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Knowledge and practice of emergency contraception among female students of public university of Ouagadougou, Burkina Faso, West Africa

Sexual activity has started increasingly early. A document published by the Ministry of Health in 2008, revealed that in the 15-19 age range between 1996 and 2006, there was a considerable increase in the proportion of sexually active women, exposing, earlier and for a longer period of time, these women to reproductive events (unwanted pregnancy and abortion). Approximately 42 million abortions take place each year worldwide, of which nearly 20 million are unsafe and responsible for 70,000 maternal deaths. Students are particularly exposed to risky sex; behaviours that result in unwanted pregnancies, abortions and sexually transmitted infections including HIV / AIDS. Virtually all deaths and cases of disability due to abortion could be prevented ABSTRACT


INTRODUCTION
Sexual activity has started increasingly early. 1,2 A document published by the Ministry of Health in 2008, revealed that in the 15-19 age range between 1996 and 2006, there was a considerable increase in the proportion of sexually active women, exposing, earlier and for a longer period of time, these women to reproductive events (unwanted pregnancy and abortion). 1 Approximately 42 million abortions take place each year worldwide, of which nearly 20 million are unsafe and responsible for 70,000 maternal deaths. Students are particularly exposed to risky sex; behaviours that result in unwanted pregnancies, abortions and sexually transmitted infections including HIV / AIDS. 2 Virtually all deaths and cases of disability due to abortion could be prevented by sex education, the use of effective contraceptives. 3 It is estimated that about 214 million women in developing countries want to delay the time to have a child or to have no more children but who do not use contraception. 4 In Africa, 23.5% of women of childbearing age have an unmet need for modern contraceptives. 4 Thus, the need to promote reproductive health of young people, the Ministry of Health of Burkina Faso has intensified its actions through several strategies such as the strategic plan for securing reproductive health products 2006-2015, and the national plan of Family Planning Revitalization 2013-2015. 5 Despite these efforts, it is clear that the contraceptive rate remains low. The results of the fourth Demographic and Health Survey reported a contraceptive prevalence of 15% in 2010, of which 14% for modern contraception. 6 In view of this, the promotion of emergency contraception could contribute to the reduction of unwanted pregnancies. Indeed, emergency contraception (EC) prevents 95% of pregnancies when it is taken within 5 days of intercourse. 7 Wanting to contribute to the reduction of unwanted pregnancies in a student environment, we initiated this work, which evaluated the knowledge of female students at public universities in Ouagadougou on emergency contraception and their practices.

METHODS
This study was carried out in the public universities of Ouagadougou in Burkina Faso (University Ouaga I Professor Joseph KI ZERBO and University Ouaga II) This was a cross-sectional descriptive study that took place from March 1st to October 31st, 2016. The study population was students regularly enrolled in the public universities of Ouagadougou, during the year 2015-2016. Regularly enrolled students who voluntarily accepted and completed the survey cards were included in present study. Female students whose survey cards were incompletely completed (68 cases) were excluded from the study.
Present study was conducted in the health service of the National Center of University Works located in the public universities of the city of Ouagadougou in Burkina Faso. The data were collected using a written and anonymous questionnaire and administered after a pre-test performed on 45 female students.
The questionnaires were completed by the students themselves and then collected on the spot. According to a previous study in 2012, the prevalence of emergency contraception was 35.2% in the student environment (p = 0.352).
Using the Schwartz formula n = z² p (1-p) / e² (z = 1.96, e = 0.05 accepted margin of error), the minimum sample size to obtain a representative sample of students was 351 individuals. This minimum size was corrected by the 5% no response rate. The estimated minimum size was 369 students. We included 732 students.
The data were collected using a written and anonymous questionnaire and administered after a pre-test performed on 45 female students. The cards were completed by the students themselves and then retrieved immediately afterwards.
Variables such as sociodemographic characteristics, gynecological history, knowledge on emergency contraception, use of emergency contraception were reported. On the ethical front, the conditions for collecting and keeping the information respected the fundamental principles of human rights. The anonymity of the questionnaire and the confidentiality of the data have been respected. The approval of the ethics committee was obtained before the completion of this work.

Sociodemographic characteristics
During this study period, we surveyed 732 students. The age of female students ranged from 19 to 35 with an average age of 22.7 years. Female undergraduates were the most numerous with 82.38%. Table 1 gives the distribution of female students by different characteristics.

Student knowledge of emergency contraception
Regarding emergency contraception, 637 students representing 87.02%, said they had heard about it.
Of these, 389 (61.07%) knew the definition of emergency contraception. Female students who could not correctly define emergency contraception accounted for about 39%. Figure 1 gives the distribution of female students by source of information on emergency contraception (EC). Almost all the students who have ever heard of EC (98.90%) knew the utility. Only 7 students (1.1%) thought that the role of EC was to regulate the menstrual cycle. Regarding the use of EC, 81.94% of female students knew the mode of administration, 8.63% had a false knowledge and 9.42% of female students had no idea.  In this question, the majority of respondents, 83.47%, said they had not received enough information about emergency contraception.
They proposed the organization of awareness sessions on emergency contraception. Only 16.53% said that this information was available.

Student practices of emergency contraception
Of the 732 students, 529 reported being sexually active (72.27%). The average age of first intercourse for these students was 17.6 years. About 15% of these students (14.93%) reported having an abortion at least once.
Only 23 students (4.35%) said they had consulted in a health center for emergency contraception. These are students who have had sexual intercourse without their consent and those who have been scared after consensual sex.
As for the use of emergency contraception, 235 students (44.42%) reported having already used the EC against 55.58 who never used it. Reasons for using contraception included condom breakage (25.10%) and unprotected sex (74.9%).
For EC users, the number of uses is listed in The opinion of the partner was not collected before the use of emergency contraception, in 56, 10% of female students.

DISCUSSION
Nearly 9 out of 10 students (87.02%) had heard of emergency contraception. This rate is higher than those of Ekok et al, Ezebialu and Eke in Nigeria, Addo et al in Ghana who found respectively 71.2%, 51.6% and 51.4%. 2,9,10 It is lower than that of Veloso et al in Brazil [1] which was 96%. The sources of information for students varied by series. In our series, the media is the main source of information (42.54%) while in Nigeria it is the peers and friends with 51%. 9 Sexually active female students accounted for 72.27%. This rate is comparable to that of Ekok et al in Nigeria which is 69.2%. It is higher than those of Veloso et al in Brazil, Ezebialu and Eke in Southeast Nigeria and Gupta et al in India which are respectively 60%, 21.8% and 1%. 1,2,8,9 This high rate is explained by the Westernization of African society. Indeed, African culture and different religions do not tolerate sex outside marriage.
Female students who consulted in health center for emergency contraception accounted for only 4.35%, yet 44.42% of female students reported having used emergency contraception. Procurement of emergency contraception was directly in pharmacy without prescription in 93,68%. This could be explained by the fact that the emergency contraceptive pill is sold over the counter in pharmacies on the one hand, and on the other hand by the persistence of sociocultural restraints that are unfavorable to sex outside marriage. Indeed, some students, for reasons of modesty, and unwilling to expose themselves to the accusing eyes of other people do not go to health centers to obtain emergency contraception.
The reasons for using contraception are condom breakage (25.10%) and unprotected sex (74.9%). According to Moreau C, in France, the main reasons are slippage or condom breakage (30.7%) and forgetfulness of taking a pill (30.1%). 11 Unprotected sex, as a reason for taking EC, was between 18% and 23.5% depending on the age of the woman. 11 As a result, students take considerable risks, exposing themselves to sexually transmitted infections, including HIV.
The use of emergency contraception remains most often unique. The majority of users use it only once. In our series 65.53% took emergency contraception once, Onefifth of users (20.85%) took it twice and 13.61% reported using it three or more times. Our results corroborate with those of Caroline Moreau in France who found in her study that the rates of users who had taken emergency contraception one, two, three times and more, are respectively 67.3%; 21.7% and 11%. 11 The multiple use of emergency contraception is explained by the fact that the majority of female students being single, their sexual relations with men are usually casual and unprotected. In our series, about 20% of female students reported that emergency contraception is not a good practice. This is related to the socio-cultural context in which the students live. The most common opinion equates emergency contraception with an abortive method. The same view was put forward by the US Food and Drug Administration at the time of George Bush. 13

CONCLUSION
Emergency contraception gives women a last chance to avoid an unwanted pregnancy after unprotected sex. This is a method that is not very well known by students limiting its use. The main reason for users is unprotected sex. Because of the early onset of sexual intercourse and low contraceptive prevalence among female students, actions should be considered to increase awareness and promote this ultimate contraception.