Akanni Ibukun Akinyemi, Obafemi Awolowo University; Akinrinola Bankole, Guttmacher Institute; Melissa Stillman, Guttmacher Institute; Onikepe Owolabi, Guttmacher Institute, and Temitope Erinfolami, Obafemi Awolowo University
Unintended pregnancy is common among women of reproductive age in Nigeria and a substantial number end in abortion. Annually between 2015 and 2019, almost three million pregnancies were unintended. Forty eight per cent ended in abortion.
Many of these abortions are unsafe and some result in serious maternal morbidity or death. The main reason for this is that termination is only allowed legally in Nigeria if a woman’s life is in danger. This drives women to obtain abortions clandestinely through unqualified providers using inappropriate methods.
But abortions have become relatively safer since the emergence and increasing availability of medication abortion, especially misoprostol. Misoprostol was approved in Nigeria in January 2006 for the treatment of postpartum haemorrhage. Evidence suggests that Nigerian women are beginning to access and use it safely to induce their own abortions.
A recent study showed that 94% of women who used misoprostol – which they obtained from drug sellers (pharmacists and patent medicine vendors) in Lagos State – reportedly completed their abortions without further actions.
In Nigeria, patent and proprietary medicine vendors are outlets without formal training in pharmacy who sell orthodox pharmaceutical products on a retail basis for profit. Pharmacies are regulated in Nigeria.
Having uncomplicated abortions using misoprostol is a positive development for Nigerian women. It promotes their health and prevents unnecessary deaths due to unsafe abortion. Additionally, the privacy that the method provides protects women’s health and saves lives. It also has the ability to reduce social stigma and the financial cost of resolving an unintended pregnancy with an abortion.
In sum, in the context of restrictive abortion laws, promoting access to misoprostol as a harm reduction strategy is a life saver.
In our study, we assessed the quality of care provided to women who obtained misoprostol for abortion from drug sellers (patent medicine vendors and pharmacies) in 2018 across six local government areas in Lagos State, south west Nigeria. Our study emphasised the need to understand the knowledge of drug-sellers on provision of medication abortion and the extent of information they provided to their clients. This is important for ensuring the efficiency of medication abortion.
Drug sellers are not the only providers of misoprostol. But most women prefer to patronise them. Understanding the quality of care provided during the abortion process is therefore critical to ensuring that women are able to self-manage abortions safely and effectively.
Our study therefore set out to determine if the quality of abortion care differed by drug seller type. Our research involved collecting insights from drug sellers as well as from women who had procured the drug.
Our findings show that women are more likely to obtain medication abortion at patent medicine vendors than at pharmacies. Also, there are differences in the socioeconomic characteristics of women who obtain care from patent medicine vendors compared with pharmacies. Medication abortion drugs are usually paid for out-of-pocket by women. Thus, we hypothesise that women who may have lower purchasing power or prefer to pay less are more likely to visit patent medicine vendors than pharmacies. Patent medicine vendors usually have lower prices and are easily accessible.
In assessing quality care we looked at three broad domains: the technical competence of the drug seller, information given to clients, and client experience of care.
We examined these domains from the perspective of drug sellers, as well as from those of the women.
We selected local government areas that had at least one higher-level educational institution. We hypothesised that areas with higher-level educational institutions would have a greater market for misoprostol due to the concentration of young females with a secondary education or higher, a population that has a relatively higher estimated incidence of abortion in Nigeria
Field activities were organised into two major components.
The drug seller study included two categories of drug sellers – registered pharmacies and patent and proprietary medicine vendors. Those who reported selling misoprostol-containing medication were selected.
The second component was women who procured these drugs from the drug sellers to terminate a pregnancy.
We included 126 drug sellers while 386 women completed all three prospective interviews during the study.
We explored the consistency between the drug sellers’ and the women’s reporting on the quality of care received. This was to shed light on potential discordance between what and how information is given, intended, received and used.
Our findings suggest that, in general, more women seek safe abortion care from patent medicine vendors than from pharmacists. Additionally, we found that drug sellers’ knowledge about medication abortion was sub-optimal. And there was a gap in the knowledge and information they are expected to give to women who obtained medication abortion from them.
Anecdotally, pharmacy staff are regarded as better providers. But our results suggest there was no difference between the technical knowledge of patent medicine vendors and pharmacy staff related to prescribing medication abortion.
It is however important to note that a greater proportion of patent medicine vendors reported receiving on-the-job training in safe abortion and post abortion care than pharmacy staff. Regulatory agencies and other stakeholders should consider this as utmost priority.
We also found that women experienced better quality of care at patent medicine vendors compared with pharmacies. They reported receiving more accurate information on what kinds of medicines they were prescribed, how to use them, and what to expect after using the medicines.
In an abortion-restrictive setting like Nigeria, local pharmacies and proprietary patent medicine vendors continue to play a major role in the provision of medication abortion, including misoprostol.
Drug sellers – particularly patent medicine vendors – are often the most accessible frontline health workers in many communities in Nigeria. In some settings they may indeed be the only healthcare provider immediately accessible to patients.
Our findings confirmed that drug sellers are important providers within the healthcare system. That they are trusted by individuals within the community. And that they can provide essential sexual reproductive healthcare including medication abortion.
Our evidence suggests they are an important part of the health system and can provide the same quality of care as pharmacies, or better. Also, women trust them. But the strength of patent medicine vendors is particularly underused in public health strategies compared with formal pharmacies.
To expand access to sexual reproductive health care commodities and services Nigeria should systematically train and integrate them into programmes and interventions. This has already been done with community health workers and traditional birth attendants for maternity care.
There is also a need to strengthen the capacity and skills of patent medicine vendors in dispensing and administration of medical abortion drugs. This would serve as an important harm reduction strategy. Also, the skills of frontline providers must be improved.
Dr. Onikepe Owolabi was at the Guttmacher Institute during the time of this research and continues to collaborate on this data with them.
Akanni Ibukun Akinyemi, Professor, Obafemi Awolowo University; Akinrinola Bankole, Senior Fellow, Guttmacher Institute; Melissa Stillman, Research Associate, Guttmacher Institute; Onikepe Owolabi, Public Health Researcher, Guttmacher Institute, and Temitope Erinfolami, PhD Candidate, Obafemi Awolowo University