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Freeman C, Rodríguez S. The chemical geographies of misoprostol: Spatializing abortion access from the biochemical to the global. ANNALS OF THE AMERICAN ASSOCIATION OF GEOGRAPHERS 2024; 114:123-138. [PMID: 38204958 PMCID: PMC7615505 DOI: 10.1080/24694452.2023.2242453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/26/2023] [Indexed: 01/12/2024]
Abstract
C22W38O5 is a chemical that travels. Better known as misoprostol, it was designed as a stomach ulcer drug but is now used around the world as an abortion pill due to the self-experimentation of Latin American communities who were seeking ways to end unwanted pregnancies. We develop a chemical geography approach to misoprostol that allows us to scale inward to understand the chemical properties of this medication while also being able to scale out to understand how medicinal effects are interwoven with and determined by global politics. Misoprostol as a chemical alone does not guarantee a successful abortion and instead 'scaffolding' in the form of mobility and information is required to transform misoprostol from a chemical to a safe and effective technology of abortion. First, we examine how misoprostol is moved by feminist networks in Mexico and Peru. Second, we argue that in order to be useful it is not enough just to access the pills, information on how to use them is required. These themes culminate in our contribution of 'pharmacokinetical geographies'; the micro-geography of the placement of pharmaceuticals in and on a body and its ramifications. The chemical geographies of misoprostol tell a story of power, bodily autonomy, and resistance.
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Affiliation(s)
- Cordelia Freeman
- Department of Geography, University of Exeter. Amory Building, Rennes Drive, Exeter, EX4 4RJ
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Rodriguez MI, Edelman A, Hersh A, Gartoulla P, Henderson J. Medical abortion offered in pharmacy versus clinic-based settings. Cochrane Database Syst Rev 2021; 6:CD013566. [PMID: 34114643 PMCID: PMC8193989 DOI: 10.1002/14651858.cd013566.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Medical abortion is usually offered in a clinic or hospital, but could potentially be offered in other settings such as pharmacies. In many countries, pharmacies are a common first point of access for women seeking reproductive health information and services. Offering medical abortion through pharmacies is a potential strategy to improve access to abortion. OBJECTIVES To compare the effectiveness and safety of medical abortion offered in pharmacy settings with clinic-based medical abortion. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, four other databases, two trials registries and grey literature websites in November 2020. We also handsearched key references and contacted authors to locate unpublished studies or studies not identified in the database searches. SELECTION CRITERIA We identified studies that compared women receiving the same regimen of medical abortion or post-abortion care in either a clinic or pharmacy setting. Studies published in any language employing the following designs were included: randomized trials and non-randomized studies including a comparative group. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed both retrieved abstracts and full-text publications. A third author was consulted in case of disagreement. We intended to use the Cochrane risk of bias tool, RoB 2, for randomized studies and used the ROBINS-I tool (Risk Of Bias In Non-randomized Studies of Interventions) to assess risk of bias in non-randomized studies. GRADE methodology was used to assess the certainty of the evidence. The primary outcomes were completion of abortion without additional intervention, need for blood transfusion, and presence of uterine or systemic infection within 30 days of medical abortion. MAIN RESULTS Our search yielded 2030 records. We assessed a total of 89 full-text articles for eligibility. One prospective cohort study met our inclusion criteria. The included study collected data on outcomes from 605 women who obtained a medical abortion in Nepal from either a clinic or pharmacy setting. Both sites of care were staffed by the same auxiliary nurse midwives. Over all domains, the risk of bias was judged to be low for our primary outcome. During the pre-intervention period, the study's investigators identified a priori appropriate confounders, which were clearly measured and adjusted for in the final analysis. For women who received medical abortion in a pharmacy setting, compared to a clinic setting, there may be little or no difference in complete abortion rates (adjusted risk difference (RD)) 1.5, 95% confidence interval (CI) -0.8 to 3.8; 1 study, 600 participants; low certainty evidence). The study reported no cases of blood transfusion, and a composite outcome, comprised mainly of infection complications, showed there may be little or no difference between settings (adjusted RD 0.8, 95% CI -1.0 to 2.8; 1 study, 600 participants; very low certainty evidence). The study reported no events for hospital admission for an abortion-related event or need for surgical intervention, and there may be no difference in women reporting being highly satisfied with the facility where they were seen (38% pharmacy versus 34% clinic, P = 0.87; 1 study, 600 participants; low certainty evidence). AUTHORS' CONCLUSIONS Conclusions about the effectiveness and safety of pharmacy provision of medical abortion are limited by the lack of comparative studies. One study, judged to provide low certainty evidence, suggests that the effectiveness of medical abortion may not be different between the pharmacy and clinic settings. However, evidence for safety is insufficient to draw any conclusions, and more research on factors contributing to potential differences in quality of care is needed. It is important to note that this study included a care model where a clinician provided services in a pharmacy, not direct provision of care by pharmacists or pharmacy staff. Three ongoing studies are potentially eligible for inclusion in review updates. More research is needed because pharmacy provision could expand timely access to medical abortion, especially in settings where clinic services may be more difficult to obtain. Evidence is particularly limited on the patient experience and how the care process and quality of services may differ across different types of settings.
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Affiliation(s)
- Maria I Rodriguez
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
| | - Alison Edelman
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
| | - Alyssa Hersh
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
| | | | - Jillian Henderson
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
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de Castro F, Place JM, Allen-Leigh B, Barrientos-Gutierrez T, Dues K, Eternod Arámburu M, Hernández-Avila M. Perceptions of adolescent 'simulated clients' on barriers to seeking contraceptive services in health centers and pharmacies in Mexico. SEXUAL & REPRODUCTIVE HEALTHCARE 2018; 16:118-123. [PMID: 29804755 DOI: 10.1016/j.srhc.2018.03.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 02/06/2018] [Accepted: 03/13/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To examine adolescent simulated clients' perceived barriers to quality care as they sought information on contraceptives in public-sector healthcare facilities and pharmacies in Mexico. STUDY DESIGN We used a qualitative research design and conducted semi-structured interviews with eight young women who posed as simulated clients at health centers and pharmacies in Mexico City. Grounded Theory was used to analyze the transcripts. RESULTS Barriers to receiving information about contraceptives included healthcare professionals who gave administrative pretexts to avoid providing services. Simulated clients also felt judged by healthcare professionals and reported a lack of simple, understandable and pertinent information. Healthcare professionals did not ensure clients understood and had no further questions about using contraceptives, which resulted in clients' poor perceived self-efficacy, as well as a lack of confidence in the healthcare system to help them. CONCLUSIONS When healthcare professionals fail to provide services according to the World Health Organization's five basic criteria of adolescent friendly care, adolescents perceive important barriers in their access to contraceptive methods. Quality of sexual health care in Mexico would benefit from efforts to improve healthcare professionals' knowledge, attitudes and skills related to adolescent friendly service delivery.
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Affiliation(s)
- Filipa de Castro
- Reproductive Health Division, Center for Population Health Research, National Institute of Public Health, Cuernavaca, Mexico; Universidad No. 655 Colonia Santa Maria Ahuacatitlan, Cerrada Los Pinos y Caminera, C.P. 62100 Cuernavaca, Morelos, Mexico
| | - Jean Marie Place
- Ball State University, Department of Nutrition and Health Science, Muncie, IN, USA; Department of Nutrition and Health Science, Cooper Science Building, CL 325, Ball State University, Muncie, IN 47306, USA.
| | - Betania Allen-Leigh
- Reproductive Health Division, Center for Population Health Research, National Institute of Public Health, Cuernavaca, Mexico; Universidad No. 655 Colonia Santa Maria Ahuacatitlan, Cerrada Los Pinos y Caminera, C.P. 62100 Cuernavaca, Morelos, Mexico
| | - Tonatiuh Barrientos-Gutierrez
- Reproductive Health Division, Center for Population Health Research, National Institute of Public Health, Cuernavaca, Mexico; Universidad No. 655 Colonia Santa Maria Ahuacatitlan, Cerrada Los Pinos y Caminera, C.P. 62100 Cuernavaca, Morelos, Mexico
| | - Kiya Dues
- Ball State University, Department of Nutrition and Health Science, Muncie, IN, USA; Department of Nutrition and Health Science, Cooper Science Building, CL 325, Ball State University, Muncie, IN 47306, USA
| | - Marcela Eternod Arámburu
- National Institute of Women of Mexico, Blvd. Adolfo Lopez Mateos 3325, Piso 5., San Jeronimo Lidice, Distrito Federal. CP 10200, Mexico
| | - Mauricio Hernández-Avila
- Reproductive Health Division, Center for Population Health Research, National Institute of Public Health, Cuernavaca, Mexico; Universidad No. 655 Colonia Santa Maria Ahuacatitlan, Cerrada Los Pinos y Caminera, C.P. 62100 Cuernavaca, Morelos, Mexico
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Reiss K, Footman K, Burke E, Diop N, Ndao R, Mane B, van Min M, Ngo TD. Knowledge and provision of misoprostol among pharmacy workers in Senegal: a cross sectional study. BMC Pregnancy Childbirth 2017; 17:211. [PMID: 28673342 PMCID: PMC5496238 DOI: 10.1186/s12884-017-1394-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 06/22/2017] [Indexed: 11/24/2022] Open
Abstract
Background Making misoprostol widely available for management of postpartum haemorrhage (PPH) and post abortion care (PAC) is essential for reducing maternal mortality. Private pharmacies (thereafter called “pharmacies”) are integral in supplying medications to the general public in Senegal. In the case of misoprostol, pharmacies are also the main supplier to public providers and therefore have a key role in increasing its availability. This study seeks to understand knowledge and provision of misoprostol among pharmacy workers in Dakar, Senegal. Methods A cross-sectional survey was conducted in Dakar, Senegal. 110 pharmacy workers were interviewed face-to-face to collect information on their knowledge and practice relating to the provision of misoprostol. Results There are low levels of knowledge about misoprostol uses, registration status, treatment regimens and side effects among pharmacy workers, and corresponding low levels of training on its uses for reproductive health. Provision of misoprostol was low; of the 72% (n = 79) of pharmacy workers who had heard of the product, 35% (n = 27) reported selling it, though rarely for reproductive health indications. Almost half (49%, n = 25) of the respondents who did not sell misoprostol expressed willingness to do so. The main reasons pharmacy workers gave for not selling the product included stock outs (due to product unavailability from the supplier), perceived lack of demand and unwillingness to stock an abortifacient. Conclusions Knowledge and availability of misoprostol in pharmacies in Senegal is low, posing potential challenges for delivery of post-abortion care and obstetric care. Training is required to address low levels of knowledge of misoprostol registration and uses among pharmacy workers. Barriers that prevent pharmacy workers from stocking misoprostol, including weaknesses in the supply chain and stigmatisation of the product must be addressed. Low reported sales for reproductive health indications also suggest limited prescribing of the product by health providers. Further research is needed to explore the reasons for this barrier to misoprostol availability.
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Affiliation(s)
- Kate Reiss
- Health Systems Department, Marie Stopes International, 1 Conway Street, London, W1T 6LP, UK
| | - Katharine Footman
- Health Systems Department, Marie Stopes International, 1 Conway Street, London, W1T 6LP, UK.
| | - Eva Burke
- Marie Stopes International Senegal, Sacre Coeur III, 10082 VDN, Dakar, Senegal
| | - Nafissatou Diop
- Population Council Senegal, Sacre Coeur Pyrotechnie, Appartement 2ème Etage à Droite, BP: 21027, Dakar, Ponty, Senegal
| | - Ramatoulaye Ndao
- Marie Stopes International Senegal, Sacre Coeur III, 10082 VDN, Dakar, Senegal
| | - Babacar Mane
- Population Council Senegal, Sacre Coeur Pyrotechnie, Appartement 2ème Etage à Droite, BP: 21027, Dakar, Ponty, Senegal
| | - Maaike van Min
- Health Systems Department, Marie Stopes International, 1 Conway Street, London, W1T 6LP, UK
| | - Thoai D Ngo
- Health Systems Department, Marie Stopes International, 1 Conway Street, London, W1T 6LP, UK
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Wainwright M, Colvin CJ, Swartz A, Leon N. Self-management of medical abortion: a qualitative evidence synthesis. REPRODUCTIVE HEALTH MATTERS 2016; 24:155-67. [PMID: 27578349 DOI: 10.1016/j.rhm.2016.06.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 06/25/2016] [Accepted: 06/26/2016] [Indexed: 11/28/2022] Open
Abstract
Medical abortion is a method of pregnancy termination that by its nature enables more active involvement of women in the process of managing, and sometimes even administering the medications for, their abortions. This qualitative evidence synthesis reviewed the global evidence on experiences with, preferences for, and concerns about greater self-management of medical abortion with lesser health professional involvement. We focused on qualitative research from multiple perspectives on women's experiences of self-management of first trimester medical abortion (<12weeks gestation). We included research from both legal and legally-restricted contexts whether medical abortion was accessed through formal or informal systems. A review team of four identified 36 studies meeting inclusion criteria, extracted data from these studies, and synthesized review findings. Review findings were organized under the following themes: general perceptions of self-management, preparation for self-management, logistical considerations, issues of choice and control, and meaning and experience. The synthesis highlights that the qualitative evidence base is still small, but that the available evidence points to the overall acceptability of self-administration of medical abortion. We highlight particular considerations when offering self-management options, and identify key areas for future research. Further qualitative research is needed to strengthen this important evidence base.
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Affiliation(s)
- Megan Wainwright
- Postdoctoral Research Fellow, Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, South Africa.
| | - Christopher J Colvin
- Associate Professor, Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Alison Swartz
- Lecturer, Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Natalie Leon
- Specialist Scientist, Medical Research Council, South Africa
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Evidence of global demand for medication abortion information: an analysis of www.medicationabortion.com. Contraception 2013; 89:174-80. [PMID: 24360644 DOI: 10.1016/j.contraception.2013.05.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 05/09/2013] [Accepted: 05/10/2013] [Indexed: 01/23/2023]
Abstract
INTRODUCTION The worldwide expansion of the Internet offers an important modality of disseminating medically accurate information about medication abortion. We chronicle the story of www.medicationabortion.com, an English-, Spanish-, Arabic- and French-language website dedicated to three early abortion regimens. METHODS We evaluated the website use patterns from 2005 through 2009. We also conducted a content and thematic analysis of 1910 emails submitted during this period. RESULTS The website experienced steady growth in use. In 2009, it received 35,000 visits each month from more than 20,000 unique visitors and was accessed by users in 208 countries and territories. More than half of all users accessed the website from a country in which abortion is legally restricted. Users from more than 40 countries sent emails with individual questions. Women often wrote in extraordinary detail about the circumstances of their pregnancies and attempts to obtain an abortion. These emails also reflect considerable demand for information about the use of misoprostol for self-induction. CONCLUSION The use patterns of www.medicationabortion.com indicate that there is significant demand for online information about abortion, and the findings suggest future priorities for research, collaboration and educational outreach.
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Sneeringer RK, Billings DL, Ganatra B, Baird TL. Roles of pharmacists in expanding access to safe and effective medical abortion in developing countries: a review of the literature. J Public Health Policy 2012; 33:218-29. [PMID: 22402571 PMCID: PMC3510770 DOI: 10.1057/jphp.2012.11] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Unsafe abortion continues to be a major contributor to maternal mortality and morbidity around the world. This article examines the role of pharmacists in expanding women's access to safe medical abortion in Latin America, Africa, and Asia. Available research shows that although pharmacists and pharmacy workers often sell abortion medications to women, accurate information about how to use the medications safely and effectively is rarely offered. No publication covered effective interventions by pharmacists to expand access to medical abortion, but lessons can be learned from successful interventions with other reproductive health services. To better serve women, increasing awareness and improving training for pharmacists and pharmacy workers about unsafe abortion - and medications that can safely induce abortion - are needed.
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Affiliation(s)
- Robyn K Sneeringer
- Medical Abortion Initiative, Ipas, 300 Market Street, Suite 200, Chapel Hill, NC 27516, USA. E-mail:
| | - Deborah L Billings
- Arnold School of Public Health, Health Promotion, Education and Behavior & Women's and Gender Studies, University of South Carolina, Health Sciences Building, 401 800 Sumter Street, Columbia, SC 29208, USA
| | - Bela Ganatra
- Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland
| | - Traci L Baird
- Medical Abortion Initiative, Ipas, 300 Market Street, Suite 200, Chapel Hill, NC 27516, USA. E-mail:
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Stenson AL, Kapungu CT, Geller SE, Miller S. Navigating the challenges of global reproductive health research. J Womens Health (Larchmt) 2010; 19:2101-7. [PMID: 20849297 PMCID: PMC3004132 DOI: 10.1089/jwh.2010.2065] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Reproductive health research in low-resource settings poses unique and complex challenges that must be addressed to ensure that global research is conducted with strict adherence to ethical principles, offers direct benefit to the research subjects, and has the potential for adoption of positive findings to the target population. This article addresses challenges to conducting reproductive health research in low-resource settings in the following areas: (1) establishment and maintenance of global collaboration, (2) community partnerships, (3) ethical issues, including informed consent and the role of incentives, (4) staff training and development, (5) data collection and management, and (6) infrastructure and logistics. Particular attention to these challenges is important to ensure that research is culturally appropriate and methodologically sound and enhances the adoption of health-promoting behaviors. Rigorous evaluation of interventions in low-resource settings may be a cost-effective and time-efficient way to identify interventions for large-scale program replication to improve women's health.
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Affiliation(s)
- Amy L Stenson
- David Geffen School of Medicine at the University of California, Los Angeles, California 90095, USA.
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Pharmacy worker practices related to use of misoprostol for abortion in one Mexican state. Contraception 2009; 79:445-51. [DOI: 10.1016/j.contraception.2008.12.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2008] [Revised: 12/23/2008] [Accepted: 12/23/2008] [Indexed: 11/19/2022]
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Foster AM, Wynn L, Rouhana A, Diaz-Olavarrieta C, Schaffer K, Trussell J. Providing medication abortion information to diverse communities: use patterns of a multilingual web site. Contraception 2006; 74:264-71. [PMID: 16904422 DOI: 10.1016/j.contraception.2006.03.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2006] [Revised: 03/17/2006] [Accepted: 03/20/2006] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study analyzes the use patterns of , an English-, Spanish-, Arabic- and French-language web site dedicated to three methods of early pregnancy termination: mifepristone/misoprostol, methotrexate/misoprostol and misoprostol alone. METHODS This study examines both the overall and language-specific use patterns of the web site from October 1, 2004, through September 30, 2005. Data were recorded using Wusage 8.0, a web site statistics program. RESULTS Over the 12-month study period, received more than 78,000 visits and nearly 240,000 page requests. The English version is the most popular version of the web site (accessed in 46.1% of all visits), followed by the Spanish (35.0%), Arabic (10.4%) and French (8.8%) versions. Spanish-language visits are nearly three times as likely to access the misoprostol-only section of the web site when compared with the other language versions (p<.001). CONCLUSION This study confirms that multilingual, medically accurate online resources have the potential to expand information about medication abortion to both providers and women considering the option of abortion in diverse communities. Analysis of the language-specific use patterns highlights the different priorities of various types of web site visitors and suggests future priorities for educational outreach, collaboration and research.
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Affiliation(s)
- Angel M Foster
- Ibis Reproductive Health, 2 Brattle Square, Cambridge, MA 02138, USA.
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