Emergency contraception (EC) is important for the South African population because of the high number of unplanned and unwanted pregnancies. There are more than 14 million cases of unplanned pregnancies recorded per year.^1,2,3 Emergency contraception involves various methods used to prevent pregnancy after unprotected sexual intercourse,¹ sexual assault¹ or contraceptive failure.² Emergency contraception, unlike regular contraception, is used after sexual intercourse but before the potential time of implantation.¹ Emergency contraception use should not replace the regular contraception, and regular contraception methods should be offered following the use of EC.

Unprotected sexual intercourse is common, and although there are no accurate data from South Africa, about 14% of women who seek EC in the United States (US) report at least one episode of unprotected intercourse in the previous six days, and up to 40% reported multiple episodes of unprotected intercourse in the cycle before presentation.² Similarly, up to 19% of women in the US report a history of rape or attempted rape,² and as many as 45% of all pregnancies in the US are unplanned.⁴ In South Africa, rape is also a major problem, with the country ranking first globally with a per capita rate of 417 out of 100 000 women reporting rape.^5,6 This high rate of sexual assault is one of the driving indications for EC use in South Africa. In a recent study conducted among human immunodeficiency virus (HIV)-positive women in Eastern Cape province, up to 71% of pregnancies were unplanned.⁷ Despite the high rates of unplanned pregnancy and sexual assault among women in South Africa, the sub-Saharan African region, including South Africa, has the lowest rate (29.4%) of contraceptive use globally.¹ Data on the use of EC in South Africa are very sparse. A scoping review reported that only 11.3% of participants in South African studies reported the use of EC previously. Although the awareness of EC is on the rise in South Africa,¹ many women, pharmacists, and doctors are not well informed about the available options of EC.⁴ Both the Practical Approach to Care Kit guide (PACK) (used in the Western Cape province), and the Advanced Practice Clinical guidelines (APC) (used outside the Western Cape province) have some pages dedicated to EC in the contraception and sexual assault pages. However, there still appears to be a lack of awareness among medical practitioners. This lack of awareness may partly explain the high numbers of unwanted pregnancies and possibly contribute to the high termination of pregnancy rate and maternal deaths in South Africa.⁴ As EC does not prevent sexually transmitted infections (STIs) including HIV, it is important to also offer HIV prophylaxis and treatment for STI to women seeking EC after sexual exposure or assault.²

A study in Johannesburg, South Africa, concluded that despite the country’s commitment to achieving universal access to sexual and reproductive health services, there are challenges with the current contraception services delivery, specifically regarding contraceptive counselling.⁸ In the primary care setting, health care providers play a vital role in offering timely access to EC, including educating patients and addressing any concerns. Health care providers in primary care settings should, therefore, be knowledgeable about the various types of EC and be able to facilitate the provision of the best option for each patient in the correct time frame, in an understanding and sensitive manner.² This article provides up-to-date evidence on the indications, effectiveness and special considerations on commonly used EC methods to health care providers. This may assist in improving access to EC, reduce the number of unplanned pregnancies and potential adverse pregnancy-related outcomes, including maternal deaths.

Emergency contraception is usually indicated for unprotected intercourse,⁴ contraceptive failure (e.g. condom breakage, missed birth control pills),⁴ post sexual assault⁹ and sexual coercion.⁴ In this article, the authors refer to sexual assault as an act of sexual abuse in which one intentionally sexually touches another person without that person’s consent, or physically forces a person to engage in a sex against their will. It is a form of sexual violence.^5,6 It must be provided to women, including children from the Breast Tanner Stage III.¹⁰

The effectiveness of EC is a function of the time elapsed from the time of exposure to unprotected sex to the time of administering the EC.⁷ It is, therefore, important that patients at risk of unwanted pregnancy present as early as possible after exposure to unprotected sex. In addition, the clinician needs to observe the time elapsed because it has implications for the choice of the EC method and the ability to effectively prevent unwanted pregnancy.

Emergency contraception is available either as oral pills or as intrauterine devices (IUDs) (hormonal or non-hormonal). The exact mechanisms of action for ECs are generally unclear but, broadly speaking, may be attributable to interference with follicle maturation or the ovulatory process, cervical mucus, sperm migration, corpus luteum sufficiency, endometrial reproductivity, fertilisation, or zygote development, transport, or adhesion. The choice of EC differs according to the type of EC as well as the time elapsed from exposure to unprotected intercourse and ovulation.^3,11

Ensuring good pregnancy outcomes requires a woman to conceive when her health and socioeconomic conditions are optimal. The high rates of unplanned pregnancy and sexual assault, and the poor outcomes of maternal and women’s health care services in South Africa, all necessitate promoting the use of EC. Health care providers in primary health care (PHC) are best placed to ensure that women are educated on EC and have timely access to this important service. While the information provided in this article has potential to scale up the use of EC and promote good reproductive health outcomes, training of health care providers and uninterrupted supply of different types of ECs are other key imperatives.