Emergency contraception in Tunisia: A multi-methods assessment of availability, accessibility, and acceptability
Awarded 2011
Large Research Grants
Angel Foster, MD, DPhil, AM
Ibis Reproductive Health

Background: In 2001, Tunisia became the first country in the Arab world to register a dedicated emergency contraceptive pill (ECP). Over the last decade, emergency contraception (EC) has been integrated into both the public and private health sectors and into national service delivery guidelines. In 2005, ECPs were made available, without a prescription, directly from pharmacists. Use of EC has steadily increased, and in 2010 approximately 36,000 units of ECPs were procured by the retail pharmacy sector. Although ECPs have been registered in seven other Arab countries, Tunisia remains the only country in the region to have undertaken significant efforts to expand access to EC. However, although Tunisia’s policies and programs evince a longstanding national commitment to comprehensive reproductive health service delivery that is exceptional within the region, national statistics mask persistent regional disparities as well as practices that exclude unmarried women from family planning services. To date, little research has been undertaken to systematically evaluate the service delivery and use patterns of ECPs in Tunisia and our proposed study aimed to fill this gap. Methods: This multi-methods study aimed to comprehensively assess the availability, accessibility, and acceptability of EC in Tunisia and focused on the perspectives and experiences of pharmacists and both married and unmarried women. We conducted in-person interviews with representatives of 208 retail pharmacies in eight Tunisian governorates (administrative areas akin to states or provinces). Using two distinct client profiles we also conducted a mystery client survey at 50 urban pharmacies in Tunis, Nabeul, and Sousse. Finally, we completed ethnographic fieldwork to understand better women’s experiences obtaining reproductive health services in the post-revolutionary period. We analyzed our data using descriptive statistics and content and thematic analytic techniques. We obtained approval to conduct this study through the Research Ethics Board at the University of Ottawa with support from the American Research Center (CEMAT) in Tunis. Results: Our results revealed that there are geographic disparities in ECP availability, but there was much greater parity that we originally hypothesized. Over 80% of retail pharmacies had ECPs in stock at the time of the interview and there were very few communities in which ECPs were not available in at least one pharmacy. Overall, pharmacy representatives’ knowledge of EC (including provision protocols, retail price, etc.) was excellent. However, there were several pharmacy representatives – all in the center and south – that believed that EC continues to require a prescription. We also found that access to ECPs differs by marital status. Some pharmacies, as a matter of policy, reported that they do not provide EC to unmarried women. Our mystery client study revealed that unmarried women do appear to be subjected to more intrusive questioning regarding the circumstances surrounding need but are also given more information about ongoing contraceptive methods and condoms than married women. Finally, the revolution in 2011 and the victory of an Islamic party in the subsequent elections has created a broader cultural space for the expression of religious conservatism. In the absence of enforcement mechanisms or professional repercussions, it appear that some healthcare providers are now imposing moral judgments on certain groups of women seeking services. Discussion and Recommendations: Our findings suggest that there is a need to support continuing education for pharmacists and pharmacy technicians with respect to ECPs. The registration and introduction of ulipristal acetate (projected for early 2014) will likely provide a window of opportunity to work with professional societies and public sector agencies to make sure that updated, evidence-based information about progestin-only ECPs is included in national circulars and through in-service trainings. Further our results suggest that there is continued need to support and expand youth-friendly sexual and reproductive health services as some unmarried women experience barriers to accessing ECPs through community based pharmacies. Finally, the 2011 Tunisian revolution and the subsequent victory of Ennahda in the Constituent Assembly elections, has raised new questions and concerns about the availability of reproductive health services. Although Ennahda has not, to date, enacted any legal or policy reforms impacting reproductive health, the socio-cultural space created in the wake of the revolution has shaped women’s experiences and created new localized barriers to access. The importance of the upcoming elections on reproductive health and women’s status should not be underestimated.