Background: Emergency contraception pills (ECPs) also called morning-after pills refers to methods of contraception that can be used to prevent pregnancy after sexual intercourse. These are recommended for use within 5 days but are more effective when used immediately after intercourse. The problem is that females who use ECPs are not aware that emergency contraceptive pills are not regular family planning methods, may not know their side effects, how they work, their availability and the general education about these pills. This study seeks to assess the prevalence and knowledge level of emergency contraceptive pills and its association with sexually transmitted infections (STIs) among female students.

Methods: The design for this study is a cross sectional study targeting female students at Kumasi Technical University. Structured questionnaire was used to obtain information from 517 respondents.

Results: The prevalence rate of emergency contraceptive pills use among female students is 48% with about 98% awareness level. More than half of the people believe ECPs as early abortion. Many ECPs users do not apply them appropriately and are also not abreast with the side effects which may include headache, tommy pains, changes to their next period or feeling of being sick. The use of ECPs is statistically significant to acquiring STIs.

Conclusion: There is a high association between ECPs use and contracting STIs. The choice of contraceptives use by respondents is highly associated with source of knowledge, marital status and life time sexual partners. There should be continuous education among our female students regarding the use, the function and the effects of ECPs use. Awareness must also be created among students about the risk between ECPs use and STIs.

Emergency contraception pills [ECPs] also called morning-after pills refers to methods of contraception that can be used to prevent pregnancy after sexual intercourse. These are recommended for use within 5 days but are more effective when used immediately after intercourse [20]. ECPs is grouped into three types: emergency contraceptive pills [ECPs], combined oral contraceptive pills and copper-bearing intrauterine devices [IUDs]. Women are more likely to use ECPs if they already have them when needed. Also, the availability of ECPs enable women to take them as soon as possible after unprotected sex, when they will be most effective [1]. Over 100 million sexual intercourse acts take place daily in the world, which contribute to about 3 million conceptions, of which 50% are unplanned and 25

Study design and Setting

The study adopted a quantitative research approach. Cross sectional study design was adopted. The focus of this study was on the socio-demographic characteristics of students, sexual and reproductive characters of the students as well as their attitude towards the use of ECPs and their level of knowledge. The study setting was Kumasi Technical University central campus at Amakom, in the Ashanti region of Ghana. The institution currently has seven Faculties and twenty-six Departments. The study design is shown in figure 1.

Questionnaire was used as the instrument of data collection for this study. This method was deployed to allow for comparability and scalability of responses. Data collection started spanning a period of three weeks between 3RD and 24TH July 2022, when the students were having the mid semester examinations. During this period there were not much academic activity so students who consented after the briefing were handed the questionnaires as soon as they were done with their examinations and are allowed enough time to complete them. The questionnaire had four broad sections. They are; socio-demographic characteristics, knowledge about ECPs, prior experience with ECPs and associated risk factors and finally attitude towards ECPs use.

Demographic characteristics of respondents

A total number of 560 female students from Kumasi Technical University were involved in the study. Out of this, 538 agreed to participate in the study whilst 22 did not agree to participate. However, out of 538 who agreed to partake in the study, 21 of them did not complete the interview whilst 517 successfully completed the interview giving a response rate of about 92%. The results show that in all, about 48 % of the respondents have used ECPs before.

Table 1 shows that majority (70.41%) of the participants falls between 20-24 years. The age group with the least percentage (0.39%) was 35-39 years. About 80% of the respondents reported being single whilst about 14% were into consensual relationship with 6% married. Most (58.22%) of the respondents experienced their menarche at the ages ranging between 13-15 years and close to 1% (0.97%) experiencing it before attaining age 10. A good number of the respondents, about 40% (40.23%) experienced their first sexual intercourse between 15-19 years, about 32% (31.51%) of them had it between 20 -24 years whilst 23% of them have never had sex before. Thus, respondents who have no life time sexual partners are about 23 %. This means that less than a quarter of the participants have not had sex before. Those who have single sex partners were about 35%, whilst those having between 2 to 3 sex partners are about 31% and those who have had at least 4 life time sex partners are about 11%. This is very serious due to the health implications associated with such practice. Eighteen percent of the respondents have also been pregnant before.

Knowledge about emergency contraceptives

The level of knowledge about emergency contraceptive pills (ECPs) was assessed. From Table 2, it can be seen that, majority (98.07 Percentage) of the participants have heard about ECP before, with only 1.93 Percentage of them having no knowledge about ECPs. Regarding the source of knowledge, a little over 35 Percentage of the respondents heard it from health personnel, about 31 Percentage from friends, 19 Percentage from audio/visual media and the rest coming from family members and partners. Close to 95 Percentage of the respondents did not know Norlevo as a type of ECPs. Regarding the maximum acceptable time after sex for which a woman could take ECP; 43.13 Percentage of the participants admitted that they don’t know, 26.69 Percentage said between 24-48 hours, 18.18 Percentage thought between 12-18 hours whereas 11.41 Percentage and 0.58 Percentage said 72-120 hours and 124-160 hours respectively. Majority (51.26 Percentage) of the participants believed that ECPs is a method of early abortion. About 52.61 Percentage of the participants noted that ECPs cannot prevent sexually transmitted infections (STIs) when taken early. On how the drug works, 45.65 Percentage of the participant said it kills the sperm, 31.72 Percentage said they don’t know it works whilst 11.22 Percentage and 11.41 Percentage said it delays ovulation and thickens cervical mucus respectively. About 11 Percentage of the respondents agreed that ECPs can be used as many times as the individual can tolerate, 20 Percentage believe it could be used once a month whilst close to 10 Percentage think about twice a year with the remaining 59 Percentage don’t seem to have an idea about how often ECPs should be used.

Experience with ECPs and Associated Risk Factors

Tables 3 and Table 4 present participants experience with ECPs and associated risk factors. The results show that about 48 Percentage of the respondents have used ECPs before compared with 52 Percentage who have never used it. Almost 50 Percentage of the participants started using ECPs between the ages of 20-24 years, followed by about 42 Percentage using ECPs between 15-19 years with close to 4 Percentage using ECPs before attaining age 15. Among the ECPs users, about 59 Percentage of them use Lydia whilst about 23 Percentage use Postino2, about 11 Percentage use Levon, 2 Percentage use post pills whilst the remaining 5 Percentage could not classify the types they use. The results further show that among students who use ECPs, the types are usually recommended by partners and friends (about 72 Percentage) whilst 24 Percentage are recommended by health personnel and the remaining 4 Percentage coming from family members. This shows that partners and friends mostly recommend the type of ECPs that one can use. Meanwhile among those who use ECPs, only 40 Percentage of them use it anytime they have sex. The remaining 60 Percentage do not use ECPs frequently. The main reason why they fail to use the pills always is the fact that they have sex during safe period (29.25 Percentage). Majority (93.9 Percentage) cited prevention of pregnancy as their main reason for using ECP whereas 3.25 Percentage believe it prevents STIs that is why they use them. But 10.83 Percentage of the study participants have ever contracted STIs in the past and there is a high correlation between ECPs use and STIs (Table 4).  With respect to whom participants will confide should they contract STIs, close to 62 Percentage of them said health personnel, 20 Percentage said partners, with the remining 18 Percentage choosing between family members and friends. More than half (54.35 Percentage) of the participants or their partners use condom contraceptive to prevent STIs. Those who engaged in abstinence were 19 Percentage and surprisingly those who believe in taking birth control pills as a means of preventing STIs were 6 Percentage. About 37 Percentage of the respondents have had at least 3 sexual partners during the past three months, 5 Percentage had at most 2 sexual partners whilst over 58 Percentage never had any sexual partner during the past three months. 

The results show that 48  Percentage of the respondents have used emergency contraceptive pills before. This is very serious in that about half of the female student population use ECPs. This result compares that of a study conducted in Ethiopia in 2018 to assess the prevalence of ECPs.

Most [98.07 Percentage] respondents in this study are aware of emergency contraceptive pills. This is not surprising since the study was carried out in an academic environment with its target population being students. This results falls outside an awareness range reported in a study on the use and awareness of ECPs among women of reproductive ages in Sub-Saharan Africa by [11]. In their study they reported that the rate of ECPs awareness in Ethiopia is between 10.1 Percentage and 93.5 Percentage. Our result is however consistent with a study conducted among female senior high students in Ho Municipality of the Volta Region of Ghana by [12]. Their study found that, about 98.8 Percentage of female senior high students were aware of emergency contraceptive pills. In another research, by [13], about 96.15 Percentage of women in their reproductive age in Kwadaso Municipality, Ghana is also aware of ECPs. Our results contradicts that of similar studies conducted in Nairobi which found 74 Percentage of women being aware of emergency contraceptives pills [14] and [15], reporting only 34.1 Percentage of Ethiopian women seeking induced abortion in public Hospital at Eastern Tigray are aware of emergency contraceptives. The results from this study indicate that 35.35 Percentage of the respondents’ source of knowledge about ECPs were from health personnel, which corroborates the results of [15]. [15], further enquired about the knowledge and found that 40.4 Percentage of the women are knowledgeable about ECPs. [15] noted 56.3 Percentage women from Eastern Tigray of Ethiopia source of information about ECPs were from health workers. This however contradicts with the findings in Ghana reported by [12] who found that 41.6 Percentage on awareness of ECPs were derived from the mass media. In this current study, Audio/Visual media reported 18.93 Percentage regarding the source of knowledge on ECPs. In a sharp contrast, in Nairobi, the major source of information about ECPs is from family and friends [14]. Interestingly, this study along with Konlan et al., (2020) noted keenly that friends were the second leading source that create awareness of emergency contraceptives [30.57 Percentage in this study and 39.6 Percentage from [12]. Moreover, (88.59 Percentage) of the respondents did not know the type of ECPs. This may be dangerous to one’s health if they are probably using ECPs but do not know the type, how to use it or the possible side effects. Because emergency contraceptive pills are good for preventing unwanted pregnancies but are taken within a recommended dose and time interval after having unprotected sex [13,15].  More than half of the respondents believe that ECPs usage is a method of early abortion. This corroborates the findings by Abraha et al., in Ethiopia [15]. Attesting to this majority, [51.26 Percentage] of the participants in this study confirmed that ECPs is a method of early abortion. [13], hinted that emergency contraceptives have 99 Percentage likelihood of preventing unwanted pregnancy when taken correctly. In our study, regarding the maximum acceptable time after sex for a woman to take ECPs; 26.69 Percentage said it was between 24 and 48 hours, 43.13 Percentage did not know and only 11.41 Percentage said, between 72 and 120 hours. This stands to reason that a lot of these young ladies are using ECPs at the wrong times. The study by [12], found that [57.9 Percentage] of their respondents agreed the required time for taking ECPs was immediately after sex; 1.2 Percentage of them said 24 hours  and 30.6 Percentage did not know which contradicts the results of our study. In addition [16], also observed that in Nigeria ECPs can effectively be used within 24 hours [49.4 Percentage].  About 68 Percentage of women in a study by Yeboah et al., claimed that the recommended duration for taking ECPs should be within 72 hours [13]. The prevalence usage of ECPs in this study was 47.58 Percentage. This was lower than a similar findings of 76.9 Percentage reported from a study conducted in Kwadaso in the Ashanti Region by [13]. This is however, higher than the 33.9 Percentage of women  together who had used ECPs in Denmark, Norway and Sweden [17]. According to [17], the prevalence use of ECPs in Denmark is 32.3 Percentage, Norway is 35.1 Percentage and Sweden is 34.6 Percentage. Based on these findings this study could say that there is high usage of ECPs among KsTU female students. In Nigeria, the prevalence use of ECP is 54.1 Percentage [11]. Surprisingly, the prevalence among female sex workers in Swaziland is 27.5 Percentage [18],  which is 20.08 Percentage lower compared with the rate of 47.58 Percentage in this study. The study results show that about 50 Percentage of females start using emergency contraceptives between the ages of 20 and 24 years.  The type of emergency contraceptive pills frequently used by respondents in this study was Lydia [58.54 Percentage], but Lydia was not found among the commonly use ECPs such as postinor2 as reported by [11]. About 93.6 Percentage of the respondents said they use ECPs mainly for the prevention of pregnancy. Previous studies noted that emergency contraceptives are mainly used for the prevention of unintended pregnancies [12,14,18,19]. However, the common method that participants use to avoid contracting sexually transmitted diseases was condom [54.35 Percentage]. Condoms are used for prevention HIV and even more effective to prevent both HIV/STIs and pregnancy [18]. The results show a significant association between ECPs use STIs.

The prevalence rate of emergency contraceptive pills use among female students is 48 Percentage with close to 98 Percentage awareness level. More than half of the people believe ECPs as early method of prevention abortion. Many ECPs users do not apply them appropriately and are also not abreast with the side effects which may include headache, tommy pains, changes to their next period or feeling of being sick. About 94 Percentage of the respondents who use ECPs are aware about how they work, which is for prevention or delaying ovulation. There is a positive correlation between emergency contraceptive pills use and sexually transmitted infections among students.

Inadequate finance to compare two or more schools limited comparative analysis of the study. Secondly, because majority of the questions were closed-ended, limited respondents to express their views fully. There should be continuous education among female students regarding the use, function and effects of ECPs. Awareness must be created among students about the risk between ECPs use and STIs. Further study is recommended for scholars, public health and academia to expand this study.

Ethics Approval and consent to participate: All methods were performed in accordance with the University (KsTU) ethics and guidelines. This was approved by KsTU Research Ethics Committee. Informed consent was obtained from all paricipants who took part in the study.

Consent for publication: Not applicable

Availabilty of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests: The authors have decalred that no competing interests exist.

Funding: The authors received no specific funding for this work.

Authors Contributions: Author M.F.O and D.N developed the idea, designed the study, run the statistical analysis and drafted the first report; author A.A.A and E.K.N reviewed the literature and proofread the first draft. Authors D.N and A.A.A collected the data cleaned it and also contributed in the data analysis. All the three authors reviewed the final manuscript and agreed to its current state.

Acknowledgement: We thank all the authors whose passion led to the achievement of this study. We acknowledge the study participants for their voluntary participation that led to the success of this study. Our biggest appreciation goes to Kumasi Technical University, particularly the research ethics committee for allowing us to conduct the study 

Authors’ information (optional):  Not applicable