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What Does Informal Access to Misoprostol in Colombia Look Like? a Mystery Client Methodology in Bogotá and the Coffee Axis

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What Does Informal Access to Misoprostol in Colombia Look Like? a Mystery Client Methodology in Bogotá and the Coffee Axis Original research BMJ Sex Reprod Health: first published as 10.1136/bmjsrh-2019-200572 on 5 July 2020. Downloaded from What does informal access to misoprostol in Colombia look like? A mystery client methodology in Bogotá and the Coffee Axis Ann M Moore ,1 Nakeisha Blades,1 Juliette Ortiz,2 Hannah Whitehead,1 Cristina Villarreal2 ► Additional material is ABSTRACT Key messages published online only. To view Introduction In 2006, abortion was please visit the journal online decriminalised in Colombia under certain (http:// dx. doi. org/ 10. 1136/ ► Even though abortion became less bmjsrh- 2019- 200572). circumstances. Yet, women avail themselves restricted in Colombia in 2006, informal of ways to terminate pregnancy outside of the 1Division of Research, access to misoprostol is one way that Guttmacher Institute, New York, formal health system. This study explored how women induce abortion. New York, USA drug sellers engage with women who attempt to 2 ► Mystery clients attempting to purchase Research Area, Fundación purchase misoprostol from them. misoprostol received very little Oriéntame, Bogotá, Colombia Methods A mapping exercise was undertaken information on how to use the drug Correspondence to to list small- chain and independent drug stores correctly or what to expect when taking Dr Ann M Moore, Research, in two regions in Colombia. A sample (n=558) it. Guttmacher Institute, New York, of drug stores was selected from this list and ► Drug sellers require greater training on NY 10038-4723, USA; amoore@ visited by mystery clients between November and guttmacher. org misoprostol to help improve the quality December 2017. Mystery clients sought to obtain of information women get; this has the The work was previously a medication to bring back a delayed period, potential to improve abortion safety. presented at the 2018 Clacai: and described the experience, the information Consorcio Latinoamericano obtained and the medications proffered in exit contra el aborto inseguro INTRODUCTION conference in Quito, Ecuador interviews. http://jfprhc.bmj.com/ In 2006, Colombia lifted its absolute ban (October, 2018), at the 2019 Results Misoprostol was offered for purchase Population Association of on induced abortions and legalised the in 15% of the visits; in half of visits, only America meetings in Austin procedure under three circumstances: information about misoprostol was shared, while (April, 2019) and at the 2019 when the pregnancy threatens the life or CLACAI conference in Santa no information about misoprostol was provided Cruz, Bolivia (June, 2019). mental or physical health of the woman as on the remaining visits. Over half of sellers certified by a doctor, when the fetus has who refused to sell any medication provided Received 23 December 2019 an abnormality incompatible with life, Revised 18 February 2020 referrals, most commonly to an abortion on September 29, 2021 by guest. Protected copyright. Accepted 26 February 2020 and when the pregnancy results from rape provider. Among visits which included discussion or incest.1 Misoprostol was approved of misoprostol, two out of five sellers provided for medical abortion by the National dosage instructions with most recommending Institution of Medication Surveillance the minimum adequate dosage. Mystery clients (Colombia) in 2007; mifepristone was received little information on the physical effects approved 10 years later. The Ministry to expect with the use of misoprostol and of Health (MOH) (Colombia) guidelines © Author(s) (or their possible complications. employer(s)) 2020. Re- use for medical abortion recommend the use permitted under CC BY- NC. No Conclusions As misoprostol is being obtained of misoprostol alone up to 12 weeks of commercial re- use. See rights from some drug sellers without a prescription, pregnancy, or in combination with mife- and permissions. Published by capacitating this cadre with at least a minimum pristone up to 10 weeks of pregnancy. BMJ. of standardised information on dosage, Both misoprostol and mifepristone are To cite: Moore AM, Blades N, routes of administration and expected effects legally available with a prescription; the Ortiz J, et al. BMJ Sex Reprod and outcomes have the potential to improve Health Published Online First: combi- pack is not available. Misoprostol [please include Day Month reproductive health outcomes for women who is possible to access without a prescrip- Year]. doi:10.1136/ choose to terminate pregnancies this way in tion while mifepristone is not accessible bmjsrh-2019-200572 Colombia. outside of facilities. Moore AM, et al. BMJ Sex Reprod Health 2020;0:1–7. doi:10.1136/bmjsrh-2019-200572 1 Original research BMJ Sex Reprod Health: first published as 10.1136/bmjsrh-2019-200572 on 5 July 2020. Downloaded from Since the change in law, women have reported not refer clients to an abortion provider (n=566). being denied legal abortion, or having multiple obsta- Smaller pharmacies were selected because they serve cles put into their way.2 The most recent abortion as community resources for many types of basic health incidence study in the country (conducted in 2008) information. Additionally, they are are environments found almost all abortions were occurring outside of in which it’s easier to hold a private conversation with the legal context, and that half were induced using the drug seller, some of whom women may already misoprostol.3 This was shortly after misoprostol was have relationships with. For these reasons, they are the approved; since then, misoprostol has likely become preferred sources of misoprostol acquired informally increasingly accessible. Without additional evidence from drug stores. to suggest a change in the situation observed in 2008, women’s experiences acquiring misoprostol without Data collection a prescription to induce abortion demanded further We employed eight professional mystery clients and inquiry. We undertook a study on women’s access to four exit interviewers, all trained on the study protocol misoprostol without a prescription from drug sellers and instrument. To prepare mystery clients to pose as to examine: women who wanted something to bring back their a. Whether women are offered a chance to buy misoprostol. periods, we provided a profile: 20 years old, unmar- b. What information drug sellers give women that try to ried, nulliparous, with 1 year of university education buy misoprostol. and experiencing a 2- month menstrual delay. We c. What quantity of misoprostol is sold, and what instruc- selected that profile because, according to Oriéntame’s tions on use are provided. client demographics, women of that age and education Gaining a better understanding of women’s expe- most frequently seek abortions at their facilities, and riences when they seek to acquire drugs from drug likely overall. Mystery clients were trained to follow a sellers to terminate a pregnancy outside of the health script, provide specific responses to questions posed to sector allows new insights into women’s pathways to them and probe in specific ways for more information abortion and demand for post- abortion care. Further- to ensure consistency in the data collected. The script more, it provides information on drug sellers’ knowl- had mystery clients gather as much information as the edge about how to administer misoprostol safely and drug seller was willing to provide about any medica- effectively. tion that would bring back her period including how to use the drug, what physical effects she could expect METHODS and whether she might experience complications. At The study was a collaboration between the Guttmacher each site, mystery clients were allowed to spend up Institute, a sexual and reproductive health research and to 50 000 Colombian pesos (~US$17) on any offered policy institute in the USA, and Fundación Oriéntame, medications, and they were allowed to negotiate a service provider and research organisation based in prices. This amount was based on the costs set by the Colombia. Data collection took place in Bogotá and the MOH for misoprostol. http://jfprhc.bmj.com/ Coffee Axis between November and December 2017. In line with best practice guidelines, directly These two locations have concentrations of reproduc- following each visit the exit interviewer administered a tive medical services that serve the population of those survey to the mystery client.4–8 These structured inter- areas and women in the surrounding vicinity. views addressed all aspects of the interaction with the drug seller: whether the client was offered anything to Sample bring back her period, what was offered, whether she For over 10 years, Oriéntame has engaged with received instructions on how to use the drug(s) and on September 29, 2021 by guest. Protected copyright. drug sellers in these areas to provide evidence- based what to expect after taking them, how to recognise information and training on contraception and legal complications, and whether the recommended drug(s) abortion to increase sellers’ knowledge and improve was/were purchased. Mystery clients were also asked the quality of services provided to women seeking to report whether other people were within earshot sexual and reproductive health information. They during the exchange, the demeanour of the seller have assembled a list of drug sellers in these regions and any other observations about the interaction that through this work. Prior to data collection, field- might be of note. Data were collected on Android workers conducted a mapping exercise beginning with
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