Due to unavoidable administrative reasons, the number of students included in Bahir Dar University was smaller than the allocated size. The majority of our students were in the age group of 20-24
years, the age group considered as sexually active group [15
According to this study, about 103 (16.5%) have ever had sexual intercourse. This figure is less than other similar studies done in Addis Ababa, Kenya and Ghana reported sexual intercourse in (19.5%) [16
], (47.6%) [17
] and (38%) [18
], respectively, among university female students. This could be due to unwillingness to report having sex with a particular partner or being coerced to have sex.
Nearly two fifth (37.9%) of the students had two or more sexual partners in the past. This figure is much higher than the Ethiopian demographic and health survey results [19
]. This might be due to the difference in population that we have used institution based population away from family and are exposed to have more partners than the general population. In addition, university students are at a stage in their lives characterized by searching, discovery, and experimentation, including sexual experimentation [20
]. They live and socialise with large numbers of other young adults, which encourages sexual activities that are not mutually monogamous. For this reason, university students are reportedly engaging in unsafe sex, which places them at higher risk than the general public to contract STIs, including HIV and AIDS, as well as unwanted pregnancies [20
In contrast to rates of unintended pregnancy and induced abortion, the reported lifetime prevalence of STIs was lower for female students than a previous study in South Africa (25%) [21
]. This may be due to under-reporting, to the presence of certain STIs such as chlamydia and gonorrhoeal infections that remain largely asymptomatic especially among women [22
], to embarrassment or financial costs preventing students from seeking medical care, to the limited availability of testing for chlamydia infections in the study area, or to the fact that the university students' sexual network was not developed enough to allow the spread of STI.
Although the unintended pregnancy rate of 16.5% in this study is comparable with Ethiopian Demographic and Health Survey 2005, of 16.2% [24
]. Limited condom use and especially multi-partnership are to blame, as evidenced by the fact that all the students who reported history of unintended pregnancy also reported sexual intercourse with multiple sexual partners. One of the most unfavourable outcomes of unplanned, unprotected sex is unintended pregnancy. Unlike in the past when pre-marital pregnancy used to result in compulsory marriage of the girl to the father of her child, today, due to western civilization and the erosion of traditional family and community values, young women are having greater freedom regarding their sexuality. The high cost of education and the desire to continue schooling for enhanced socio-economic status are also pressurizing young women to delay childbearing by resorting to induced abortion as the major method of resolving unwanted pregnancy [25
]. In this study, abortion rate is higher than the national average of 2.3% [26
]. The high abortion rates in these areas are likely the result of many factors, including that the availability of private health care providers draws women from surrounding areas. Previous studies indicated that women seeking induced abortion had a mean age of 23, and the majorities (54%) were single [26
] which is in agreement with the demographic profile of this study. From the total students reported previous history of abortion, 37.5% reported two or more abortions, highlighting the importance of introducing safe sex education.
The result from this study revealed that more than two third of the respondents had heard of EOC. This is higher than the previous reports from different university students of Ethiopia; 43.5% in Addis Ababa [16
], 41.9% in Jimma [29
] and 47.6% in Haramaya [30
]. Other studies among female students have indicated that 45.1, 56.5, 58 and 61 percent had heard about EOC at university of Uganda, South Africa, Benin and three tertiary institutions in Eastern Nigeria, respectively [31
]. The result from this study has also revealed that knowledge of correct timing was better than all above studies. This could be due to the high health promotion and availability of EOC in pharmacies. However, more than half of respondents said EOC is not effective and didn’t know about its effectiveness in preventing unwanted pregnancy. Advocacy on EOC use as a back-up contraceptive method for condom failure or non-use should be considered.
In our study, we have identified that more than half of students were willing to use and recommend EOC to others. In addition, female youth who think EOCs are highly effective in preventing pregnancy are nearly four times less likely to use condoms as compared to those who say EOCs are not effective. The findings of this survey support previous studies showing consistent EOC users do not necessarily consider using a condom for STI prevention [6
Despite the potentially devastating outcomes that can result from unprotected sexual intercourse, university students do not consistently take the necessary precautions to protect themselves from contracting an STI and instead see pregnancy prevention as the primary issue. For example, in a survey of 797 college students, 28% cited pregnancy prevention only as the reason for using contraception [35
]. This may due to incorrect believe that emergency contraceptive methods provide protection from disease [36
]. These findings may be attributed to a lack of knowledge or incorrect beliefs about the effectiveness of oral contraceptives in preventing STIs [35
]. Many university students believe that condoms and oral contraceptives are equal choices, rather than understanding that both are required for maximal protection against STIs and unwanted pregnancy [37
]. To develop effective disease-prevention messages, better understanding is needed of why women at risk for HIV infection who are using contraceptive methods other than condoms do not use condoms for disease prevention.
Although not statistically associated with condom use, two fifth of respondents think that EOC can prevent STI. This may be due to incorrect beliefs about the effectiveness of oral contraceptives in preventing STIs [35
]. According to this study, about 75% of students responded that unintended pregnancy is the problem of youth while only 55% responded that unintended sex is problem. There is some concern that Ethiopian students may be putting themselves at unnecessary risk of STI by choosing the oral contraceptive pill for prevention of pregnancy while remaining at risk of acquiring an STIs through unprotected sex. The problem appears to be with the interplay between the need to prevent pregnancy and the need to protect against STIs. If this trend continues together with the increase in early sex initiation associated with more non-regular and more multiple partnerships, the vulnerable subpopulation of students engaging in unsafe sexual practices will expand, potentially leading to an increased incidence of induced abortion and probably increased future STIs and HIV infection. This concern is supported by many previous studies indicating that an early age of sexual debut is associated with negative outcomes such as unwanted pregnancy, induced abortion, and STIs [38
On the other hand, the level of knowledge on condoms is better than that for the EOC in this study. Participants who believe that condom prevents STIs were more than ten times more likely to use condoms as compared to those who did not believe in condoms. However, sexually active students aged 20 or older and those who thought that EOC is effective in preventing pregnancy are less likely to use condom. This tells, on the other hand, that youth are afraid of the pregnancy than the STIs. In line with this, a study in Canada asked respondents which of AIDS, STIS and pregnancy they worried about most as a possible outcome of sexual intercourse. Pregnancy was selected most often by all groups of students [41
]. Another study in Norway showed that the majority of adolescents who use contraception (pills or condoms) do so for protection against unintended pregnancy and not for protection against STIs [6
]. Some of the reasons for not using condoms or inconsistently using condoms among students with good knowledge are condom discomfort, possibility of breakage, cost, interruption of sexual activity, need for proper technique, loss of penile sensation, preference for other forms of birth control, or stigma of using a method associated with promiscuity and STIs [42
]. College women in particular may not use condoms because they are less likely to perceive themselves at risk and believe that condoms do not play a role in a relationship based on love, trust, and commitment [14
This study has some limitations. First, the study was carried out in only two universities of Northwest Ethiopia, and thus the finding cannot be generalized to EOC users in Ethiopia. Second, we cannot guarantee that students provided honest answers to the questions, since the survey involved a sensitive matter (i.e. sex), therefore; it is important to remember that the reliability of results of this study are dependent upon the accuracy of the responses. Its cross-sectional design was also limited in evaluating cause-and-effect associations. In addition, the study is limited to women. Knowledge and attitudes of men need to be considered as well if we hope to make changes in the use of contraceptives in this population. However, to our knowledge this article is the first of its type to look at effect of emergency oral contraception on condom use among students in Ethiopia.