Reviewer's report 
 Knowledge and use of emergency contraception among women in South Africa: A cross-section Title: 
study 
 1  16 February 2007 Version: Date: 
 caroline moreau Reviewer: 
Reviewer's report: 
General 
This paper addresses an important and still scarcely documented research question on knowledge and use 
of emergency contraception in the critical Southern African context; contend with both high rates of 
unintended pregnancies and high rates of HIV transmission. In this context, it is hypothesised that EC used 
as a back-up contraceptive method where condom failure occurs, could have a significant role in reducing 
unintended pregnancies. 
Using data from a cross sectional multi-center survey of 831 women, recruited at 30 public sector clinics in 
the province of Cape Province, South Africa, the authors found that only 30% of women had heard of EC. 
Awareness was significantly lower in the most rural area and among single women and less educated 
women. 
The study design and statistical analysis are appropriate and well described. 
The results are clearly reported and the discussion thoroughly written. 
------------------------------------------------------------------------------- Major Compulsory Revisions (that the author must respond to before a decision on publication can be 
reached) 
A few suggestions would improve the understanding of some of the results. 
1. When describing the women’s contraceptive use at last intercourse, it is unclear to me to which 
population these results refer to. Is it all women or women who are at risk of unintended pregnancy 
(excluding those who are pregnant or intended to get pregnant)? Analysis should be restricted to the later 
(women at risk). It would also be useful to know when the last sexual intercourse occurred (in the last month? 3 months? year ?). 
2. While overall knowledge of EC in the general population is interesting, it seems however more relevant to 
examine EC awareness among potential users. Therefore, I would suggest restricting the analysis of EC 
knowledge to non sterilised women. This remark includes tables 1, 2, 3 3. It would be helpful to add the p value for the comparison of rural vs urban for spontaneously citing EC. ------------------------------------------------------------------------------- 
Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the author 
can be trusted to correct) 
------------------------------------------------------------------------------- 
Discretionary Revisions (which the author can choose to ignore) 
Few other specific remarks follow 
Abstract: 
Introduction: In the first sentence, authors make a direct link between availability of ECPs and the remaining 
high rates of teenage and unintended pregnancies. In fact, no studies up to date have shown that increased 
access to ECPs results in lower rates of unintended pregnancies or abortions. Unintended pregnancy rates 
are driven by multiple dimensions (including sexual activity, contraceptive coverage and effectiveness). ECPs are unlikely to have an impact alone. I would suggest breaking this first sentence into 2: Emergency 
contraception is available free of charge at all public sector clinics in South Africa since xxxx. In the same 
time, rates of teenage and unintended pregnancies are high.” Discussion: It is unclear why EC would increase contraceptive coverage. 
Line 4 of the discussion/ remove the word “it”: for it’s use, before the need of ECP arises. 
Introduction 
Line 7: “has the potential to reduce the incidence of unintended pregnancy”: maybe add, “if used when the 
need arises”. 
Paragraph 2: same remark as in the Introduction paragraph of the abstract. 
Also, consider changing to “75% of pregnancies in South Africa” 
Paragraph 3: are ECPs available over or behind the counter? 
Findings: 
Page 6, first sentence: remove “meaning they were not protected from pregnancy or STI at last intercourse”. 
We have no information on the woman’s and her partner’s HIV or STI status. If both partners have no 
infection and have shared that information, they are not at risk 
Page 6, line 7. It would be helpful to add the p value for the comparison of rural vs urban in spontaneously citing EC. Page 7, line 7. “associated with the type…” 
Page 9, line 14. “context of high levels” 
Page 9, 3rd paragraph 1rs sentence: seeking EC at the pharmacy rather than at public clinics may also reflect a selection “bias”: women who are aware and use ECPs are more educated (and possibly 
wealthier?) 
Page 9, line 21. change “at weekends” by “on weekends” 
Page 10, last line: remove the word “it”: for it’s use, before the need of ECP arises. 
Table 1 
Change to 
“did not know if ECPs were available at public clinics “thought ECPs were not available at public clinics 
 Unable to decide on acceptance or rejection until the authors have responded to the major What next?: 
compulsory revisions 
 An article whose findings are important to those with closely related research interests Level of interest: 
 Acceptable Quality of written English: 
 Yes, and I have assessed the statistics in my report. Statistical review: 
Declaration of competing interests: 
I declare that I have no competing interests