Adolescents’ access to emergency contraception in Africa: An empty promise?

1 Introduction

Governments the world over increasingly realise the necessity of paying attention to the rights and needs of adolescents. Consequently, they have committed themselves at international human rights fora to prioritising programmes aimed at adolescents’ development and wellbeing, particularly their educational and health needs.1 Such programmes include those focused on adolescents’ sexual and reproductive health,2 and are aimed at enabling adolescents to manage in a positive manner their awakening sexuality. African countries, too, have focused their efforts on adolescents and, consequently, various African regional human rights instruments3 emphasise the right of adolescents to access sexual health care information and services, including those relating to emergency contraception.

Adolescents in sub-Saharan Africa face numerous sexual and reproductive health hazards, including unintended pregnancies; unsafe abortions; and sexually-transmitted infections (STIs)4 as a result of their involvement in early - and often unprotected - sexual activity.5 In addition, approximately 40 per cent of all pregnancies worldwide are unintended, with higher unintended pregnancy rates in African countries.6 In a review of the sexual and reproductive health and rights of adolescents in nine countries in sub-Saharan Africa,7 it was noted that adolescents in the region are particularly vulnerable to sexual and reproductive health issues such as high adolescent birth rates.8 According to the review, sub-Saharan Africa contributes over 50 per cent of the global adolescent birth rate, as well as over 23 per cent of the burden of diseases associated with pregnancy and child and maternal ill-health.9 Consequently, these adolescents’ education and livelihood options are negatively affected.10 Unintended pregnancies among adolescents, therefore, represent a major health challenge in many African countries.

The high level of unintended pregnancies in Africa is associated with a low level of contraceptive use in the region, especially among adolescent girls who not only face significant discrimination and inequality when accessing contraceptive information and services, including particular information on where and how to access emergency contraceptives,11 but who also frequently are victims of sexual assault and violence. 12

The poor sexual health outcomes associated with adolescence in sub-Saharan Africa are discouraging as, in theory, adolescents are ‘protected’ and guaranteed access to contraceptive information and services, including emergency contraceptives.13 While emergency contraception does not protect against STIs, unhindered access to it is an important tool in the prevention of unintended pregnancies among adolescents - especially pregnancies resulting from sexual violence - and consequently lends protection against sexual ill-health and maternal mortality.14

In relation to emergency contraception, specifically, Williams reports that the dearth of knowledge about relevant sexual and reproductive health care services by women and adolescent girls in sub-Saharan Africa indisputably hinders the demand for emergency contraception as women’s awareness of this contraception continues to be below 10 per cent in Senegal and Zambia.15 According to Williams, even in countries such as Kenya, where reports reveal high levels of awareness of the method, the actual use of emergency contraception remains low.16

Because of these alarming statistics, African governments have resolved to integrate emergency contraception into their family planning service delivery policies and guidelines,17 and many governments offer the contraceptive method in public sector services.18 Further, adolescents’ access to emergency contraception is premised on the obligation of state parties to human rights instruments to guarantee to adolescent girls the right to enjoy the highest attainable standard of health through their access to sexual health care services and information and, indeed, their right to choose their preferred method of contraception.19 Also based on the provisions of human rights instruments, African governments are compelled to ensure that emergency contraceptives not only are accessible, but that they are affordable and readily available to adolescents.

Despite these guarantees in human rights instruments,20 emergency contraception remains largely inaccessible. In light of this, the article analyses obstacles in the way of adolescent girls’ access to emergency contraception in sub-Saharan Africa, specifically focusing on the access to emergency contraception of adolescent girls in Nigeria. Selected comments by treaty-monitoring bodies, including those of the African Committee of Experts on the Rights and Welfare of the Child (African Children’s Committee), are analysed in order to support arguments for African adolescents’ access to emergency contraception in the promotion of their rights to sexual and reproductive health care. In addition, methods that may be adopted in overcoming obstacles to the use of emergency contraceptives are examined in order to determine whether they may be helpful in ensuring adolescents’ access to emergency contraception on the African continent.

Below we begin with a description of emergency contraceptives and their use.

2 What is emergency contraception?

Emergency contraceptives are contraceptives that can be used to prevent pregnancy during the first few days after intercourse.21 Often referred to as the ‘morning-after pill’, emergency contraceptives prevent ovulation or fertilisation and are intended for emergency use following unprotected intercourse, contraceptive failure or incorrect use,22 rape or coerced sex.23

The emergency contraceptive pill may be taken up to 72 hours24 after unprotected sex, but is more effective when used within the first 24 hours after sexual intercourse.25 While emergency contraceptives should not replace the oral contraceptive pill which is taken daily, the emergency contraceptive pill may be taken by any girl or woman in order to avoid an unwanted pregnancy.26

In use since the mid-1960s, emergency contraception initially was developed to treat rape victims in order to prevent unintended pregnancies.27 In the early 1970s, the Yuzpe regimen - a combination hormone formula - replaced the high-dose oestrogen emergency contraceptive methods of the 1960s and became the gold standard of treatment for post-coital contraception.28 During this period the copper intra-uterine device (IUD) was also introduced and used by health care providers as the only non-hormonal method of emergency contraception to date.29 Although it is an effective form of emergency contraception as it is able to prevent pregnancy for up to five days after unprotected intercourse, the copper-releasing IUD usually is not recommended for use in adolescents. 30

Regarding the importance of emergency contraception, the Planned Parenthood Organisation explains that it provides women (and adolescent girls) with a second chance to prevent pregnancy in cases of unanticipated sexual activity, contraceptive failure or sexual assault.31 Likewise, Babatunde remarks that emergency contraception is a safe, effective and relatively inexpensive means of preventing unplanned pregnancies after unplanned or unprotected sexual intercourse.32 According to him, especially because of their earlier and often unplanned initiation into sexual activities, the use of emergency contraceptives in adolescence is particularly appropriate as adolescents often engage in sporadic and occasional sexual encounters which pose a serious challenge to their sexual health. 33

In addition to providing a second chance to prevent unwanted pregnancies, emergency contraception has been proven safe and effective. It has no long-term effects on the health of the adolescent girl or woman, and does not affect future fertility or increase the risk of ectopic pregnancies.34 The Planned Parenthood Organisation explains that two factors influence the effectiveness of the use of emergency contraception, namely, the length of time that elapses after unprotected intercourse; and at which stage during the menstrual cycle of the woman or adolescent it is used. When taken during the first few days after unprotected intercourse this form of contraception is most effective. Also, the closer a woman is to ovulation at the time of unprotected intercourse the less likely the method is to succeed.35 However, emergency contraception is not as effective as the consistent use of other regular contraceptive methods,36 neither does it protect against STIs and HIV.37

We now move on to present a brief outline of guarantees in human rights instruments of the SRH rights of adolescents. Because of the focus of the article, we highlight the rights of female adolescents.

3 An overview of adolescents’ sexual and reproductive health rights

[A]s a matter of policy, the sexual and reproductive health of adolescents matter because they comprise almost one half of the world's population. As a matter of international human rights law, adolescents have reproductive and sexual health rights.38

The period of adolescence is critical: Adolescents transition from being dependents to being providers; and adolescents’ health and sexual choices during the period to a large extent shape their futures.39 In fact, improvements in the sexual and reproductive health status of a region over time depend on the degree to which governments invest in adolescent sexual health.40 The situation is particularly tendentious in the case of adolescent girls as they are constantly faced with peer pressure to engage in early sexual relations,41 and also often are victims of sexual violence.42

Internationally, apart from the Universal Declaration of Human Rights (Universal Declaration) and other human rights instruments generally recognising the right of everyone to the highest attainable standard of health,43 children’s rights to sexual and reproductive health were given the status of legally-binding international law with the adoption by the United Nations (UN) Convention on the Rights of the Child (CRC) on 20 November 1989.44 In 1994, at the International Conference on Population and Development (ICPD),45 governments from all over - including Africa - acknowledged the need to recognise adolescents’ sexual and reproductive health rights.46 Following the lead of the ICPD, several additional international declarations have urged governments to commit to the realisation of adolescent sexual and reproductive health rights through their access to quality sexual and reproductive health care services.47

According to Durojaye the adoption of a rights-based approach to realise the rights of adolescents to emergency contraception is necessary as it creates an avenue for holding governments accountable for the fulfilment of adolescents’ sexual rights under international and regional human rights law. 48

In Africa the right of adolescents to sexual and reproductive health care - specifically their right of access to emergency contraception - may be inferred from the right to health as recognised in article 16 of the African Charter on Human and Peoples’ Rights (African Charter),49 and articles 14(1), 14(2)(b) and 14(2)(f) the African Charter on the Rights and Welfare of the Child (African Children’s Charter).50

Additional rights that are necessary for the enjoyment of adolescents’ rights to access emergency contraceptives include the rights to equality (non-discrimination); life; dignity; privacy; information; and education,51 also guaranteed in these instruments. Particularly, article 11(2)(h) of the African Children’s Charter makes provision for the ‘direction of the education of children towards their understanding of primary health care’. This provision is such that it may be interpreted to accommodate giving adolescent girls information regarding emergency contraceptive services, as the provision of advice on family planning and contraception constitutes a part of primary health care services. Also, the right to privacy protected in the African Children’s Charter52 is of paramount importance in guaranteeing the protection of the sexual health of adolescent girls in the region. This is so because assurances that their privacy will be protected positively influence adolescent girls’ readiness to access emergency contraception where available.53

In addition to the above, the African Children’s Charter contains three major guarantees which influence adolescent girls’ access to emergency contraception in Africa: the best interests of the child;54 the right of the child to participate in decisions affecting them;55 and the ‘evolving capacities of the child’ concept.56 With the inclusion of these provisions, the Children’s Charter demonstrates an acceptance that adolescent girls not only mature at different rates, but that they attain various levels of competence and insight as they grow. Also, it is these levels of competencies that must be considered when adolescent girls require confidential information on emergency contraception or about the services themselves.

Despite these admirable provisions, a major criticism of the African Children’s Charter is that it fails adequately to protect the rights of female children in the region because of the gender-insensitive manner in which some of its provisions are couched, thereby trivialising ‘adolescent girls’ sufferings’.57 The adoption in 2003 of the Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa (African Women’s Protocol),58 which focuses on issues that hitherto have not been addressed, and which indirectly domesticates the Beijing Declaration and the ICPD

Programme of Action in the African region,59 was aimed at correcting criticisms of gender insensitivity levelled against the African Children’s Charter. The African Women’s Protocol did this through its proactive inclusion of adolescent girls as among the women whom it protects.60 Viljoen notes that although the African Women’s Protocol was drafted as an addition to the African Charter, unlike its international counterpart, the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW), the African Women’s Protocol expands on the protective scope of women’s rights as it addresses concerns that are particular to African women. 61

Article 14 of the African Women’s Protocol protects the sexual and reproductive health of all women and affirms their right to reproductive choice and autonomy.62 In relation to adolescent girls’ rights to access emergency contraceptive information and services, it recognises the rights of adolescent girls to control their fertility;63 to choose any method of contraception;64 and to access family planning education.65 It also recognises the obligation that African governments adopt all appropriate measures to provide adequate, affordable and accessible health services and information.66 Thus, with the inclusion of these provisions, the African Women’s Protocol actively promotes the recognition of adolescent girls’ rights to access information and services on emergency contraceptives in order to prevent unplanned pregnancies.

4 Nexus between adolescents’ sexual and health rights and their access to emergency contraception

As explained above,67 the connection between good sexual health practices by adolescents and their access to sexual and reproductive health care information and services - especially contraceptive information and services, including emergency contraceptives - has received increased attention during over recent decades, with international and regional bodies pledging their commitment towards the recognition of adolescents’ rights to access sexual and reproductive health care as a means of fulfilling other rights and meeting development needs.68 Thus, attention to the sexual and reproductive health of adolescent girls is closely associated with the need to eradicate poverty and inequality which affect many girls, as a lack of access to sexual and reproductive health care education - including important information on where to access emergency contraceptives - cause female adolescents to bear the brunt of society’s negligence by giving birth to unplanned and unwanted children.69

The importance and relevance of realising adolescents’ sexual and reproductive rights in the context of reducing poverty are similarly recognised in the AU Commission’s Continental Policy Framework for the Promotion of Sexual and Reproductive Health and Rights in Africa (Continental Policy Framework).70 The Continental Policy Framework expressly recognises the connections between poverty and sexual and reproductive health, as well as their importance to sustainable development. 71

In sub-Saharan Africa, as in the rest of the world, the protection of adolescents’ sexual and reproductive health through their access to contraceptive services and information (including emergency contraception) not only generates concern among stakeholders, but also continues to be a constant subject of government policies and programmes due to the spread of HIV and unintended teenage pregnancies in many African countries.72 These stakeholders either canvass for the restriction of adolescent girls’ access to contraceptives and other sexual and reproductive health care information or services, or champion the increase of their access to the life-saving information and services.73

An important issue connected to adolescent girls’ sexual health and rights to access emergency contraception relates to the recognition of their autonomy.74 Representing an increasing segment in many societies,75 adolescents encounter various transitions, including the development of the identity; the acquisition of skills; and a move towards social and economic independence.76 In addition, increased physical and sexual maturity leads to the start of sexual activity.77

However, the initiation of sexual activity, especially in Africa, gives rise to problems associated with adolescents’ rights to access emergency contraception, in particular, and contraceptive information and services, in general. This is so because various stake-holders, including parents, tend to fight for control over the right to determine adolescents’ sexual health needs, thus putting them in danger of sexual ill-health and unplanned pregnancies.78 Tied to this struggle for control is the realisation that it is in the best interests of adolescent girls to recognise their autonomy and for them to access emergency contraceptives in confidential and adolescent-friendly environments in order to guarantee good sexual health outcomes.79

In Gillick v West Norfolk and Wisbech Area Health Authority & Another,80 the court held that a doctor would not be acting unlawfully if he gave contraceptive advice or treatment to an adolescent who is ‘Gillick competent’.81

Another means of achieving adolescent girls’ access to emergency contraceptives involves the adoption of approaches that guarantee access to factual sexuality information coupled with access to affordable and accessible emergency contraceptive services in general.82 In a review of emergency contraception literature from various countries - including developing countries - Family Health International notes that in all countries there is little awareness of the existence of emergency contraceptives.83 Even in countries where this concept is known, knowledge regarding its accurate use is low. In Tanzania, for example, although government policies support the use of emergency contraception and advise that the pills should be made available at every level of the health system, the use of emergency contraception remains low due to a lack of knowledge about their availability.84 In fact, in a Nigerian study adolescent girls identified their peers and friends as their major source of information on emergency contraception - not government health initiatives.85

In Uganda, although emergency contraception was re-introduced in 2007 after a period of government restriction,86 more than two-thirds of Ugandan women and adolescent girls have never heard of it, and consequently its use remains very low.87 This lack may be the result of the fact that Uganda has banned comprehensive sexuality education in its schools due to religious and societal opposition.88 Uganda further has a very high unsafe abortion rate which contributes to the high maternal mortality rate in that country.89 Emergency contraception may help reduce the rate of unwanted pregnancies, so reducing the high rate of unsafe abortions.

The same problem of access to accurate knowledge about emergency contraceptive use is observed in Nigeria and Ghana, where only 12 per cent and 11 per cent respectively of adolescents know the correct time frame for starting emergency contraception.90 In South Africa, even though several contraceptive methods are available withour charge at public hospitals - including emergency contraceptives - its utilisation among sexually-active adolescents remains relatively low.91

Restricted access to sexual and reproductive health care services, generally, and contraceptives (including emergency contraception), in particular, negatively impacts adolescents. This negative impact is seen in higher rates of unwanted pregnancies among adolescents.92 In a community-based study on abortion prevalence rates in Nigeria, it was revealed that a third of the women who obtained abortion procedures were adolescents who, due to the stringent anti-abortion laws in the country,93 end up patronising quacks under unsafe conditions.94 Also, in Côte d’Ivoire where restrictive abortion laws are in place, it was revealed that 70 per cent of abortions are carried out on girls and women aged 13 to 24, with the agreement of their parents or partners and upon payment of huge sums of money to health-care providers who do so illegally.95 In that country, those who cannot afford this expense are compelled to undergo backstreet abortion procedures which often have disastrous consequences.96 It is necessary to highlight that even in countries in Africa where abortion is legal, such as in South Africa,97 young women still face barriers which cause them to undergo unsafe procedures. 98

Adolescents not only experience unplanned and unwanted pregnancies, but also early child bearing which is linked to increased maternal mortality and morbidity rates.99 Especially in the African region early pregnancy is a major cause of death and illness among adolescent girls between the ages of 15 to 19 years, who experience disabilities associated with early sexual initiation, pregnancy and child birth due to their lack of physiological development, and emotional immaturity making them unable to adequately care for a child.100 These drawbacks underscore the urgency of guaranteeing adolescents’ access to accurate information on contraceptives - including emergency contraceptives - and quality adolescent-friendly sexual health care services.

Nevertheless, as shown above, adolescents possess only limited knowledge about contraceptives, generally, and emergency contraceptives in particular. It has also been shown that they lack access to sexual health care services or do not feel comfortable using these.101 A gradual increase in the age at which young people get married has also ensured that greater numbers engage in premarital sexual intercourse and, therefore, leads to an increase in unwanted pregnancies.102 According to the Demographic and Health Surveys (DHS) in Ghana,103 Kenya104 and Namibia,105 the proportion of currently-pregnant women under the age 20 who reported that their pregnancies were mistimed or unplanned was 42 per cent,106 52,7 per cent107 and 30,2 per cent108 respectively.

Given the high levels of unwanted adolescent pregnancies in Africa, it is self-evident that emergency contraception is an under-utilised method of primary pregnancy prevention, especially given its potential to reduce the number of unplanned pregnancies and, therefore, unsafe abortions.109 Ojule et al remark that emergency contraceptives have a considerable role to play in reducing the rates of unwanted pregnancies and unsafe abortions.110 However, low literacy levels, limited access to emergency contraceptive services and traditional beliefs that impede the use of modern contraceptive methods pose considerable challenges to their promotion.111

Sexual violence against women and female adolescents is one of the most pernicious consequences of the continued presence of economic, social and cultural inequalities between men and women.112 According to available data from the World Health Organization (WHO), one-third of women world-wide will experience violence in their lifetime; an estimated 7,2 per cent of women will be sexually assaulted and many more will experience unwanted sex from an intimate partner. Compounding the trauma of sexual violence and rape are fears of and unwarranted exposure to the risk of pregnancy and exposure to STIs and HIV.113

In Africa and the rest of the world, adolescents are constantly subjected to various forms of sexual violence in their homes, schools and communities. In Kenya, the African Child Policy Forum in a 2010 survey discovered that schools were the second-most common location for the perpetuation of sexual violence against girls aged 13 to 17. In Sierra Leone , 30 per cent of reported rapes were school-related. Similarly, in Swaziland it was revealed that one-third of adult women experienced some form of sexual violence as an adolescent.114 Plummer and Njuguna note that constant sexual abuse is a significant problem in many African countries, with girls experiencing sexual violence at a younger age than boys.115 Female victims have a higher risk of experiencing unplanned pregnancies and HIV. 116

While some African countries have developed policies for the management of sexual assault and to provide post-rape care,117 others do not have specific guidelines that may be followed in treating victims of sexual violence.118 Specifically in relation to Nigeria, there is no policy (whether local or national) that addresses the clinical management needs of rape survivors in that country.119

The administration of emergency contraceptives has consistently been identified as one of the minimum core requirements for the post-rape care of victims of sexual violence, as up to 5 per cent of sexual assault victims fall pregnant as a result of the assault.120 Consequently, as a matter of respect for the human rights of female adolescents and a public health imperative, it is essential that emergency contraceptives are readily available in emergency health care facilities. However, while HIV prevention treatments tend to be readily available, emergency contraception often is inaccessible despite the reality that the risk of an unintended pregnancy occurring is as high as the risk of HIV infection.121 A case in point is that of the Democratic Republic of the Congo (DRC) where, despite high rates of sexual violence, access to emergency contraception is absent from key national health policies, and is not used in post-rape care.122 This is so despite the fact that the WHO’s Global Guidance on Sexual Violence recommends the provision of emergency contraceptives as an integral part of prompt and comprehensive women-centred sexual and reproductive health care.123

5 Challenges to adolescents’ access to emergency contraception: A case study of Nigeria