctly identified the 72-h time-limit for proper use; among those who had already used it about one-third still did not know what the correct time-frame was. Most of them did not actually know about the proper indications for use, or what the most probable reason for EC failure was. EC awareness ought to be improved, in particular by providing adolescents with more appropriate information. Apart from that, teenagers should also be informed about the risks of unprotected sex, because in our study underestimating the risk of getting pregnant was the second most popular reason after the lack of EC awareness for not using EC after unprotected sexual intercourse. Based on our personal experience, the use of the “safe period” is a popular way of monitoring fertility amongst teenage girls in China. This is similar to Moreau et al.’s French study [10].

Published data remain conflicting on the capacity of EC to prevent unwanted pregnancies and decrease abortion rates. For example, data from the UK showed that widespread distribution of advance supplies of EC through health services might not be an effective way of reducing the incidence of unintended pregnancy in the UK [11]. However, data from Shanghai showed that more than 30,000 cases of induced abortion had been reduced, with a network of good quality EC services since the introduction of EC in 1995–1998 when it began to be distributed OTC [12]. In China, EC sales continue to rise sharply, from 510,000 boxes in 1998 to 58,700,000 boxes in 2005 (personal data from the EC product company). EC can only be effective in preventing unwanted pregnancy if correctly used after unprotected intercourse or contraceptive failure. This can only be ensured by better awareness and better services. Being the main EC providers to sexually active adolescents in China, pharmacists should receive systematic training about EC and other forms of contraception. Results from a survey in Shanghai showed that 54.87% of the customers who bought EC pills from pharmacists did not receive any explanation and 43.06% did not obtain full information on how to correctly use EC pills [9]. Trained pharmacists should be encouraged to counsel women about EC, focusing on indications for use, side effects, safety, and time-frame for correct use, and distribute written materials containing easily understandable and medically accurate information. Information about other, more effective contraception methods and instructions on dual protection (condom and oral contraception) should also be provided to women by pharmacists, because if EC is used as an ongoing method, it is far less effective than most other routine contraceptive methods.

5. Conclusions 

The awareness of EC among adolescents does not have a negative impact on their contraceptive behavior. Lack of EC awareness and underestimating the risk of becoming pregnant are the main reasons for not using it after unprotected intercourse. The impact of education on plans for future EC use is encouraging. Sex education programs should be launched in schools to improve awareness of EC and the risk of unprotected sex. Pharmacies are the main EC providers to sexually active adolescents for reasons of confidentiality. Training pharmacists is critically important, as they are frequently in direct contact with adolescents and should take the responsibility for offering information about correct EC usage and other, more reliable contraceptive methods.