The study assessed the knowledge, attitudes, perceptions and use of contraceptives among female undergraduate students of Makerere University. Our findings show that knowledge was universal, but contraceptive use was suboptimal. The most commonly known and used methods were the male condoms and oral pills, but knowledge of the female condom was very low. Positive perceptions and attitudes were strongest on couple counseling acceptability of contraceptives at the university and benefits of contraceptives to males. Negative perceptions about contraceptives being for the poor or their use being wrong were mentioned. High level of contraceptive knowledge does not translate into actual use in this study or from other studies [14, 15]. Religious beliefs as evidenced by lower use of contraceptives by evangelicals or Seventh Day Adventist have a clear negative influence of utilization; this has also been shown in other university setting in western Uganda . Religious and moral beliefs clearly overlap and need further exploration in a University setting.
The level of knowledge about contraceptives was found to be lower in similar African university settings, ranging 53.3 % to 86.3 % [17–21]. It is possible that even though students were universally aware of a range of contraceptive methods and knew where to get the services, they may have faced other obstacles that we did not directly measure in our study. For example, previous studies done in Uganda have highlighted social-cultural factors as critical barriers to contraceptive use in young females [15, 22]. Nalwadda and colleagues (2010) conducted a study in rural Uganda that specifically showed that societal norms such as condemning early engagement in sex, pregnancy and use of contraceptives among young unmarried girls presents a major obstacle to contraceptive use . In our urban-based study, similar socio-cultural factors still have a lot influences leading to poor uptake of contraceptive among female students. In designing youth-friendly interventions it is imperative that efforts should be geared towards disseminating specific contraceptive information and education that is culturally-sensitive to the local setting.
Students knew the main sources of contraceptives services as government hospitals and private clinics but we did not verify if these were there major sources of contraceptive information. Awareness of sources was shown to reduce barriers and improve contraceptive use among female students in the University of Lesotho . However, a study done in Ethiopia that evaluated major sources of information about contraceptives found out that a high knowledge of sources was not enough to result into actual use, rather the students needed more information about freely available contraceptive services [19, 24]. These observations suggest that reproductive health education programs should offer accurate and comprehensive information while building skills for negotiating safer sexual behaviours .
Overall the students had positive attitudes and perceptions towards using contraceptives. However, negative perceptions and attitudes existed about accessibility to contraceptive services; these included discussion of sexual issues with partner, contraceptives being for the poor and wrong perceptions about contraceptive use. A study in Nigeria reported that a high proportion of students perceived contraceptive use as bad because they believed it caused infertility . However, studies have reported positive attitudes specifically toward emergency contraceptives among students at Jimma and Adama university in Ethiopia [26, 27] and negative attitudes toward emergency contraceptives increasing promiscuity in female students of Trinidad and Tobago .
Sexual activity among adolescents and young females is often associated with a greater risk for unintended pregnancies . In our study, nearly 70 % of the students were sexually active in the past 12 months. This finding supports results from the Uganda demographic health survey showing that premarital sex is common, with at least one in five young females aged 15–24 being sexually active . Young females joining universities often become sexually active partly due to peer-pressures, alcohol use, or as result of a perceived sense of being in control of their social lives . Similar levels of sexual activity were reported from other studies done among female university students of the same age group . In contrast, some earlier studies done in Africa showed lower levels of sexual activity among university students, these ranged from 14 % to 48 % [20, 25, 26, 30, 31]. The differences in levels of sexual activity may be due to temporal events like increased sexual reproductive health over time or could be explained by differences in religious and cultural beliefs surrounding premarital sex .
Contraceptive use of any method among the university students was 46.6 % which is nearly twice as high as the contraceptive prevalence of Uganda. On the other hand, the rate of use is lower than 79 % contraceptive used among females that was reported from a study done in Mbarara University in Uganda  and in other university students in Lesotho, Kenya and Ethiopia [1, 14, 33]. Factors that were significantly associated with contraceptive use in this study are consistent with findings from a recent survey in a nationally representative in Ugandan women . The high level of sexual activity and the risk of unintended pregnancies point to a need to promote sexual and reprodcutive health sevices in this setting. Male condoms were the most common contraceptive methods followed by oral pills among the sexually active students. Similar findings have been obseved elsewhere in both the developed [13, 31, 34] or developing countries [1, 25, 27, 28, 35]. However methods such as oral pills and injectable contraceptives have also been mentioned as being common in some settings such as Adama University, Ethiopia .
Among the sexually active students, one in five were engaging in unsafe sex suggesting high risk to unintended pregnancies and sexually transmitted diseases including HIV infection. Unsafe sexual practices are common among young adults especially in universities and other higher educational institutions [10, 11, 13]. The reported prevalence of unsafe sex may be higher in this setting if some students also use emergency contraceptives for prevention of pregnancy. Previous studies elsewhere have shown high level of unsafe sex [31, 33] in similar settings. However, our study did not specifically evaluate the use of emergency contraceptives.
The prevalence of reported pregnancy at the time of survey was low (2 %) but probably under-reported due to associated stigma among unmarried pregnant women. However, 9 % of the sexual active students reported being ever pregnant. Among the ever-pregnant females, 40 % had ever tried to terminate the pregnancy suggesting a high level of both unmet need for contraceptive and unintended pregnancy in this setting. The reported 40 % ever pregnant who tried to terminate a pregnancy may be an under estimate because abortion is illegal in Uganda, and can be very stigmatizing. Similar findings about abortion have been observed in Mexico public university among first year medical students where half (52 %) of the ever been pregnant female students performed unsafe abortions , and in Addis Ababa University Ethiopia 9 in 10 (90 %) of the ever pregnant students terminated their pregnancies with induced abortion .
Study strengths and limitations
Although the findings from this study are consistent with results from other university settings, we encountered some limitations. The planned random sampling based on the sampling frame from the University’s academic registrar was dropped in favor of convenience sampling. However, interviewers were assigned/stationed at multiple academic units and asked to as much as possible randomly select participants without any specific characteristics. Some of the information especially on issues such as abortion may be under-reported because abortion is illegal and stigmatizing. Also pregnancy among unmarried females is culturally unacceptable thus leading to a potential for under-reporting. However, the study team recruited and trained experienced interviewers within the age range of the respondents as a way of minimizing reporting bias. The consistence in the contraceptive use indicators with other studies and the nationally representative samples such as the Uganda demographical and health surveys provide credence and strength to findings observed in this study.