1
|
Jacobson LE, Baum SE, Pearson E, Chowdhury R, Chakraborty NM, Goodman JM, Gerdts C, Darney BG. Client-reported quality of facility-managed medication abortion compared with pharmacy-sourced self-managed abortion in Bangladesh. BMJ SEXUAL & REPRODUCTIVE HEALTH 2024; 50:33-42. [PMID: 37699668 DOI: 10.1136/bmjsrh-2023-201931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 08/14/2023] [Indexed: 09/14/2023]
Abstract
OBJECTIVE We used the newly developed Abortion Care Quality Tool (ACQTool) to compare client-reported quality of medication abortion care by source (facility-managed vs pharmacy-sourced self-managed abortion (SMA)) in Bangladesh. METHODS We leveraged exit and 30-day follow-up surveys collected to develop and validate the ACQTool collected at nongovernmental organisation (NGO)-supported or -operated facilities in the public and private sector and pharmacies from three districts in Bangladesh. We used bivariate statistics to compare 18 client-reported quality indicators grouped in six domains and eight abortion outcomes, by source (facility vs pharmacy). We used multivariable logistic regression to identify factors associated with selected quality indicators and outcomes (abortion affordability, information provision, and knowing what to do for an adverse event), controlling for client sociodemographic characteristics. RESULTS Of 550 abortion clients, 146 (26.5%) received a facility-managed medication abortion and 404 (73.5%) had a pharmacy-sourced SMA. Clients reported higher quality in facilities for five indicators, and higher in pharmacies for two indicators; the remaining 11 indicators were not different by source. Compared with facility-based clients, pharmacy clients had higher odds of reporting that the cost of abortion was affordable (adjusted odds ratio (aOR) 3.55; 95% CI 2.27 to 5.58) but lower odds of reporting high information provision (aOR 0.14; 95% CI 0.09 to 0.23). Seven of eight abortion outcomes showed no differences; pharmacy clients had lower odds of knowing what to do if an adverse event occurred (aOR 0.45; 95% CI 0.23 to 0.82). CONCLUSIONS In Bangladesh, there is no difference in client-reported quality of medication abortion care between health facilities and pharmacies for the majority of quality and outcome indicators. However, information provision and preparedness were higher quality at facilities, while pharmacies were more affordable.
Collapse
Affiliation(s)
- Laura E Jacobson
- OHSU-PSU School of Public Health, Health Systems & Policy, Portland, Oregon, USA
| | - Sarah E Baum
- Ibis Reproductive Health, Oakland, California, USA
| | - Erin Pearson
- University of California San Diego, Center on Gender Equity and Health, La Jolla, California, USA
| | | | | | - Julia M Goodman
- OHSU-PSU School of Public Health, Health Systems & Policy, Portland, Oregon, USA
| | | | - Blair G Darney
- Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
| |
Collapse
|
2
|
Guilbert E, Bois G. Évaluation de l'information transmise sur l'avortement médicamenteux dans les cliniques d'avortement du Québec en 2021 - Partie 2. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:125-133. [PMID: 36567050 DOI: 10.1016/j.jogc.2022.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 11/14/2022] [Accepted: 11/14/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Communication of information is a key component of quality family planning services. It allows for an informed choice between surgical and medication abortion. METHODS Québec abortion clinics were contacted by 2 mystery client clinical profiles (PC) between October 8 and November 17, 2021. Data collection was done simultaneously by a data collector. The unit of analysis was the PC. Descriptive analyses and statistical tests were performed, as well as a qualitative analysis of the collected comments. RESULTS Of the 17 information topics deemed necessary for an informed choice, 35% were obtained spontaneously. These included what tests to perform (78%), professionals to meet before the procedure (77%), gestational age limit (64%), side effects (49%) (especially alarming ones), and the number of visits required (42%). On a score of 12, the average information quality score was 7.2 (standard deviation [SD] 2.7). A score of less than 7/12 was obtained by 41% of PCs. A high information quality score was associated with a perceived friendlier attitude of the person responding to the call, and the unprompted transmission of more information. For 51/78 PCs, abortifacient medications were served at the clinic, and for 13 of them, the first medication had to be taken in front of the physician. CONCLUSION The information received when calling Québec abortion clinics for an appointment for abortion was often insufficient and made it difficult to make an informed choice between the 2 methods of abortion. This may explain the low proportion of medication abortion in Québec.
Collapse
Affiliation(s)
- Edith Guilbert
- Département d'obstétrique, gynécologie et reproduction, Université Laval, Québec, QC.
| | - Geneviève Bois
- Département de médecine familiale et de médecine d'urgence, Université de Montréal, Montréal, QC
| |
Collapse
|
3
|
Sigdel A, Angdembe MR, Khanal P, Adhikari N, Maharjan A, Paudel M. Medical abortion drug dispensing practices among private pharmacy workers in Nepal: A mystery client study. PLoS One 2022; 17:e0278132. [PMID: 36417473 PMCID: PMC9683563 DOI: 10.1371/journal.pone.0278132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 11/09/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Pharmacies are the first point of contact for women seeking medical abortion (MA) and act as important sources of information and referral in Nepal. Over the counter sale of MA drugs is not currently allowed in Nepal. This study aimed to assess the MA drug dispensing practices of pharmacy workers using mystery clients in Nepal. METHODS A cross-sectional study using the mystery client approach was conducted in 266 pharmacies in September-October 2019. These pharmacies had either received harm reduction training or medical detailing visits. A total of 532 visits were conducted by six male and six female mystery clients. Mystery clients without prescription approached the sample pharmacy and filled out a standard digital survey questionnaire using the SurveyCTO application immediately after each interaction. RESULTS Pharmacy workers dispensed MA drugs in 35.7% of the visits while they refused to provide MA drugs to the mystery clients in 39.3% of visits. Lack of evidence of prior consultation with a physician (27.5%), referral to other health facilities (21.8%), unavailability of MA drugs in the pharmacy (21.3%) and lack of prescription (16.4%) were the main reasons for refusal. Seventy percent of the pharmacy workers inquired clients about last menstrual period/months of pregnancy while 38.1% asked whether the pregnancy status was confirmed. During 65.1% of the visits, mystery clients were told about when to take the MA drugs while in 66.4% of visits, they were told about the route of drug administration. Similarly, mystery clients were briefed about what to expect during the abortion process in half of the visits, and information about the possible side effects of the MA drug was provided in 55.9% of the visits. Pharmacy workers provided correct information on taking MA drugs to mystery clients in 70.7% of visits. CONCLUSION Despite legal provision of sale of MA drugs only on prescription, pharmacy workers dispensed MA drug in one out of three visits. As pharmacies are the initial contacts of women for abortion services in Nepal, correct supplementary information through pharmacy workers can be an effective strategy to expand access to quality safe abortion services.
Collapse
Affiliation(s)
- Anil Sigdel
- Population Services International, Lalitpur, Nepal
| | | | - Pratik Khanal
- Population Services International, Lalitpur, Nepal
- * E-mail:
| | | | | | | |
Collapse
|
4
|
Singh S, Shekhar C, Bankole A, Acharya R, Audam S, Akinade T. Key drivers of fertility levels and differentials in India, at the national, state and population subgroup levels, 2015-2016: An application of Bongaarts' proximate determinants model. PLoS One 2022; 17:e0263532. [PMID: 35130319 PMCID: PMC8820640 DOI: 10.1371/journal.pone.0263532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 01/20/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES The transition to small family size is at an advanced phase in India, with a national TFR of 2.2 in 2015-16. This paper examines the roles of four key determinants of fertility-marriage, contraception, abortion and postpartum infecundability-for India, all 29 states and population subgroups. METHODS Data from the most recent available national survey, the National Family Health Survey, conducted in 2015-16, were used. The Bongaarts proximate determinants model was used to quantify the roles of the four key factors that largely determine fertility. Methodological contributions of this analysis are: adaptations of the model to the Indian context; measurement of the role of abortion; and provision of estimates for sub-groups nationally and by state: age, education, residence, wealth status and caste. RESULTS Nationally, marriage is the most important determinant of the reduction in fertility from the biological maximum, contributing 36%, followed by contraception and abortion, contributing 24% and 23% respectively, and post-partum infecundability contributed 16%. This national pattern of contributions characterizes most states and subgroups. Abortion makes a larger contribution than contraception among young women and better educated women. Findings suggest that sterility and infertility play a greater than average role in Southern states; marriage practices in some Northeastern states; and male migration for less-educated women. The absence of stronger relationships between the key proximate fertility determinants and geography or socio-economic status suggests that as family size declined, the role of these determinants is increasingly homogenous. CONCLUSIONS Findings argue for improvements across all states and subgroups, in provision of contraceptive care and safe abortion services, given the importance of these mechanisms for implementing fertility preferences. In-depth studies are needed to identify policy and program needs that depend on the barriers and vulnerabilities that exist in specific areas and population groups.
Collapse
Affiliation(s)
- Susheela Singh
- Guttmacher Institute, New York, New York, United States of America
| | - Chander Shekhar
- Department of Fertility Studies, International Institute for Population Sciences (IIPS), Mumbai, India
| | | | | | - Suzette Audam
- Guttmacher Institute, New York, New York, United States of America
| | - Temitope Akinade
- Guttmacher Institute, New York, New York, United States of America
| |
Collapse
|
5
|
Biggs MA, Ralph L, Morris N, Ehrenreich K, Perritt J, Kapp N, Blanchard K, White K, Barar R, Grossman D. A cross-sectional survey of U.S. abortion patients’ interest in obtaining medication abortion over the counter. Contraception 2022; 109:25-31. [DOI: 10.1016/j.contraception.2022.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/08/2022] [Accepted: 01/12/2022] [Indexed: 11/15/2022]
|
6
|
Durocher J, Kilfedder C, Frye LJ, Winikoff B, Srinivasan K. A descriptive analysis of medical abortion commodity availability and pricing at retail outlets in 44 countries across four regions globally. Sex Reprod Health Matters 2021; 29:1982460. [PMID: 34719353 PMCID: PMC8567879 DOI: 10.1080/26410397.2021.1982460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Pharmacies in low- and middle-income countries play an important role in increasing the availability of medical abortion to individuals for self-use. We aimed to document the costs to users of medical abortion products at outlets across geographies and understand the diversity of available products, primarily in low- and middle-income countries or in places where access to abortion is restricted. A descriptive analysis of price data was completed for identified medical abortion products at retail outlets visited in 44 countries from November 2017 to February 2018. Median prices and ranges are reported in $US for mifepristone 200 mg tablets, misoprostol 200 mcg tablets, and combipacks. Misoprostol, mifepristone, and combipacks were found in 44, 19, and 16 countries, respectively. Nearly two-thirds of products (321/508) required a prescription. The median price of misoprostol was $0.63 per tablet (range $0.09–$27.63) based on 304 price points. Mifepristone and combipacks had fewer price points available (n = 59 and n = 44, respectively). Median prices were $11.78 per mifepristone tablet (range $1.77–$37.83) and $11.18 per combipack (range $3.50–$35.86). Overall, prices were highest in Latin America and lowest in South/Southeast Asia. Only 11.5% (7/61) of the total unique misoprostol brands were quality-assured (i.e. approved by a stringent regulatory authority or pre-qualified by the World Health Organization), compared to 25.0% (4/16) of unique combipack products. There was wide variation in product pricing and availability across settings. The infrequent availability of mifepristone and combipacks, in addition to the limited availability of quality-assured medicines and high cost of abortion medications, are important factors affecting access to high-quality abortion care.
Collapse
Affiliation(s)
- Jill Durocher
- Senior Director, Gynuity Health Projects, New York, NY, USA. Correspondence:
| | - Catherine Kilfedder
- Senior Programme Adviser, International Planned Parenthood Federation, London, UK
| | - Laura J Frye
- Director, Gynuity Health Projects, New York, NY, USA
| | | | - Karthik Srinivasan
- Chief Medical Adviser, International Planned Parenthood Federation, London, UK
| |
Collapse
|
7
|
Percher J, Saxena M, Srivastava A, Diamond-Smith N. Differential treatment in the provision of medication abortion at pharmacies in Uttar Pradesh, India. AJOG GLOBAL REPORTS 2021; 1:100025. [PMID: 36277455 PMCID: PMC9563544 DOI: 10.1016/j.xagr.2021.100025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND OBJECTIVE STUDY DESIGN RESULTS CONCLUSION
Collapse
|
8
|
Sunil B. Running an obstacle-course: a qualitative study of women's experiences with abortion-seeking in Tamil Nadu, India. Sex Reprod Health Matters 2021; 29:e1966218. [PMID: 34651568 PMCID: PMC8525933 DOI: 10.1080/26410397.2021.1966218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Irrespective of the legal status of abortion, access to abortion services for women is fraught with numerous challenges across the world. A recent study in India found that most women who had an abortion sought care outside an authorised facility or from a less qualified provider. An analysis of women’s experiences in seeking abortion services would provide a better understanding of the underlying reasons. This paper is based on a qualitative study of the experiences of 16 married women from rural Tamil Nadu, India. The in-depth interviews focused on their pregnancy and childbirth experiences and access to abortion services. The study highlights the obstacle course that women seeking to terminate an unwanted pregnancy have to traverse. Many women were not aware of the legal status of abortion, and frontline workers discouraged them and gave misleading information. The pathways to seeking an abortion were more complex for women from marginalised communities. Providers were judgemental and used delaying tactics or denied abortion services. For the less privileged women, abortion services from government health facilities were conditional on the acceptance of female sterilisation. The providers’ attitudes in government and private health facilities were disrespectful of the women seeking abortion services. To uphold the reproductive and human rights of women who seek abortion services, we need accessible and publicly funded health care services that respect the dignity of all women, are empathetic and uphold women’s right to safe abortion services.
Collapse
|
9
|
Qureshi Z, Mehrtash H, Kouanda S, Griffin S, Filippi V, Govule P, Thwin SS, Bello FA, Gadama L, Msusa AT, Idi N, Goufodji S, Kim CR, Wolomby-Molondo JJ, Mugerwa KY, Bique C, Adanu R, Fawole B, Madjadoum T, Gülmezoglu AM, Ganatra B, Tunçalp Ö. Understanding abortion-related complications in health facilities: results from WHO multicountry survey on abortion (MCS-A) across 11 sub-Saharan African countries. BMJ Glob Health 2021; 6:bmjgh-2020-003702. [PMID: 33514590 PMCID: PMC7845704 DOI: 10.1136/bmjgh-2020-003702] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 12/04/2020] [Accepted: 12/09/2020] [Indexed: 12/03/2022] Open
Abstract
Introduction Complications due to unsafe abortions are an important cause of morbidity and mortality in many sub-Saharan African countries. We aimed to characterise abortion-related complication severity, describe their management, and to report women’s experience of abortion care in Africa. Methods A cross-sectional study was implemented in 210 health facilities across 11 sub-Saharan African countries. Data were collected on women’s characteristics, clinical information and women’s experience of abortion care (using the audio computer-assisted self-interviewing (ACASI) system). Severity of abortion complications were organised in five hierarchical mutually exclusive categories based on indicators present at assessment. Descriptive bivariate analysis was performed for women’s characteristics, management of complications and reported experiences of abortion care by severity. Generalised linear estimation models were used to assess the association between women’s characteristics and severity of complications. Results There were 13 657 women who had an abortion-related complication: 323 (2.4%) women were classified with severe maternal outcomes, 957 (7.0%) had potentially life-threatening complications, 7953 (58.2%) had moderate complications and 4424 (32.4%) women had mild complications. Women who were single, multiparous, presenting ≥13 weeks of gestational age and where expulsion of products of conception occurred prior to arrival to facility were more likely to experience severe complications. For management, the commonly used mechanical methods of uterine evacuation were manual vacuum aspiration (76.9%), followed by dilation and curettage (D&C) (20.1%). Most frequently used uterotonics were oxytocin (50∙9%) and misoprostol (22.7%). Via ACASI, 602 (19.5%) women reported having an induced abortion. Of those, misoprostol was the most commonly reported method (54.3%). Conclusion There is a critical need to increase access to and quality of evidence-based safe abortion, postabortion care and to improve understanding around women’s experiences of abortion care.
Collapse
Affiliation(s)
- Zahida Qureshi
- Department of Obstetrics and Gynaecology, School of Medicine, University of Nairobi, Nairobi, Kenya
| | - Hedieh Mehrtash
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and ResearchTraining in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Seni Kouanda
- Institut de Recherche en Science de la Santé, Burkina Faso and Institut africain de Santé Publique, Ouagadougou, Burkina Faso
| | - Sally Griffin
- Centro Internacional Para Saúde Reprodutiva (ICRH-M), Maputo, Mozambique
| | - Veronique Filippi
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Philip Govule
- Department of Epidemiology and Disease Control, School of Public Health, University of Ghana, Accra, Ghana
| | - Soe Soe Thwin
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and ResearchTraining in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | - Luis Gadama
- College of Medicine, Department of Obstetrics and Gynaecology, University of Malawi, Zomba, Malawi
| | - Ausbert Thoko Msusa
- Centre for Reproductive Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Nafiou Idi
- Université Abdou Moumouni de Niamey, Niamey, Niger
| | - Sourou Goufodji
- Centre de Recherche en Reproduction Humaine et en Démographie (CERRHUD), Cotonou, Benin
| | - Caron Rahn Kim
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and ResearchTraining in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | | | - Cassimo Bique
- Mozambican Society of Obstetrician and Gynaecologists (AMOG), Maputo, Mozambique
| | - Richard Adanu
- Department of Population, Family and Reproductive Health, University of Ghana School of Public Health, Accra, Ghana
| | - Bukola Fawole
- Department of Obstetrics and Gynaecology, University of Ibadan, Ibadan, Nigeria
| | | | - Ahmet Metin Gülmezoglu
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and ResearchTraining in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Bela Ganatra
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and ResearchTraining in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Özge Tunçalp
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and ResearchTraining in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| |
Collapse
|
10
|
Kaller S, Morris N, Biggs MA, Baba CF, Rafie S, Raine-Bennett TR, Creinin MD, Berry E, Micks EA, Meckstroth KR, Averbach S, Grossman D. Pharmacists' knowledge, perspectives, and experiences with mifepristone dispensing for medication abortion. J Am Pharm Assoc (2003) 2021; 61:785-794.e1. [PMID: 34281806 DOI: 10.1016/j.japh.2021.06.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/15/2021] [Accepted: 06/15/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND The U.S. Food and Drug Administration (FDA) restricts dispensing of mifepristone for medication abortion to certified health care providers at clinical facilities, thus prohibiting pharmacist dispensing. Allowing mifepristone dispensing by pharmacists could improve access to medication abortion. OBJECTIVE To assess the feasibility of pharmacists dispensing mifepristone to patients who have undergone evaluation for eligibility and counseling for medication abortion by a clinician. METHODS Before providing a study training on medication abortion, we administered baseline surveys to pharmacists who participated in a multisite mifepristone-dispensing intervention. The survey assessed medication abortion knowledge-using a 15-item score-and perceptions about the benefits and challenges of the model. We administered follow-up surveys in the study's final month that also assessed the pharmacists' satisfaction and experiences with mifepristone dispensing. To investigate the association of the study intervention with the pharmacists' knowledge, perceptions, and experiences dispensing mifepristone, we conducted multivariable linear regression analyses using generalized estimating equation models, accounting for clustering by individual. RESULTS Among the 72 pharmacists invited from 6 pharmacies, 47 (65%) completed the baseline surveys, and 56 (78%) received training. At the study's end (mean 18 months later), 43 of the 56 pharmacists who received training (77%) completed the follow-up surveys. At follow-up, 36 (83%) respondents were very or somewhat satisfied with mifepristone dispensing, and 24 (56%) reported experiencing no challenges dispensing mifepristone. Four (6%) of the 72 pharmacists invited objected to participating in mifepristone dispensing. In regression analyses, average knowledge scores, perceived ease of implementation, and level of support for the pharmacist-dispensing model were higher at follow-up (P < 0.001). CONCLUSION Most pharmacists were willing to be trained, dispensed mifepristone with few challenges when given the opportunity, were satisfied with the model, and had higher knowledge levels at follow-up. Our findings support removal of FDA's restriction on pharmacist dispensing of mifepristone.
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
Footman K, Chelwa N, Douthwaite M, Mdala J, Mulenga D, Brander C, Church K. Treading the Thin Line: Pharmacy Workers' Perspectives on Medication Abortion Provision in Lusaka, Zambia. Stud Fam Plann 2021; 52:179-194. [PMID: 33826147 DOI: 10.1111/sifp.12151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
CONTEXT Despite liberal abortion laws, safe abortion access in Zambia is impeded by limited legal awareness, lack of services, and restrictive clinical policies. As in many countries with restricted abortion access, women frequently seek abortions informally from pharmacies. METHODS We conducted 16 in-depth interviews in 2019 to understand the experiences and motivations of pharmacy workers who sell medication abortion (MA) drugs in Lusaka. RESULTS We found that pharmacy staff reluctantly assume a gatekeeper role for MA due to competing pressures from clients and from regulatory constraints. Pharmacy staff often decide to provide MA, motivated by their duty of care and desire to help clients, as well as financial interests. However, pharmacy workers' motivation to protect themselves from legal and business risk perpetuates inequalities in abortion access, as pharmacy workers improvise additional eligibility criteria based on personal risk and values such as age, partner approval, reason for abortion, and level of desperation. CONCLUSION These findings highlight how pharmacy staff informally determine women's abortion access when laws and policies prevent comprehensive access to safe abortion. Reform of clinical guidelines, public education, strengthened public sector availability, task sharing, and improved access to prescription services are needed to ensure women can legally access safe abortion.
Collapse
Affiliation(s)
- Katharine Footman
- MSI Reproductive Choices, London, W1T 6LP, UK.,Department of Social Policy, London School of Economics and Political Science
| | | | | | | | | | | | | |
Collapse
|
13
|
Dangi NB, Subedi S, Gyawali M, Bhattarai A, Bhandari TR. Medical abortion kit dispensing practices of community pharmacies in Pokhara Metropolitan, Nepal. PLoS One 2021; 16:e0244969. [PMID: 33439882 PMCID: PMC7806136 DOI: 10.1371/journal.pone.0244969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 12/18/2020] [Indexed: 11/18/2022] Open
Abstract
Background Medical abortion (MA) refers to the use of medicines to terminate the pregnancy. There is an urgent need to spread safe abortion services in the community. This study assessed the MA kit dispensing practices of community pharmacies in Pokhara Valley, Nepal. Methods A cross-sectional descriptive study was conducted in Pokhara Valley, Nepal from December 2017 to November 2018. Among the community pharmacies of Pokhara Valley, 115 community pharmacies were selected using a consecutive sampling method. A semi-structured questionnaire was used to collect data. MA kit and related information were requested by simulated male clients visiting the community pharmacies. The information obtained from the pharmacy workers was recorded in the data collection sheet. Results Nine brands of MA kit from eight manufacturing companies were found in practice in Pokhara Valley, out of those only five (56%) were registered in Nepal. Seven brands were sold at more than the labeled price. The pharmacy workers asked about the gestational age and confirmation of pregnancy in all the cases. Most of them counseled the clients on the frequency, duration, and direction of use. Dispensing practice and level of counseling were found to be significantly correlated (r = 0.40, p value = 0.01). Conclusion Despite the awareness of the pharmacy workers on the MA kit, most of them provided limited information to the clients. Nearly half unregistered MA kits were found in practice at the community pharmacies. Thus, the Department of Drugs Administration and other concerned authorities must provide relevant training and awareness programs to the pharmacy workers of the community pharmacies for preventing the malpractice of MA kit. The Government of Nepal must restrict the illegal entry of unregistered brands and assure the standards of MA kit by regulating drug acts and policies effectively.
Collapse
Affiliation(s)
- Nim Bahadur Dangi
- Faculty of Health Sciences, School of Health and Allied Sciences, Pokhara University, Pokhara, Nepal
- * E-mail:
| | - Sangam Subedi
- Faculty of Health Sciences, School of Health and Allied Sciences, Pokhara University, Pokhara, Nepal
| | - Mahasagar Gyawali
- Janamaitri Foundation Institute of Health Sciences (JFIHS), Hattiban, Lalitpur, Nepal
| | - Aashish Bhattarai
- Faculty of Health Sciences, School of Health and Allied Sciences, Pokhara University, Pokhara, Nepal
| | - Tulsi Ram Bhandari
- Faculty of Health Sciences, School of Health and Allied Sciences, Pokhara University, Pokhara, Nepal
| |
Collapse
|
14
|
Singh S, Hussain R, Shekhar C, Acharya R, Stillman M, Moore AM. Incidence of treatment for postabortion complications in India, 2015. BMJ Glob Health 2020; 5:e002372. [PMID: 32690482 PMCID: PMC7371025 DOI: 10.1136/bmjgh-2020-002372] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 05/28/2020] [Accepted: 06/02/2020] [Indexed: 11/05/2022] Open
Abstract
Abortion has been legal under broad criteria in India since 1971. However, access to legal abortion services remains poor. In the past decade, medication abortion (MA) has become widely available in India and use of this method outside of health facilities accounts for over 70% of all abortions. Morbidity from unsafe abortion remains an important health issue. The informal providers who are the primary source of MA may have poor knowledge of the method and may offer inadequate or inaccurate advice on use of the method. Misuse of the method can result in women seeking treatment for true complications as well as during the normal processes of MA. An estimated 5% of all abortions are done using highly unsafe methods and performed by unskilled providers, also contributing to abortion morbidity. This paper provides new representative abortion-related morbidity measures at the national and subnational levels from a large-scale 2015 study of six Indian states-Assam, Bihar, Gujarat, Madhya Pradesh, Tamil Nadu and Uttar Pradesh. The outcomes include the number and treatment rates of women with complications resulting from induced abortion and the type of complications. The total number of women treated for abortion complications at the national level is 5.2 million, and the rate is 15.7 per 1000 women of reproductive age per year. In all six study states, a high proportion of all women receiving postabortion care were admitted with incomplete abortion from use of MA-ranging from 33% in Tamil Nadu to 65% in Assam. The paper fills an important gap by providing new evidence that can inform policy-makers and health planners at all levels and lead to improvements in the provision of postabortion care and legal abortion services-improvements that would greatly reduce abortion-related morbidity and its costs to Indian women, their families and the healthcare system.
Collapse
Affiliation(s)
| | | | - Chander Shekhar
- Fertility Studies, International Institute for Population Sciences, Mumbai, India
| | | | | | - Ann M Moore
- Research, Guttmacher Institute, New York, New York, USA
| |
Collapse
|