The European Journal of Contraception and Reproductive Health Care March 2007;12(1):6369

Emergency contraception: Knowledge and attitudes of Turkish nursing and midwifery students
Mustafa Celik*, Hasan Cetin Ekerbicer**, Ufuk Guney Ergun* and Nermin Tekin{
*Kahramanmaras Sutcuimam University, Medical Faculty, Department of Family Medicine, Kahramanmaras, Turkey; **Kahramanmaras Sutcuimam University, Medical Faculty, Department of Public Health, Kahramanmaras, Turkey; { Educational Staff, Kahramanmaras Sutcuimam University, Health School, Nursing Department, Kahramanmaras, Turkey
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ABSTRACT

Objectives To assess the knowledge and attitudes of emergency contraception (EC) among nursing and midwifery students of a university in the Eastern-Mediterranean region of Turkey. Methods The survey was conducted among 210 nursing and midwifery students. Results One hundred and twenty-ve participants (59.5%) knew at least one method of EC. One hundred and fourteen participants (54.3%) had heard about emergency contraceptive pills (ECPs), but only 17 (8.1%) knew what they contained. Rates of hearing about ECPs were statistically higher in third and fourth classes than rst and second classes, and in midwifery students than in nursing students (P 5 0.001). In spite of their very unsatisfactory level of knowledge, 166 students (79.0%) thought that ECPs should be sold in pharmacies. Conclusion The nursing and midwifery students we assessed have a very insufcient knowledge of EC. Probably therefore, many are prejudiced against it. They should be much better acquainted with this modality of contraception since, after graduation, they will play an important role in the dissemination of information about EC in the population.

K E Y W O R D S Emergency contraception, Nursing students, Midwifery students, Turkey

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INTRODUCTION

Emergency contraception (EC) refers to methods that women can use to prevent pregnancy after unprotected sexual intercourse, method failure, or incorrect use1. In 1974, Professor Albert Yuzpe suggested a regimen that consisted of 100 mg ethinyl oestradiol and either 1 mg norgestrel or 0.5 mg levonorgestrel (LNG) taken within 72 h of unprotected intercourse and repeated 12 h later2. Progestin-only preparations are also used for EC3. The copper-T intrauterine

contraceptive device (IUCD) offers an alternative; it should be inserted within 5 days of unprotected sex or, beyond this limit, within 5 days after ovulation, when the time of ovulation can be estimated. The most commonly used EC methods are hormonal regimens including a combination of ethinyl oestradiol with LNG (Yuzpe), and LNG alone. Products specically designed for EC use also known as the morning-after pill are available on

Correspondence: Dr Mustafa Celik, KSU Tip Fakultesi, Aile Hekimligi Anabilim Dali, TR-46100 Kahramanmaras, Turkey. Tel: 90 3442212337. Fax: 90 3442212371. E-mail: drmcelik@gmail.com MS 451 2007 European Society of Contraception DOI: 10.1080/13625180600996761

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the market46. Despite being an effective and safe method, EC is still not widely used4 because of inadequate knowledge of the health-care providers working in family-planning (FP) settings, as well as their prejudices regarding its use7,8. In Turkey, FP counselling and effective contraceptives are provided by health care personnel working in FP units. This service is part of the primary health care supplied in government health centres throughout the country. Until recently, there was no morning after pill as such that was commercially available in Turkey; combined oral contraceptives (COCs) were being used for this purpose. During their training, healthcare workers were taught the dosage of oestrogen and progestin, and the brand name of the COCs that could be used for EC. Today, there are two emergency contraceptive pills (ECPs) available on the market, one combined, the other one containing a progestin only. Studies have evaluated the knowledge and the views of providers concerning EC in different countries718. In Turkey, limited data are available on the level of acquaintance of providers and users, and the frequency of EC use5,6,14, but the knowledge and attitudes of Turkish nursing and midwifery students were not investigated so far. The educational curriculum of the Midwifery Department of the Health School of Kahramanmaras Sutcuimam University includes a specic course (2 h per week for 14 weeks) on Family Planning in the third year and the students are being educated and informed about ECs during this course. On the other hand, students in the Department of Nursing have only 2 h of informative lecture in the same semester in the course of Nursing in Obstetrics and Gynaecology. This study aimed at evaluating the knowledge of and attitudes with regard to EC of the nursing and midwifery students.
MATERIALS AND METHODS

team, a nursemidwife instructor, asked the students to complete the questionnaire during an ordinary class and explained that participation was voluntary. The forms were completed in the classroom, left in a closed box, collected, and kept condentially by the project leader. The questionnaire had both closed and openended questions on the students socio-demographic characteristics, knowledge of and attitudes towards EC. The questionnaire had been tested previously in a pilot project among 30 Health Technical Vocational School students. All variables were expressed as numbers and percentages. The Chi-square test was used for statistical analysis; P values 5 0.05 were considered statistically signicant. All data were entered into and processed by Epi Info 2002 software (CDC, Atlanta, GA, USA).
RESULTS

Two hundred and ten students (112 nursing students and 98 midwifery students) out of 286 returned the completed questionnaires. This represented a retrieval rate of 73.4%. The average age of participants was 21.1+1.7 years (min. 17 years, max. 25 years). All were single and Muslims. Some characteristics of the participants are summarized in Table 1. Knowledge of emergency contraception One hundred and fourteen participants (54.3%) had heard about ECPs: about 30% in rst and second classes, 75% in third classes, and 84% in fourth classes. The difference between rst and second classes, and third and fourth classes, was statistically signicant (P 5 0.001) (Table 2). Only 25 students (11.9%) answered the question When should ECPs be taken? correctly as Within 72 hours after sexual intercourse. The answers of the third- and fourth-class students were more often correct than those of rst- and second-class students (P 5 0.001). One hundred and fourteen participants (54.3%) answered Emergency contraceptive pills to the question Which emergency contraception methods do you know?, eight (3.8%) answered Intrauterine contraceptive device, three (1.4%) answered High dose oral contraceptive pills. On the other hand, eight students (3.8%) answered erroneously Vaginal douche, and four (1.9%) Withdrawal.

The city of Kahramanmaras, with a central population of 350 000 people, is located in the EasternMediterranean region of Turkey. All of our students are Muslims and originate from families of average socio-economic level. This cross-sectional study was conducted among nursing and midwifery students of the Health School of Kahramanmaras Sutcuimam University by using a questionnaire survey. The study was undertaken over a 2-week period in June 2005. A member of the study

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Table 1 Socio-demographic characteristics of the study population Number of participants (n)

Table 2 Awareness about emergency contraceptive pills according to class and department Heard about ECPs

Characteristics Gender Female Departments Nursing Midwifery Class (Year of school) 1. 2. 3. 4. Education of mother Had not completed primary school Primary School Secondary and High School Education of father Had not completed primary school Primary School Secondary and High School

% Yes n (%) No n (%) Total P*

210 112 98 50 58 52 50 85 92 33 27 89 94

100.0 53.3 46.7 23.8 27.6 24.8 23.8 40.5 43.8 15.7 12.8 42.4 44.8 Class First Second Third Fourth Total Department Nursing Midwifery Total 15 (30.0) 19 (32.8) 39 (75.0) 41 (83.7) 114 (54.5) 48 (43.2) 66 (67.3) 114 (54.5) 35 (70.0) 39 (67.2) 13 (25.0) 8 (16.3) 95 (45.5) 63 (56.8) 32 (32.7) 95 (45.5) 50 (100.0) 58 (100.0) 52 (100.0) 49 (100.0) 209 (100.0) 111 (100.0) 98 (100.0) 209 (100.0) 50.001**

50.001

Seventy-three participants (34.8%) answered No to the question Are ECPs effective after pregnancy starts? whereas 137 (65.2%) gave a wrong or no answer. The answers of third- and fourth-class students were more often correct than those of rstand second-class students (P 5 0.001). One hundred and fourteen participants answered the open ended question What do ECPs contain?. Only 17 of them (8.1%) answered correctly. More participants in third and fourth classes answered this question correctly than participants in rst and second classes (P 5 0.001). Information on EC methods was gained by the students mainly from medical sources of information such as health school 106 (50.5%), doctors 75 (35.7%) and nursesmidwives 47 (22.4%). Ninety participants (42.9%) answered afrmatively to the question Are ECPs available in Turkey? and 120 (57.1%) answered I do not know or gave no answer. The participants knowledge of EC and ECPs is shown in Table 3.

*Chi-square test, P 5 0.05 statistically signicant. **The percentages of students in third and fourth classes who had heard of ECPs were signicantly greater than those of students in rst and second classes.

Attitudes with regard to emergency contraception One hundred and fourteen participants (54.3%) answered afrmatively and 96 (45.7%) negatively to the question Have you ever needed information about contraception?. Eighty-three participants (39.5%) answered afrmatively to the question Do you use ECPs when needed or do you recommend ECPs to a friend?, 18 (8.6%) answered No and 109 (51.9%) answered I am not sure. Other data concerning students attitudes towards EC are mentioned in Table 4; these latter were not affected by their parents level of education (P 4 0.05).
DISCUSSION

Only 54.3% of the participants had heard about ECPs. Awareness was signicantly greater in third and fourth

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Table 3 Students knowledge of emergency contraception (EC) and emergency contraceptive pills (ECPs) Item On which days of the menstrual cycle days are women more likely to become pregnant after sexual intercourse? Middle of menstrual cycle (correct answer) Wrong answer or no answer Which EC methods do you know? Emergency contraceptive pills Intrauterine contraceptive device High dose oral contraceptive pills Wrong answers: Vaginal douche, withdrawal No answer Where did you obtain information about EC methods from?* School Doctor NurseMidwife Brochure Newspaper/Magazine/Television Internet Traveller pharmaceutical rm Family Friend No answer What do ECPs contain? Correct answer Wrong answer or no answer Do you know the side effects of ECPs? Knew at least one side effect Wrong answer or no answer Are ECPs available in Turkey? Yes (correct answer) I do not know or no answer Where can you buy ECPs? Pharmacy Health centre Wrong answer or no answer When should ECPs be taken? Within 72 h after sexual intercourse (correct answer) Wrong answer or no answer Are ECPs effective after pregnancy starts? No (correct answer) Wrong answer or no answer *Since the respondents could give more than one answer, the sum of percentages exceeds 100%. n (%)

138 (65.7) 72 (34.3) 114 (54.3) 8 (3.8) 3 (1.4) 12 (5.7) 73 (34.8) 106 (50.5) 75 (35.7) 47 (22.4) 36 (17.1) 24 (11.4) 15 (7.1) 12 (5.7) 9 (4.9) 8 (3.8) 96 (45.7) 17 (8.1) 193 (91.9) 8 (3.8) 202 (96.2) 90 (42.9) 120 (57.1) 88 (41.9) 25 (11.9) 97 (46.2) 25 (11.9) 185 (88.1) 73 (34.8) 137 (65.2)

classes than in rst and second classes, and among midwifery students than nursing students (P 5 0.001) (Table 2). This difference could be attributed to the curriculum of the third classes of the midwifery and nursery departments. We think that students of rst and second classes represent the adolescents who have

not been taught family planning. In this respect, there is unquestionably a great deciency in awareness about EC. Studies concerning this matter showed that, among students of different countries, 58% of those from Nigeria15, 84% in Jamaica16, 43.2% in Ghana17, 56.5% in South-Africa18 and 79.7% in Sweden19 have

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heard about ECPs. In our study, although participants were midwifery and nursing students, only half had heard about ECPs. One-third of the rst- and secondclass students had heard about ECPs; this rate of awareness was lower than among students of many developing countries. Rates of hearing about ECPs in third and fourth classes were higher than in developing countries and similar to those of developed countries. Mandiracioglu et al.14 and Uzuner et al.5 assessed the staff of Turkish health care centres and found that 50 and 84% of these, respectively, were aware of ECPs14. Only 17 participants in our study (8.1%) knew what ECPs contained and eight (3.8%) were aware of at least one of their side effects. Less than half (42.9%) knew that ECPs were available in Turkey. This indicates that most participants do not have a detailed knowledge of ECPs. Since there was no morning after pill commercially available until recently in Turkey, little was taught to the nursing and midwifery students on that subject, which may explain the grave shortcomings in their knowledge of ECPs. Lack of information is cited as one of the barriers to the use of EC10. The existence of a morning after pill, marketed as such, may play a

role in the recognition of this method. Awareness among physicians is considerably better in other parts of Europe, including the United Kingdom, where the ECP has been available since 19844. Since 2005, two ECPs are available in pharmacies in Turkey, one combined, the other one containing only a progestin. Several studies showed that training, the existence of a product specically designed as an ECP, and gaining experience in prescribing it, create awareness among providers and increase their level of knowledge10,11,14. The participants agreed to statements such as: ECPs should be sold in pharmacies, ECPs increase the safety of women, ECPs increase the role of women in reproduction, All sexually active women should be aware of ECPs, ECPs should be known as well as the condom, ECPs should be given a place in contraceptive counseling, All sexually active men should be knowledgeable about ECPs, ECPs should be mentioned in sex education at schools, ECPs should be given free of charge in primary health care centres (Table 4). In spite of mostly favourable opinions about ECPs, 23.8% of the respondents thought that the ECP is not

Table 4 Students attitudes with regard to emergency contraceptive pills I do not agree n (%) (11.9) (61.0) (37.1) (16.2) (13.3) 9 (4.3) 38 (18.1) 12 (5.7) 6 (2.9) 47 (22.4) 92 (43.8) 106 (50.5) 83 (39.5) 152 (72.4) 115 (54.7) 39 (18.6) 12 (5.7) 23 (10.95) 21 (10.0) 15 (7.1) 25 128 78 34 28 No answer n (%) 19 (9.1) 32 (15.2) 34 (16.2) 35 (16.7) 41 (19.6) 22 (10.5) 26 (12.4) 26 (12.4) 15 (7.1) 27 (12.8) 31 (14.8) 34 (16.2) 44 (21.0) 36 (17.1) 31 (14.8) 29 (13.8) 37 (17.6) 34 (16.2) 31 (14.8) 26 (12.4)

Item ECPs should be sold in pharmacies ECPs are not ethically justied Teenagers can take responsibility for use of ECPs ECPs give women increased safety ECPs increase womens self-control of reproduction All sexually active women should be aware of ECPs All sexually active men should be aware of ECPs ECPs should be as well known as condoms Routine information about ECPs should be included in contraceptive counselling Information on ECPs should be included in sex education at school The provision of ECPs over the counter is a good thing ECPs should be sold only to women ECPs should be sold only together with condoms ECPs should be distributed by supermarkets The cost of ECPs should be reduced for women ECPs should be provided free of charge by primary health care centres Men will be less willing to use a condom when they know about ECPs Increased knowledge of ECP results in more unsafe sex STDs will increase with the misuse of ECPs ECPs can make it more difcult for women to refuse unprotected intercourse

I agree n (%) 166 50 98 141 141 179 146 172 189 136 87 70 83 22 64 142 161 153 158 169 (79.0) (23.8) (46.7) (67.1) (67.1) (85.2) (69.5) (81.9) (90.0) (64.8) (41.4) (33.3) (39.5) (10.5) (30.5) (67.6) (76.7) (72.9) (75.2) (80.5)

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ethical. Many respondents also had negative opinions and worried about ECPs being sold only over-thecounter (OTC), only to women, only with condoms, in supermarkets, and for less money to women. Furthermore, participants were worried that if men are knowledgeable about ECPs, they will stop using condoms, unsafe sex will become more frequent, STDs will increase, and women will be forced to have unprotected sexual intercourse. These concerns can adversely affect usage of ECPs. Users knowledge is related to the contraceptive counselling given by health staff and the rate of prescription of ECPs by that personnel20. In the study of Langer et al.12, the providers stated that the best ways to overcome barriers would be to increase awareness and education of EC through training courses. Limitation of the study Since participants were allowed to complete the whole questionnaire, regardless of their level of acquaintance with EC, many of them who did not know what ECPs contained expressed opinions about the dis-

tribution of ECPs in pharmacies and ethical issues related to ECPs.

CONCLUSION

The great number of senior nursing and midwifery students whose knowledge of EC is grossly insufcient is a matter of concern. Nursing and midwifery students should be much better informed on EC since after graduation they will play an important role in the dissemination of information about EC in the population. Moreover, the morning-after-pill is now available in Turkey. The educational curriculum on family planning should be thoroughly revised. Detailed information especially on ECPs should be added to the contents of the courses given in the rst or second classes. Furthermore, supplementary information should be offered to healthcare professionals during continuing vocational education courses. The ndings of this study and our suggestions were submitted to the Head of our Health School.

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