ing to use it for self-induction of menstrual Many Bangladeshi Pharmacies Do Not Provide regulation, they also reveal that workers have Accurate Information on How to Use Misoprostol “considerable knowledge gaps,” the research- ers maintain. “Pharmacy workers have the po- tential to expand access to safe menstrual reg- Pharmacy workers in urban com- the combination of methylestrenolone and ulation with medication in Bangladesh in the monly provide medicines and dosing regi- methylestradiol) and 46% offered both. future, particularly with the recent approval mens for menstrual regulation that are not Among pharmacy workers who provided of mifepristone-misoprostol [for menstrual effective, according to a cross-sectional survey misoprostol, just 7% told the client the ef- regulation]. Training pharmacy workers and that used trained individuals posing as cli- fective dosage (four pills daily for two days), increasing their awareness of appropriate ents.1 When these mystery clients inquired while the rest gave ineffective ones. Only 32% referral networks will help to ensure safe, ef- about obtaining a drug to end a pregnancy or correctly indicated that the drug should be fective, and quality menstrual regulation ser- induce menstruation, three-quarters of phar- taken orally, while 65% said that it should be vices,” they conclude.—S. London macy workers offered misoprostol, another used both vaginally and orally; the remaining medication or both. But fewer than one in 3% indicated that they did not know the route REFERENCE 10 of those who provided misoprostol rec- of administration. Only small proportions of 1. Huda FA et al., Availability and provision of miso- prostol and other medicines for menstrual regula- ommended an effective dosing regimen for pharmacy workers counseled misoprostol re- tion among pharmacies in Bangladesh via mystery menstrual regulation, and more than seven in cipients about the potential adverse effects of client survey, International Journal of Gynecology and 10 did not provide any advice on what to do nausea and vomiting (17%), fever and chills Obstetrics, 2014, 124(2):164–168. in the event of complications. In additional, (5%) and diarrhea (1%). Nearly half (46%) the vast majority of pharmacy workers did advised clients that excessive bleeding was a not provide post–menstrual regulation fam- danger sign, but few (4%) counseled clients ily planning methods or refer clients for such that fever lasting more than a day might sig- services. nal infection. Twenty-eight percent of phar- Investigators conducted the survey in 2011 macy workers who offered misoprostol told in the Mirpur and Badda areas of dis- the clients to go to trained providers in the trict, and the Sadar area of district. event of complications, but the rest did not They trained young (aged 18–24) and middle- give any suggestion about where to go in that aged (25 or older) male and female mystery situation. The vast majority (94%) did not clients to approach pharmacy workers and provide any post–menstrual regulation family ask about the use of misoprostol specifically planning methods or referrals. or the use of a drug generally for menstrual Provision patterns varied by area and by regulation, either for themselves, a friend or the nature of the mystery client’s request. a spouse. (At the time of the study, misopro- The proportion of pharmacy workers offering stol was approved in Bangladesh only for other medicines in addition to misoprostol treatment of peptic ulcer and prevention of was higher in Badda (58%) than in Mirpur postpartum hemorrhage.) The mystery cli- or Gazipur (42% in each). Workers in Gazi- ents asked about the availability, cost, dosage, were about twice as likely as their peers route of administration, effectiveness, adverse in Mirpur or Badda to recommend using oral effects and complications of any drugs they and vaginal routes together for misoprostol received, as well as about family planning administration (90% vs. 46–47%). Finally, methods and counseling. Researchers inter- compared with workers who were asked for viewed the “clients” immediately afterward a nonspecified drug, those who were asked to capture details about the encounter. The about misoprostol were more likely to offer investigators computed descriptive statistics misoprostol alone (65% vs. 7%) and to coun- and compared differences in study outcomes sel clients that nausea and vomiting are ad- by characteristics using chi-square tests. verse effects of the drug (23% vs. 12%). The mystery clients interacted with work- Study limitations include potential recall ers (all of whom were male) at 331 pharma- bias and misreporting, the possibility that the cies. Overall, 76% of clients were offered one mystery client scenarios were unrealistic or or more medications, 23% received informa- aroused pharmacy workers’ suspicion, and tion and referrals (usually to a private clinic the findings’ questionable generalizability to or hospital) and 2% received neither. When rural areas, the investigators acknowledge. pharmacy workers offered medicines, 39% of- Nonetheless, although the results show that fered only misoprostol, 16% offered another misoprostol is widely available in pharmacies drug (e.g., emergency contraceptive pills, in the study areas and that pharmacy workers herbal medicines, hormonal preparations or are willing to provide the drug to clients seek-

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