by Mridula Shankar, Elizabeth Omoluabi, Funmilola M OlaOlorun, Anoop Khanna, Danish Ahmad, Caroline Moreau, Suzanne O Bell
SOURCE: PLOS: Global Public Health, Published: 6 January 2025. https://doi.org/10.1371/journal.pgph.0003971
Abstract
Dispensing of misoprostol and mifepristone by pharmacies and chemist shops for self-management of medication abortion (MA) fills a crucial gap in settings where abortion care by trained health professionals is not readily available. This promising service delivery pathway, endorsed by the World Health Organization (WHO), is hindered by concerns of poor quality care. Simulated clients collected data on MA pill dispensing practices from 92 pharmacies and chemist shops in three Nigerian states and 127 pharmacies in an Indian state that we have anonymized. Guided by the WHO’s abortion guideline, we measured process-related quality indicators such as medication use instructions, warning signs, and respectful treatment, among other aspects. We aggregated indicators under three domains: technical competence, information given to clients, and client experience. Overall, 51% of facilities in the Nigerian states and 32% in the Indian state offered MA pills. Most dispensing facilities offered the misoprostol-only regimen in Nigeria (68%) and the combination regimen in the Indian state (83%). Among facilities offering MA pills, 26% in Nigeria and 78% in the Indian state provided correct instructions on route of pill administration. Accurate information on the appropriate interval between pill type in the combination regimen was low in Nigeria (27%) and the Indian state (14%). Excessive bleeding as a warning sign was discussed more frequently in the Indian (56%) versus Nigerian states (32%); other abnormal bleeding patterns were rarely mentioned. Aggregate technical competency scores were low at 18% in Nigeria and 34% in the Indian state, with highest scores for client experience at 90% and 91% respectively. Findings suggest that people using MA pills purchased from the retail market are not given accurate and adequate information for most effective self-use. If MA self-management remains outside regulatory boundaries, technical quality will remain sub-standard, imposing unnecessary costs to people, their health, and health systems.
Introduction (first paragraph)
Yearly, four in 100 reproductive-aged women undergo an abortion. In countries where legal provision of abortion is restricted to narrow grounds and/or where health systems are poorly resourced, peoples’ reliance on clandestine abortion has motivated a longstanding public health focus on abortion safety. Safety estimates suggest that 45% of abortions globally are not safe, and the risk of unsafe abortions is disproportionately experienced by women in low-and middle-income regions. In recent decades the abortion landscape has evolved to include models of self-management using misoprostol with or without mifepristone, both of which are World Health Organization (WHO)-recommended medications for medication abortion (MA) and on the model list of essential medicines for health systems. Self-management of MA encompasses several service-delivery models that offer the individual an active and autonomous role in inducing and managing their abortion, in contrast to a clinician-performed procedure on the recipient of care. In this paper, we concern ourselves with a form of abortion self-management that is more typical of legally restrictive and/or poorly resourced public health care settings, where misoprostol and mifepristone (when available), and hereafter referred to as MA pills, are purchased with neither prescriptions nor access to high quality information from pharmacies, chemist shops and other medicine vendors, and used for self-inducing an abortion. We want to distinguish this form of self-management from those models that are accompanied by support and trained guidance on appropriate use of the medication regimen(s), which have demonstrated high levels of safety and efficacy.
Conclusion
The growing role that pharmacies and chemist shops play in delivering abortion care in many settings offers women safe alternatives to the use of dangerous or ineffective methods. Our results demonstrate that MA pills are available in the retail market in the three Nigerian states and in the single Indian state involved in this study, albeit to different extents. However, the quality of care associated with dispensing these pills is sub-standard in both settings, with the
implication that women who are buying and using pills purchased through the retail market are not given adequate information to follow recommended protocols for most effective self-use. Capitalizing on this pathway to safer abortion care, women’s broader access to MA pills must be complemented with adequate guidance on medication use to facilitate the most favorable health outcomes. Doing so at scale requires changes in the structural and healthcare environments, including harmonizing laws on abortion with human rights standards, formalizing roles and capacities of pharmacy and chemist shop workers in the delivery of abortion care, developing models of healthcare financing that reduce user out-of-pocket costs, and allowing healthcare beneficiaries to operate as informed and educated autonomous agents in matters of their health and well-being.