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Reported Experiences Using Misoprostol Obtained from Drug Sellers: a Prospective Cohort Study in Lagos State, Nigeria

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Reported Experiences Using Misoprostol Obtained from Drug Sellers: a Prospective Cohort Study in Lagos State, Nigeria Open access Original research BMJ Open: first published as 10.1136/bmjopen-2019-034670 on 5 May 2020. Downloaded from Women’s self- reported experiences using misoprostol obtained from drug sellers: a prospective cohort study in Lagos State, Nigeria Melissa Stillman ,1 Onikepe Owolabi ,1 Adesegun O Fatusi ,1,2 Akanni I Akinyemi ,3,4 Amanda L Berry ,1 Temitope P Erinfolami ,4,5 Olalekan S Olagunju ,4,5 Heini Väisänen ,6 Akinrinola Bankole 1 To cite: Stillman M, Owolabi O, ABSTRACT Strengths and limitations of this study Fatusi AO, et al. Women’s self- Objectives This study aimed to assess the safety and reported experiences using effectiveness of self- managed misoprostol abortions ► Data from this study are the first prospectively col- misoprostol obtained from obtained outside of the formal health system in Lagos drug sellers: a prospective lected data that capture people’s experiences with, State, Nigeria. cohort study in Lagos and the self- reported effectiveness of, self- managed Design This was a prospective cohort study among State, Nigeria. BMJ Open misoprostol abortion in a legally restrictive setting in women using misoprostol- containing medications 2020;10:e034670. doi:10.1136/ sub- Saharan Africa. bmjopen-2019-034670 purchased from drug sellers. Three telephone- ► This study used novel recruitment and retention administered surveys were conducted over 1 month. approaches: drug sellers were the source of re- ► Prepublication history and Setting Data were collected in 2018 in six local additional material for this cruitment, which leveraged existing client–provid- government areas in Lagos State. paper are available online. To er relationships; unregistered mobile phones were Participants Drug sellers attempted to recruit all women view these files, please visit distributed to participants to mitigate fears around who purchased misoprostol- containing medication. To the journal online (http:// dx. doi. potential loss of privacy; text messages were sent remain in the study, participants had to be female and org/ 10. 1136/ bmjopen- 2019- to participants periodically in between interviews, aged 18–49, and had to have purchased the medication 034670). which improved engagement and likely contributed for the purpose of abortion. Of 501 women initially to the study’s relatively high follow- up rate. http://bmjopen.bmj.com/ Received 30 September 2019 recruited, 446 were eligible for the full study, and 394 ► The follow-up period for this study was 1 month, Revised 11 February 2020 completed all three surveys. which is longer than that of previous studies, thus Accepted 12 March 2020 Primary and secondary outcome measures Using allowing more time for the medication to work self- reported measures, we assessed the quality of and potentially resulting in a more accurate self- information provided by drug sellers; the prevalence of assessment of the medications’ effectiveness. potential complications; and the proportion with completed ► This study relied on misoprostol users’ self- report abortions. for our primary outcomes, and although we believe Results Although drug sellers provided inadequate participants are capable of describing changes in information about the pills, 94% of the sample reported their own bodies, it is difficult to determine the ex- on September 26, 2021 by guest. Protected copyright. a complete abortion without surgical intervention tent to which our findings will correlate with data about 1 month after taking the medication. Assuming a collected under clinical experimental conditions. conservative scenario where all individuals lost to follow-up ► The study sites were purposively selected, and the had failed terminations, the completion rate dropped to 87%. sample could only include clients who obtained While 86 women reported physical symptoms suggestive of misoprostol from drug sellers willing to participate complications, only six of them reported wanting or needing in the study and who may be different from other health facility care and four subsequently obtained care. drug sellers in unknown ways, therefore our findings Conclusions Drug sellers are an important source of are not generalisable to the entire population of the medical abortion in this setting. Despite the limitations of state and country. © Author(s) (or their self- report, many women appear to have effectively self- employer(s)) 2020. Re- use administered misoprostol. Additional research is needed permitted under CC BY-NC. No to expand the evidence on the safety and effectiveness of seeking to terminate a pregnancy.1 While commercial re- use. See rights self-use of misoprostol for abortion in restrictive settings, and permissions. Published by and to inform approaches that support the health and well- mifepristone followed by misoprostol is the BMJ. being of people who use this method of abortion. preferred MA regimen recommended by the For numbered affiliations see WHO, misoprostol alone is recommended as end of article. a safe and effective alternative where mife- INTRODUCTION pristone is not available.2 WHO guidelines Correspondence to Globally, medical abortion (MA) has become specify self- managed mifepristone and miso- Ms Melissa Stillman; an increasingly important method for people mstillman@ guttmacher. org prostol as a viable approach for terminating Stillman M, et al. BMJ Open 2020;10:e034670. doi:10.1136/bmjopen-2019-034670 1 Open access BMJ Open: first published as 10.1136/bmjopen-2019-034670 on 5 May 2020. Downloaded from pregnancies when users have access to adequate informa- and the interviewers, we refer to participants as ‘women’ tion and a trained healthcare provider.3 However, WHO in this paper) who self-manage abortion using miso- has not yet recommended self-management of miso- prostol obtained from drug sellers in Lagos State, Nigeria. prostol alone because of limited evidence. In contexts We investigated what dosages and information women in which abortion is illegal or highly restricted, mifepri- receive when attempting to purchase misoprostol for stone is unlikely to be approved by the government, and abortion; what clinical effects they experience, including self- managed abortion with misoprostol alone is a critical potential complications; if and how they assess complete- option for individuals who may otherwise resort to other, ness; and what proportion of women have completed unsafe, methods.1 abortions. Nigeria has a population estimated at 200 million in 2019,4 and induced abortion is legally permitted only to 5 save a woman’s life. Despite the restrictive law, the rate of METHODS induced abortion in Nigeria was estimated at between 41.1 Study setting 6 and 59.4 per 1000 women of reproductive age in 2017. Data for this study were collected in six local government MA drugs, particularly misoprostol, have become more areas (LGA) in Lagos State. Lagos is the most populous 7–9 widely available in Nigeria in recent years. Nigeria has city in Nigeria and constitutes one of the largest markets a large market of drug vendors serving informally as the for MA nationally. The 20 LGAs in Lagos State were strat- first point of care for diverse health problems, and most ified into more urban and less urban based on popula- 10 medications can be procured without prescription. tion density. From each stratum, we purposively selected However, evidence from other studies suggests that drug three that each had at least one higher level educational sellers have poor knowledge of MA drugs, commonly institution. We hypothesised that areas with higher level sell medications without packaging or instructions and educational institutions would have greater market for often provide inadequate or inaccurate information to misoprostol due to the concentration of females aged women about medications, side effects and potential 20–29 and those with a secondary education or higher, 11–16 complications. populations that have a relatively higher estimated inci- There is currently a dearth of community- based dence of abortion in Nigeria.27 evidence on people’s experiences accessing misoprostol from drug sellers and the outcomes of self-managed Study design and data collection abortions. Findings from a prospective cohort study with Field activities were organised into two major compo- a very small sample of women who bought misoprostol nents: (1) a drug seller study, which included (A) a from pharmacy workers in Bangladesh indicate that 75% mapping of pharmacies and proprietary patent medicine 17 of women reported complete abortions after 2 weeks, vendors, herein referred to as drug sellers, and (B) a http://bmjopen.bmj.com/ which is just below the range of expected effectiveness for screener interview to identify those selling misoprostol for 18–21 misoprostol alone (78%–90%). Studies from several any reason; and (2) a prospective cohort study of women countries in Latin America where abortion is legally who purchased misoprostol, recruited by drug sellers. restricted suggest that even if adequate information is not provided by drug sellers, information obtained through Identifying drug sellers who sell misoprostol other means, such as hotlines, may reduce the potential Fieldworkers collected the names and Global Positioning risks of self- managed MA.1 22–24 The few studies in sub- System coordinates of all drug sellers in each LGA, gener- Saharan Africa that attempted to assess health outcomes ating the universe (n=968; figure 1). Thereafter, they on September 26, 2021 by guest. Protected copyright. from use of misoprostol
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