Introduction

Globally, over 257 million women wishing to avoid pregnancy have an unmet need for family planning and resort to unsafe methods of contraception. As a result, the number of unintended pregnancies averages 121 million per year, or a staggering 331,000 pregnancies per day. Termed as a “neglected crisis” by the United Nations Population Fund, these realities not only have lifelong implications on women, but also impact the human development index, have significant costs in healthcare, and contribute to rise in unsafe abortions [1].

Emergency contraceptive pills (ECPs) are a form of post-coital contraception that works to delay ovulation or prevent implantation thus reducing the chances of pregnancy [2]. Although the efficacy of ECPs varies depending on the exact formulation and regimen, they are effective for up to 5 days after unprotected intercourse, with a reported < 1–2 pregnancies per 100 women [1]. Furthermore, ECPs have almost no medical contraindications and are generally considered more convenient than intrauterine copper devices (IUCDs) despite the latter being regarded as the most effective form of emergency contraception [2]. However, as the name suggests, ECPs should only be used in the event of an emergency owing to their short-term contraceptive action and their inability to protect from sexually transmitted infections (STI) [3].

Despite the expected appeal for ECPs, it is a severely underutilized method and has had minimal impact at a public health level [4]. A 2014 multi-country analysis of the use of ECPs found that in 36 out of 45 countries, less than 3% of sexually active women had used ECPs. The reasons for this are multifactorial such as social, cultural, and religious barriers that influence its reach, but ultimately stem down to the extreme lack of awareness regarding ECPs, especially amongst those of a lower socioeconomic status and those living in rural areas [4].

Just like other methods of contraception, the use of emergency oral contraception has remained historically low in Pakistan. One study revealed that 88% of Pakistani women, predominantly homemakers, lacked awareness of the existence, usage and access of emergency contraception [5]. This can be attributed to a multitude of factors, such as the low literacy rates in Pakistan, the various barriers to access, and more importantly, the cultural, and religious taboos around their use [5]. A review of current literature evaluating barriers to family planning in Pakistan also identified physical inaccessibility, clinical concerns, cultural norms, and familial restrictions as pertinent barriers to contraceptive usage among married couples in Pakistan [6]. Moreover, the review also suggested that addressing attitudes toward family planning requires targeting household males in behavioral change campaigns aimed at enhancing contraceptive awareness. This is also consistent with previous evidence from Pakistan, Kenya, Nepal, and Ethiopia which articulated that joint decision-making regarding family planning may potentially increase contraceptive usage [7,8,9,10,11,12,13].

Furthermore, amongst the limited number of women utilizing ECPs, as many as 84% have acknowledged having gotten them from Lady Health Workers (LHWs). The same study shows that approximately 6% of LHWs had provided ECPs to women living in their catchment areas prior to an emergency, whereas the overriding majority of LHWs (74%) only provided the pills after an event of an emergency, such as unsafe intercourse [14]. This is in stark contrast to the Western population where sexual health clinics and primary healthcare centers are the mainstay for seeking knowledge and guidance regarding adequate contraception in cases of emergency.

Pakistan has encountered a plateau in its efforts to increase the usage of contraceptives since the 1990s, as only a mere 30–35% of the population uses them [15]. In comparison to the average of 53% usage of contraceptive methods in South Asia, Pakistan ranks the lowest amongst its neighboring countries [16]. Nearly one-quarter of women in Pakistan have an unmet need for family planning, with significantly higher rates in provinces such as Balochistan [15]. As Pakistan’s population rises at a rate of 1.9% annually, the failure to improve contraceptive utilization will have lasting repercussions years into the future [16].

For a country where the rate of long-term contraception usage in the general population is dismally stagnated and termination of unwanted pregnancies is hampered by legal, cultural, and religious barriers, the use of Emergency Contraceptive Pills (ECPs) is of prime importance in the fight against overpopulation. However, there is a complete absence of awareness regarding ECPs in significant proportions of the population, and where awareness does exist, it is permeated with myths and religious misconceptions. Additionally, where the knowledge of the usage is adequate, the availability and cost of ECPs pose undeniable uncertainties [17].

Scarce literature exists on the knowledge, practices, and most importantly, the barriers to ECP usage in Pakistan. Most earlier studies are aimed at investigating the awareness in specific communities, without looking at attitudes, sexual behavior, and use of other methods of contraception in women. Furthermore, with Pakistan primarily being a male-dominated society where men play a significant role in the use of contraception and reproductive decision-making, it is of utmost importance to further investigate and compare the gaps in knowledge and attitudes of both men and women regarding ECPs.

Materials and methods

This was a cross-sectional study conducted in the outpatient clinics of the Aga Khan University Hospital (AKUH) in Karachi, Pakistan, across four locations. These included the AKUH Stadium Road Campus, a tertiary care center, and its affiliated three secondary care centers:

  1. 1.

    Aga Khan Hospital for Women, Garden.

  2. 2.

    Aga Khan Hospital for Women, Karimabad.

  3. 3.

    Aga Khan Hospital for Women and Children, Kharadar.

The duration of data collection for this study spanned from 15th September 2023 to 25th September 2023. A sample size of 384 was determined using OpenEpi, taking into account the following assumptions: as no prior studies have assessed the awareness of ECPs among both married women and men, the estimated proportion of respondents with ECP awareness was set at 50%. These calculations were established with a confidence interval (CI) of 95% and a desired margin of error set at 5%.

The data for this study was collected using a validated questionnaire, formulated using tools from previously published studies [18,19,20,21,22]. The questionnaire, comprising 58 items, was structured into four distinct sections namely socio-demographic, knowledge, practice of ECPs, and barriers of its usage containing 17, 15, 7, and 19 questions respectively.

Sociodemographic characteristics and information about practices and barriers were collected as nominal numbers whereas knowledge was assessed using a 15-item validated questionnaire based on the study of Yongpraderm et al. [18]. Respondents were provided with the response options: “Yes”, “No” and “Not Aware” for each question. Each correct response received a single point, whereas each incorrect or not-aware response received 0 points. Therefore, this questionnaire had a maximum possible score of 15 with a minimum possible score of 0. The total scores obtained by each respondent were used to determine their level of knowledge regarding ECPs. Scores falling within the range of 0–5, 6–10, and 11–15 were defined as low, moderate, and high levels of knowledge of ECPs respectively, as defined by the study of Yongpraderm et al. [18]. The questionnaire has also been provided in the supplementary material.

Before their enrollment, all participants were provided with a formal consent form describing all the potential risks and benefits. They were assured of the voluntary nature of their participation and their right to withdraw without incurring any adverse consequences. All respondents undertook an in-person interview, conducted by one of the co-investigators. Couples were interviewed separately to mitigate any potential mutual influence. The interviewers adhered to a standardized protocol, ensuring privacy, and consistency across all interviews, and eliminating any potential biases. The questionnaire was also translated into Urdu, the native language of the participants, to minimize language barriers and enhance accessibility. The data was stored in a secure, password-protected Google Sheets document with restricted access to authorized researchers only.

Data analysis was performed using Stata 18. Categorical variables (i.e., gender and barriers to access of ECPs) were descriptively analyzed as frequencies and percentages, while continuous variables (i.e., age and knowledge scores) were summarized as mean and standard deviation. The association between categorical variables (i.e., gender and previous experience with the utilization of ECPs) and knowledge scores of ECPs (low, moderate, or high) were assessed using a Chi-square test of variance. A p-value of less than 0.05 at 95% CI was considered statistically significant.

Results

Sociodemographic characteristics

A total of 393 married individuals between the ages of 18 and 49 were enrolled in this study, of which 255 (64.9%) were female and 138 (35.1%) were male with an overall mean age of 30.78 ± 6.03. The mean age for men was 33.03 ± 5.92 while women had a mean age of 29.58 ± 5.75. Further details regarding the sociodemographic characteristics of the participants included in the study are shared in Table 1.

Only 68 (17.3%) participants had received counseling for family planning in the past two years, with over half of the respondents (52.5%) using no regular form of family contraception, followed by the use of condoms (33.9%) and withdrawal (12.1%).

Table 1 Socio-demographic characteristics of participants presenting to outpatient clinics
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ECP knowledge and associated factors

136 (34.6%) respondents were aware of the existence of ECPs, while 142 (36.1%) had heard about the morning-after pill. The mean ECP knowledge score of all the respondents was 2.32 ± 2.52 out of 15, with men and women displaying an average score of 1.93 ± 2.46 and 2.54 ± 2.54 respectively. Only one (0.25%) participant demonstrated high knowledge, 55 (14.0%) demonstrated a moderate level of knowledge, while the rest of the 337 (85.8%) participants displayed a low level of knowledge regarding ECPs. Table S1 in the supplementary file additionally presents each question alongside the number of correct responses.

Knowledge regarding ECPs was not found to be significantly associated with gender (p = 0.268, χ2 = 1.2271), age (p = 0.096, χ2 = 2.7724), employment status (p = 0.353, χ2 = 0.8624) or parity (p = 0.301, χ2 = 1.0709). However, respondents who had previously received counseling for family planning (p = 0.017, χ2 = 5.7410), or who were currently using any method of contraception (p = 0.004, χ2 = 8.2163) were significantly more likely to have a higher knowledge score. Furthermore, participants who were aware that post-coital prevention of pregnancy is possible (p < 0.001, χ2 = 18.8006) and those who expressed their willingness to use ECPs in the future (p < 0.001, χ2 = 17.1237) were also significantly associated with having higher knowledge scores. Table 2 provides a summary of all chi-square associations and their results between ECP knowledge among respondents and various other factors.

Table 2 Associations between ECP knowledge and various sociodemographic factors among study participants
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ECP usage and practices

ECPs were utilized by 43 (11.1%) participants. These participants cited various reasons for ECP usage including unprotected sexual intercourse (28), possible contraception failure (7), incorrect usage of contraceptives (6), and rape or sexual assault (2). Amongst those who had used ECPs, 21 respondents reported a singular use whereas 22 had used them twice or more. 96 individuals expressed their intent to utilize ECPs in the future if the need were to arise. Table 3 delves into further detail regarding the practices in the utilization of ECPs among the study population.

Table 3 Practices in the utilization of ECPs amongst study participants
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Barriers to ECP usage

Among the respondents, only 83 individuals (21.7%) felt that they had sufficient information about ECPs. Additionally, 221 (58%) of the respondents expressed concerns about the potential side effects of ECP usage, 128 (33.9%) believed that using ECPs contradicts their moral and religious values, and 104 (28.1%) felt that their spouses would not permit the use of ECPs. 80 participants (20.9%) believed that ECPs function as abortifacients. Moreover, 153 (40.4%) of the respondents believed that if a pregnancy occurs after using ECPs, it could result in harm to the baby. Complete detail regarding perceived barriers to ECP use is provided in the supplementary file, table S2.

Discussion

This study reports data on 393 participants who presented to the Aga Khan University Hospital and its secondary centers. It was found that a mere 14.2% of our study population had high or moderate knowledge, while the vast majority (85.8%) had low knowledge regarding ECPs. Additionally, despite there only being a total of 68 (17.3%) individuals in our study who had received counseling for family planning in the past 2 years, a significant association was found between such individuals and their knowledge regarding ECPs. This finding is of utmost significance, as it highlights the importance of family planning especially when considering Pakistan’s many unsuccessful attempts at controlling population growth through various large-scale programs and subsidized, or often, free contraceptives as this strongly indicates a lack of awareness.

It is also crucial to understand that spreading awareness about ECPs and ensuring its availability in Pakistan may not be as straightforward as in many developed countries. Results from our study showed that 81.4% of couples obtained ECPs from pharmacies or drug stores directly, as compared to only 9.3% from hospitals and clinics. A study in 2012 revealed that 84% of Pakistani women identified Lady Health Workers (LHWs) as their primary source of information regarding ECPs. In contrast, advertisements, government facilities, and private clinics contributed as a source of information for less than 10% of the study population [14]. This disparity stands in stark contrast to numerous developed countries where the primary source of information about ECPs typically involves healthcare providers such as physicians and clinics, as well as government-mandated advertisements and reliable online resources on the internet [23].

Furthermore, whilst being one of the most economically volatile nations globally, Pakistan also faces the risk of an impending population surge. Pakistan has one of the highest annual population growth rates at 1.9% and is set to replace Indonesia as the fourth most populous country in the world by 2030 [24]. This demographic upsurge can be attributed to a variety of factors, including but not limited to low literacy rates and awareness, economic instability, and established religious and societal norms against family planning.

It is crucial to acknowledge that men play a significant role in the family dynamics of a Pakistani household. A substantial number of women in Pakistan lack the autonomy to make pivotal reproductive choices, including the choice to use contraception [25]. ECPs serve as a vital resource for such women and for many such individuals, for whom an emergency contraceptive pill taken post-coitally might be the only method to prevent a pregnancy. Similarly, a study done in Syria in 2024, another developing country, revealed nearly 64% of men, despite holding a university degree or higher, had limited knowledge regarding ECPs. This finding is of considerable concern, particularly in societies like Pakistan, where men often make key reproductive decisions [26].

Similarly, this study also highlights a matter of utmost importance: knowledge regarding ECPs, or even other methods of contraception, is not significantly associated with seemingly influential factors such as socioeconomic status or the level of education. This further signifies a need to spread awareness about ECPs comprehensively across the board, encompassing people of all socioeconomic classes and educational levels.

A similar study conducted in a single teaching hospital in Karachi almost 15 years ago showed that only 40 out of 400 women (10%) were aware that postcoital prevention of pregnancy was possible, of which only 13 (3.25%) had ever used ECP [5]. In comparison, 170 (48.9%) individuals in our study were aware of postcoital prevention of pregnancy and 43 (11.1%) had used ECP previously. These figures suggest a notable, albeit insufficient, improvement in the awareness and usage of ECPs which can be partly attributed to the amplified presence of social media and the overall increased access to knowledge about ECPs through various platforms. However, further research and investigations are needed to ascertain the level of impact through governmental policies and advertisements on family planning, the various working NGOs and the increased availability of ECPs.

As highlighted by the results of this study, various myths and misconceptions surrounding the numerous side effects, religious and moral beliefs, the legality and availability of these pills and their possible role in abortion in already pregnant women further diminish the appeal of ECPs amongst the public. Previous literature stands in line with our findings and indicate that these trends are far more noticeable in numerous low and low-middle-income countries such as Ethiopia, Muslim countries like Kuwait and Egypt, and South Asian countries such as India and Bangladesh [27,28,29]. To navigate this situation and take further steps toward improvement, the involvement of physicians, nurses, teachers, and local and religious leaders is of paramount importance. It is only with firm support from the community decision-makers that population-wide interventions, such as large family planning programs, can be implemented successfully.

A few limitations must be acknowledged when interpreting the findings of this study. A considerable number of participants declined to participate during the data collection phase. The primary reasons for refusal included time constraints, disapproval from spouses, and moral or religious objections to the study. These refusals may have resulted in skewing our participant pool towards those with specific views or experiences related to ECPs. However, despite this, a substantial portion of our study population exhibited strong religious influence, with many holding negative views on the use of ECPs. Furthermore, the collection of data exclusively from only four private hospitals may have introduced selection bias, as it excluded individuals who primarily seek healthcare services in public hospitals or local primary care clinics. This may also have inadvertently excluded marginalized or underserved populations facing distinct barriers to ECP access. Consequently, these results may not comprehensively mirror the diverse experiences and perspectives regarding ECPs within the broader community. However, these concerns were mitigated to some extent through the representation of all socioeconomic strata and by the stratification of the participants accordingly. Similarly, 70% of our participants had at least a college degree or more. In a country where the literacy rate barely reaches 58%, our sample pool lacks comprehensive representation of the educational status of the Pakistani population [30]. The administration of questionnaires in only English and Urdu also led to the underrepresentation of some linguistic and ethnic groups such as Sindhi and Pashto and may have potentially impacted the study’s inclusivity. Lastly, due to the brief 10-day data collection period, potential biases may exist including, but not limited to, seasonal or temporal variations in patient visits or behavior.

Conclusion: Our study in Karachi, Pakistan, highlights critical challenges in ECP awareness and family planning. Although the results show improved ECP use than studies done in most LMICs and previously reported data from Pakistan, there is a further need to increase the reach of ECPs. Effective counseling and education regarding family planning, encompassing comprehensive information about diverse contraceptive methods and their proper utilization, stand as the primary means towards achieving informed decision-making amongst couples. Persistent myths and misconceptions hinder ECP adoption, hence the involvement of healthcare professionals and religious leaders is of utmost importance.