Unintended pregnancy is a major public health problem in Nicaragua. Although the country's estimated total fertility rate dropped from 3.9 in 1998 to 2.7 in 2006–2007,¹ about one in six pregnancies are still unwanted. Unintended pregnancy in Nicaragua is particularly problematic among adolescents, whose annual fertility rate of 109 births per 1,000 15–19-year-olds² is the highest in the Americas (the World Health Organization region comprising South, Central and North America), where the average is 61 births per 1,000 adolescents.² Approximately half of young Nicaraguan women give birth before age 20, and 45% of their births are unintended, regardless of their educational background or whether they live in urban or rural areas.³

Several aspects of life in Nicaraguan society contribute to high unintended fertility. First, women are subordinate to men⁴ and are at risk for sexual violence⁵ and unexpected, undesired and unprotected intercourse.⁶ This makes it difficult for women to control their fertility, as does their partners' refusal to use certain contraceptive methods, like condoms.⁷ Second, although Nicaraguan society often encourages young men to have premarital sex, it disapproves of young women doing so.⁸ Thus, many young unmarried women do not seek contraceptive and reproductive health services because they fear disclosing their sexual activity.⁸ In 2006, almost half of sexually active young women in Managua who were not pregnant and had no children had never used a contraceptive method.⁹

Third, Nicaragua bans abortion. In 2006, it became one of the few countries in the world where abortion is illegal even in cases of rape or a pregnancy threatening the woman's life. In part because of the Catholic Church's strong political influence, all proposals to legalize therapeutic abortion have been rejected.¹⁰ Since November 2007, the Nicaraguan penal code has punished abortion providers with up to eight years in jail, and women seeking abortion with a maximum of two years.¹¹

Moreover, when abortion is illegal, women with unwanted pregnancies may turn to providers who are untrained or work in unsanitary conditions. Unsafe illegal abortion increases maternal morbidity and is a major factor in Nicaragua's maternal mortality ratio¹⁰ of 170 per 100,000 live births,² which is far higher than the regional average of 99 per 100,000.²

To reduce unintended pregnancy and improve reproductive health in Nicaragua, women need better access to reproductive health care services, including contraceptives.¹² However, existing reproductive health care centers often lack qualified staff and a place to provide confidential counseling; thus, many Nicaraguan females face provider-related obstacles in obtaining such services and in receiving quality information and counseling regarding sexual health care or contraceptive methods.¹²

Emergency contraceptive pills are important in helping women avoid unwanted and unintended pregnancy.^13,14 This hormonal contraceptive method acts by inhibiting or delaying ovulation or by preventing fertilization of an egg.¹⁵ In addition, emergency contraceptive pills do not have any contraindications.¹⁶ The method gives women—who can use it without men's cooperation or knowledge—the ability to prevent pregnancy after having unprotected intercourse (whether because of nonuse or contraceptive failure).

Although Nicaragua's Ministry of Health recommends the use of emergency contraceptive pills as a postcoital contraceptive method in the national family planning guidelines, the Catholic Church claims that they are abortifacients⁶ whose sale and use should be prosecuted.

According to WHO, however, the method is not an abortifacient; it is not effective once the process of implantation has begun, and it does not harm the mother or the fetus.¹⁷ Although repeated use of emergency contraceptive pills would increase side effects, such as menstrual irregularities, they pose no known health risks.¹⁷ However, emergency contraceptive pills should not be a woman's main method because they are not as effective at preventing pregnancy as modern contraceptives intended for ongoing use.¹⁷

WHO lists emergency contraceptive pills as an essential medicine that should always be available and accessible.^18,19 Emergency contraceptive pills are included in Nicaragua's family planning guidelines,²⁰ and several dedicated emergency contraception products are registered and available in the country. However, emergency contraceptive pills are not offered by Nicaragua's public health care services, which provide treatment and distribute drugs for free; they are available only in the private health care sector.

Private pharmacies are the main providers of emergency contraceptive pills, which sell for US$2–3 with or without a prescription. Pharmacies keep long, flexible hours, including evenings and weekends, a practice that helps women obtain emergency contraception quickly.²¹ Pharmacies also offer an informal atmosphere in which women can obtain drugs and private health care counseling without revealing their identity²¹ and are preferred by girls who do not yet have children.⁹ According to Meuwissen et al., the majority (63%) of sexually active 11–20-year-old females in Nicaragua who are not mothers prefer to purchase their modern contraceptives in pharmacies, whereas public health services are the most common supplier of contraceptives among females who already have children (76%).⁹ Although both public health services and private pharmacies serve important functions by helping women avoid unintended pregnancy, pharmacies are especially likely to meet the needs of female adolescents, who face the highest risk of unintended pregnancy, by giving them quality reproductive health care counseling and emergency contraceptive pills.

Pharmacy personnel's knowledge and attitudes regarding emergency contraceptive pills can influence access to them, as well as their use and availability.¹⁴ Studies in other settings^22–26 have revealed that lack of knowledge and negative attitudes among pharmacy and health care staff may obstruct women's access to emergency contraception. For instance, pharmacists in Jamaica and Barbados were found to lack specific knowledge about emergency contraceptive pills and overestimated their contraindications and side effects.²² Moreover, emergency contraception providers in these two countries thought that the method could encourage sexual risk-taking and lead to an increased incidence of STIs.²² Until now, little has been known about Nicaraguan pharmacy staff's awareness of emergency contraceptive pills or the way they store and sell them. The objective of this study is to identify possible barriers to Managuan women's access to these essential drugs by examining pharmacy staff's knowledge and attitudes.

METHODS

This cross-sectional descriptive survey was conducted in August and September 2009 in Nicaragua's capital, Managua. We obtained an updated list of all licensed and operating city pharmacies from the Ministry of Health. A total of 681 pharmacies were registered, but we excluded 16 from this study because members of the public could not use them without prior medical consultation. Using random sampling, we selected 100 pharmacies and compiled a replacement list of 20 pharmacies. We replaced nine of the originally selected pharmacies because they could not be found at the address provided or had recently closed down; pharmacies in which no staff members were willing or able to participate after three visits were not replaced.

We used a semistructured questionnaire to determine pharmacy personnel's social and demographic characteristics, the availability of emergency contraceptive pills in the selected pharmacies and pharmacy personnel's selling practices, as well as their knowledge of and attitude toward emergency contraceptive pills. The final open question gave interviewees the possibility for feedback and additional personal comments. The instrument was a modified version of a questionnaire that was used in a similar study conducted in Jamaica and Barbados.²² The questionnaire was adapted to the Nicaraguan setting, translated into Spanish, proofread by local assistants and pilot-tested in the field with pharmacy personnel who were not included in the final survey.

Data collection was conducted by two trained local assistants, who visited the sampled pharmacies up to three times during workdays and main hours of operation. Pharmacy staff were informed about the purpose of the survey and asked to recommend an employee for participation. We conducted all face-to-face interviews only after having received participants' informed verbal consent. Interviews lasted approximately 20–30 minutes. Afterward, all participants received informational material about emergency contraceptives.

Data analysis was carried out using SPSS statistical software version 13.0. We used descriptive statistics to examine the frequency of responses, and cross-tabulations to explore differences in responses between the male and female pharmacy staff we interviewed. An ethics committee of the National Autonomous University of Nicaragua reviewed this study and its instrument and granted ethical approval in July 2009.

RESULTS

A total of 93 interviews were conducted and completed. In seven pharmacies, none of the present staff members wanted to participate during any of our three visits: In four, none of the staff members were willing to take part because they had no time; in three, personnel did not wish to share their opinion because the topic was sensitive.

Most participating personnel were female (65%, Table 1, page 68). Participants' ages ranged from 17 to 60, with a mean of 34. Most interviewees were either dispensary assistants (47%) or pharmacists with a university degree (24%); 15% had no pharmaceutical training. The average length of work experience among pharmacy personnel was 7.5 years, with a range of four months to 30 years. Fifty-three percent of study participants were Catholic, and 27% were Protestant.

Stocking and Selling Practices

Ninety-one pharmacies (98%) had at least one emergency contraceptive product available at the time of our visit (Table 2). The two pharmacies that did not store emergency contraceptive pills reported that they had stopped selling them because of recent criticism from the Catholic Church.

All 93 participants reported having sold at least one national emergency contraceptive pill product. The vast majority (92%) sold emergency contraceptive pills at least once a week, mainly by request to customers without a medical prescription (97%). Given that two (2%) of the staff worked at pharmacies that had stopped selling emergency contraceptive pills and five (5%) sold them less than once a week, at least 29 (81%) of the 36 staff who believed that the pills cause abortion (39%) sold the method at least once a week (not shown). None of the interviewees generally sold the pills on their own recommendation. Only 36% provided informational material to customers who purchased emergency contraceptive pills.

Knowledge about Emergency Contraceptive Pills

All interviewees knew about emergency contraceptive pills, and 50% had received information about the method in the past year (Table 3, page 70). Their main source of information was the pharmaceutical industry (60%); only 9% of pharmacy staff had received information from the Ministry of Health. Still, 79% of participants were aware that the pills should be taken after unprotected sexual intercourse, but fewer than half (45%) of these knew that emergency contraceptive pills can be taken up to three days after unprotected sex. None was aware that the pills can be taken up to five days after unprotected intercourse,²⁷ as recommended in Nicaragua's family planning guidelines.²⁰ More than half of the participants (59%) knew that emergency contraceptive pills only prevent pregnancy; however, 5% thought that emergency contraceptive pills could induce abortion, and 33% believed they could both prevent pregnancy and induce abortion. Almost half of the interviewees (47%) mistakenly believed that emergency contraceptive pills are 100% effective, and 25% stated that they are a contraceptive method for ongoing use (not shown).

The majority of participants (85%) believed that females younger than 16 or women who had used the pills in the last month (62%) could not safely take the pills (Table 4). Only 2% of study participants knew that breast-feeding women can use the method. Fifty-seven percent of interviewees incorrectly believed that emergency contraceptive pills could cause congenital malformations and 85% thought that they could lower women's fertility.

Attitudes Regarding Emergency Contraception

The majority of the participants stated that the availability of emergency contraceptive pills encourages sexual risk-taking (82%), increases HIV and STI transmission (76%), discourages the use of ongoing contraceptive methods (75%) and fosters abuse of the method or its repeated use (74%). However, 68% maintained that emergency contraceptive pills are necessary to reduce unintended and unwanted pregnancies (Table 5).

The majority (65%) of personnel were willing to provide the method to any woman who requested it, regardless of the circumstances; 84% were willing to provide emergency contraceptive pills to men who requested the method for their partner (Table 6, page 72). However, few (13%) expressed willingness to sell the method to minors without parental consent. Fifty-nine percent were ready to provide emergency contraceptive pills to women in advance and 50% said they would sell the pills to a woman more than once in a menstrual cycle (not shown). Nevertheless, only 23% reported being willing to sell emergency contraceptive pills to a woman more than five times a year. Most interviewees (69%) wanted emergency contraceptive pills to be available only with a prescription (Table 6), and 59% felt somewhat or very uncomfortable dispensing the pills without one (not shown). Their concerns about nonprescription access were repeated use, easy access for adolescents and the possibility that a woman might use the pills without a proper medical consultation.

Differences in Responses Male vs. Female Pharmacy Staff

For the most part, the study found minimal gender differences (not shown) in participants' knowledge and perception of emergency contraceptive pills. However, much greater proportions of women than of men knew that the pills could be taken within 72 hours after unprotected intercourse (43% vs. 21%), and that they work by preventing pregnancy (65% vs. 48%). Nevertheless, men were more willing than women to provide emergency contraceptive pills to minors (18% vs. 10%).

DISCUSSION

All 93 pharmacy personnel claimed to be aware of emergency contraceptive pills and to have had experience selling emergency contraceptive products. Thus, the level of awareness and experience selling the method was greater than that of providers in other settings.^23–25 The frequency of sales of emergency contraceptive pills in Managua's pharmacies substantially exceeded sales in similar pharmacy surveys in the Caribbean and Kenya.^22,24

Although most of the pharmacies stored and sold emergency contraceptive pills, two had decided to stop storing or selling them because of opposition from the Catholic Church. However, at the time of this study, the Ministry of Health did not plan to remove emergency contraceptive pills from the national family planning guidelines.

Despite their awareness and frequent sales of emergency contraceptive pills, pharmacy staff lacked specific knowledge about them, and this knowledge gap could lower the quality of counseling that users receive. For example, only about one-third of all interviewees knew that emergency contraceptive pills can be taken up to 72 hours after unprotected intercourse. Managuan pharmacy personnel's knowledge about the time frame in which the method is most effective was much lower than that of pharmacists in Jamaica and Barbados²² (45% vs. 93% and 70%).* This lack of knowledge constitutes a barrier to emergency contraceptive pill use for women who go to a pharmacy within 72 hours after unprotected intercourse, but are erroneously informed that the pills would no longer be effective. The gender difference in knowledge about when to take emergency contraceptive pills suggests that women have more personal experience and interest regarding contraceptive issues overall.

Managuan pharmacy personnel also had less knowledge about how the pills work than did their counterparts in Jamaica²² and Kenya:²⁴ Only 59% knew that the pills work by preventing pregnancy. That 39% of interviewees thought that the method could induce abortion might reflect exposure to the campaign mounted by the Catholic Church shortly before our survey. Given that inducing an abortion in Nicaragua can be punished by imprisonment,¹¹ and that these respondents believed that emergency contraceptive pills could cause abortion, it is surprising that most of them sold the method at least once a week. Their lack of understanding about how the method works, amid a high demand for it, might explain personnel's discomfort with dispensing it without a prescription. Because pharmacy staff depend on the sale of drugs for their financial livelihood, they might feel economically pressured to sell emergency contraceptive pills.

As surveys in other settings have demonstrated,^22,23 most of Managua's pharmacy staff exaggerated emergency contraceptive pills' contraindications and side effects, which could discourage use among some women. More than half of participants thought that emergency contraceptive pills could cause congenital malformations, and more than 80% believed the pills could lower women's fertility. Despite WHO's assertion that emergency contraceptive pills have no contraindications,¹⁶ more than 90% of interviewees thought that breast-feeding was contra- indicated, possibly because the package leaflet of the leading brand mentions that the product is not recommended during lactation.

Information from the emergency contraceptive pill manufacturer stating that the product is not recommended before menarche might also have influenced pharmacy staff, 85% of whom said that the pills were contraindicated for adolescents younger than 16; unwillingness among 82% to sell the method to minors without parental consent indicates that adolescents could face problems obtaining emergency contraceptive pills from pharmacies. Thus, despite their need for postcoital contraceptives, adolescent girls face access problems both from public providers, as an earlier study in Managua found,²⁸ and from private providers, such as pharmacies. Research from South Africa,²⁶ Jamaica and Barbados²² suggests that substantial proportions of health care providers in those countries also deny adolescents access to emergency contraceptive pills.

Pharmacies are important providers of contraceptives for teenagers, and one in six pharmacies sold emergency contraceptive pills mainly to adolescents. This method—which could help reduce the high rate of unintended adolescent pregnancy in Nicaragua—could allow teenagers to avoid such pregnancies without the knowledge of parents or other family members who might disapprove of premarital sexual activity. Nevertheless, pharmacy personnel did not support teenagers' use of emergency contraceptive pills and most disapproved of the method's over-the-counter availability, lest adolescents abuse it.

That pharmacy staff were most willing to sell emergency contraceptive pills to men who requested the method for their partner might be a reflection of Nicaragua's gender issues and men's dominant role within society. It also might reflect pharmacy personnel's support and appreciation for men's collaboration in contraceptive issues. Pharmacists in Jamaica and Barbados were less willing to sell the method to men (44% and 50% vs. 84%).²²

Overall, the majority of study participants expressed negative attitudes toward emergency contraceptive pills. They were particularly concerned that the pills' availability might encourage sexual risk-taking—including lack of condom use—and increase the transmission of HIV and other STIs.

This study has several limitations. The results cannot be generalized to any other urban or rural area in Nicaragua, since Managua's level of health care services and medical knowledge is the highest in the country. Also, knowledge and certain attitudes among pharmacy personnel who declined to participate in the study may differ from those of the respondents. Finally, interviewees might have provided the answers they thought the researchers wanted to hear instead of those that reflected their performance and behavior in daily practice.

CONCLUSION

Managuan pharmacies have frequent contact with Nicaraguan women in need of emergency contraception and play an important role as providers of emergency contraceptive pills and reproductive health care counselors. They also would be an ideal source for educational material, which they currently do not provide. Consequently, pharmacies are uniquely positioned to help tackle such public health problems as unintended pregnancy and the high adolescent fertility rate.

However, educational campaigns are needed to ensure a high level of knowledge about emergency contraceptive pills among pharmacy staff, so that women, particularly adolescents, who need the method can receive quality counseling and access to it. Pharmacy personnel should be informed about and involved in the planning and implementation of national recommendations and strategies regarding sexual and reproductive health.

Finally, educational campaigns about sexual health and gender issues should target teenagers and include information about contraceptive options, HIV and other STIs and the importance of condom use.