How safe is medical abortion procured from patent medicine vendors, pharmacists?

In this report by SADE OGUNTOLA, experts say that despite the abortion restrictive law, many women and girls still patronise patent medicine vendors and pharmacies for misoprostol, making their training on the drug very important to stem deaths and complications from unsafe abortion.

For Mr Hammed Adesesan, a male nurse, listening to a father cry for help to get a safe abortion to terminate a pregnancy after the younger son impregnated the older sister was better imagined than experienced.

“Watching the siblings sitting in my office, and joking away, as their father explained his dilemma and why he is seeking for abortion left me thinking of reasons that despite Nigeria’s restrictive abortion laws, many abortions still take place unabated,” recounted Mr Adesesan.

Miss Kemi Haruna’s case is different. To avoid stigma, rather than going to the hospital, a friend recommended that she should seek medical abortion. She travelled to Lagos where she had a D&C that perforated her womb.

But Miss Habibat Hareem’s case is different. Rather than wait to confirm that she was pregnant, she took doses of abortion pill every other week.

In Nigeria, abortion occurs daily. According to IPAS, a non-governmental organisation working to eliminate unsafe abortion and its resultant deaths and injuries, an estimated 1.8 million abortions occurred in Nigeria in 2017, with more than half of the abortions classified as least safe and 11 per cent of women experiencing complications for which they sought post-abortion care.

Given the numerous barriers to care, many Nigerian women seek abortion services from medicine sellers such as pharmacists and patent medicine vendors (PMVs) who dispense mifepristone/misoprostol that can be used for medical abortion. The safety and efficacy of mifepristone and misoprostol, also commonly referred to as abortion pill, are well established.

Is there any basis for women to worry about the safety of these pills obtained from pharmacy shops or patent medicine vendors? This forms the thrust of the Nigeria Medical Abortion study by IPAS to assess the clinical outcomes of the use of abortion pills outside the clinic setting.  It was carried out in Oyo, Ogun and Abia states.

The study enrolled 1,711 women aged 15 to 49 that received misoprostol alone for medication abortion from clinics and PMVs from June 2019 to April 2020. They were followed up by phone calls after purchase or provision of misoprostol to confirm pill use and assess its outcome.

It found that the women in the PMV and clinic groups were mostly similar regarding age, educational attainment, marital status, parity and previous abortion experience. Most of the women (94 per cent) reported taking one, two or three doses of misoprostol.

About 25 per cent of the women reported taking the pills according to the World Health Organisation’s recommended regimen with three hours between doses. Also, the need for additional treatment to complete the abortion was non-inferior for the PMV group compared with the clinic group.

Interestingly, “The results indicated that non-educated people actually prefer to go to the clinic while educated women patronise more PMVs rather than clinics. Also, more married women visited PMVs than clinics,” said Dr Babatunde Adelekan, a co-author of the study at its dissemination meeting in Ibadan.

He stated that, according to the study, abortion pills obtained from a PMV result in comparable clinical outcomes to pills accessed through a clinic and most women (99 per cent) had a successful abortion with repeated doses of misoprostol alone.

Adelekan, a public health expert, added, “the results of this study contribute to evidence on the safety of early medication abortion outside the clinics are the effectiveness of misoprostol-alone for induced abortion.”

Lucky Palmer, Country Director, IPAS Nigeria, also a co-author of the study, however, said that the study found that the misoprostol although available everywhere, the pills are also being abused or wrongly used very often because many fail in following its recommended guidelines.

According to him, many of the women were using the wrong dosage of misoprostol and an indication that many PMVs and pharmacists dispense wrong doses or the women were not complying with the instructions they received on the use of the drug.

He added: “confidentiality is one of the reasons why people don’t follow those instructions. They don’t want people to see it with them and part of that is driven by our restrictive law because you don’t know who will go and report.”

However, he said when PMVs remove misoprostol from its blister packs to store in transparent bags they sell drugs with so that they don’t have the drug’s package on the shelf to beat Nigeria’s restrictive laws on abortion, this ends up reducing the drug’s shelf life.

“The moment you remove misoprostol from its pack, it becomes unstable and its efficacy again can no longer be guaranteed. So if it is put inside a cellophane bag and it is not used immediately, it loses its shelf life,” he added.

What is more, Mr Palmer said there are six brands of misoprostol that are legally registered for use in Nigeria although there are over 24 brands on sale in the market.

He added that “we have over 24 brands in the market. Some brands indicate on their product packaging that it is not for medical abortion because it is not stable. That is why we try to encourage particular brands that people should stock and dispense for medical abortion.”

Mr Palmer, however, declared that there is an ongoing study to also ascertain the efficacy of the two brands of misoprostol licensed in Nigeria as part of efforts to ensure that no woman in Nigeria dies from unsafe abortion.

Mr Sola Fagorusi, executive director, Onelife Initiative, an NGO into sexual and reproductive health rights of adolescents and youth said that the study’s finding that non-educated people actually prefer to go to the clinic for abortion was in contrast to what many would have expected and so would need to be further looked into to find out why the case was so.

He, however, asked that the study should be extended to young ones less than 15 years because in Nigeria there are instances that young people less than 15 years whose parents come seeking a medical abortion because of such reasons as incest and rape.

Given that the abortion pills obtained from a PMV result in comparable clinical outcomes to pills accessed through a clinic, Mr Fagorusi said there was the need to further strengthen the capacity of PMV on appropriate use of misoprostol to ensure that no woman dies because of her choice of obtaining a medical abortion.

Dr Olaitan Oyedun, a public health physician at the Academy for Health Development (AHEAD), Ile-Ife, Osun Sate said the study further corroborate that individuals trust PMVs  and that the restrictive environment for abortion has not stopped people from procuring abortion every day. They only seek for it in a clandestine manner.

Dr Oyedun, however, said the challenge with self-managing abortion with misoprostol is not whether or not women were given the pills, but that very few were given the correct information on the drug and its use.

He added, “misoprostol has its dangers and that’s where the issue of skilled and unskilled providers come in when it comes to medical abortion. We agree that whether clandestine or overt, people trust PMVs and that is where they go. They need to be trained on what is ideal.”

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