Dr Joachim OsurExpanding Access to Medical Abortion: Building on Two Decades of Experience

Lisbon, PortugalMarch 2-4, 2010

Use of Medical Abortion Through Pharmacy Outlets

Pharmacists: The First Line of Defense

• Serve as the first source of health care to people throughout the worldoMain source among low income

populations• Use of pharmacies as a source of care

is increasingo Particularly among poor and uninsured

• Studies in Africa, LAC and Asia indicate gaps and opportunities

Current situation in much of Africa

• Restrictive laws and lack of services in the formal health system impede access to safe abortion.

• Consistent demand for abortion has led to non-clinician providers including:- Herbalists - Traditional birth attendants- Women - Pharmacy workers (trained and untrained)

• Various methods of abortion are used by these providers:- Herbs - Various instruments - A number of medicines

• However: Communities that have been sensitized about misoprostol seem to abandon other methods in favor of misoprostol.

Methods of Abortion in a Rural Community in Kenya

Safety of Abortion in the Community

• At community level, the safety of the abortion is highly dependent on the source.

• It appears that misoprostol abortions by pharmacy workers may be the safest, possibly because pharmacy workers:o Refer to health care facilitieso Avoid invasive procedureso Desire to remain in business and maintain

social standingo Know how the drug works

Relationship of Complications to Site of Abortion in a Rural Kenyan Village

Where Termination of Pregnancy Was Initiated

Complications Suffered by the Woman

TotalNone

Haemorrage not requiring transfusion death

Haemorr-hage

requiring transfusion

Pelvic infec-tion

Lower genital tract injury

Not known 6 1 1 0 1 0 9

Home 22 6 0 0 5 4 37Clinic/hospital 39 23 0 0 3 3 68

Pharmacy 9 1 0 0 0 0 10

Herbal clinic 1 2 0 2 0 0 5

Herbalist's home

0 1 0 0 0 0 1

Total 77 34 1 2 9 7 130

Not Yet Rain!• A number of problems, however, dog the

provision of medical abortion through pharmacies.

• A mystery client survey in Kenya showed :o Pharmacy workers have poor knowledge on

termination of pregnancyo Some have negative values and stigmatize

abortion• “Sorry sister. Try elsewhere”.

o For those who give misoprostol, doses of drugs dispensed are wrong in most cases

Not Yet Rain!• In Zambia and Kenya, most community

pharmacies are not registered, hence:o Pharmacy worker capacity unknowno Knowledge of MA drugs may be lackingo Possible lack of support for training by

MoH and the pharmacy society• Most community pharmacies are

currently unable to give accurate information on use of misoprostol

Reasons For Not Giving Information to Women Who Seek Abortion From Pharmacies

Case Study: Kenya• We collaborated with misoprostol distributor

to: o identify and train pharmacy workerso ensure misoprostol always in stock

• Linkages were created between trained pharmacy workers and trained health facilities.

• Pharmacy workers see their role as:o Informing and referring womeno Prescribing misoprostol to the extent allowed by

the pharmacy boardo Ensuring supply of misoprostol to health facilities

Case Study: Zambia• In collaboration with pharmaceutical society,

pharmacy workers were identified and trained.• Pharmacy workers expressed concern that their

role in abortion care had not been appreciated.• Following the training, pharmacy workers

decided they were going to:o Do on the job training for their colleagueso Come up with own scope of practice on abortion

including prescribing, referral, community educationo One pharmacist promised to follow up registration

of mifepristone

Recommendations by Pharmacy Workers

• Formally recognize their role in abortion care• Offer values clarification• Provide full package of support and training:

o Community educationo Prescribing MA drugso Referralo Registration, supply and quality monitoring of MA drugs

• Educating, and mobilizing the community to access services through the pharmacy could improve the role of pharmacies in medical abortion and increase access to care through pharmacies.

Visit us online atwww.ipas.org/medicalabortion

or write tomedicalabortion@ipas.org