BMJ Sex Reprod Health: first published as 10.1136/bmjsrh-2020-200955 on 10 May 2021. Downloaded from Original research Drug sellers’ knowledge and practices, and client perspectives after an intervention to improve the quality of safe abortion care outside of formal clinics in Nigeria Yinka Abiola Adojutelegan ,1 Amy J Coughlin,2 Kristen Shellenberg,3 Ayodeji Babatunde Oginni,4 Bridget Okeke,4 Okechi Ogueji4 ► Additional supplemental ABSTRACT Key messages material is published online Background In Nigeria, where abortion is legally only. To view, please visit the restricted, individuals seek medication abortion journal online (http:// dx. doi. ► Patent medicine vendors (PMVs) can be org/ 10. 1136/ bmjsrh- 2020- drugs, including misoprostol, directly from an important source of abortion care 200955). pharmacies or drug sellers. However, knowledge in Nigeria where abortion is legally 1Research & Evaluation, Ipas, of drug sellers or patent medicine vendors restricted. (PMVs) dispensation practices and women’s Abuja, FCT, Nigeria 2 ► The majority of PMVs in this intervention Chapel Hill, North Carolina, USA experience with self-management is limited and 3 dispensed misoprostol in appropriate Technical Excellence, Ipas, research suggests poor quality of services. This Chapel Hill, North Carolina, USA dosages and provided clients with 4Abuja, Nigeria study assesses the knowledge and practices of information on drug administration and PMVs and women’s experiences after a harm methods of contraception. Correspondence to reduction intervention to improve the provision ► Interventions designed to improve Yinka Abiola Adojutelegan, Ipas, of medication abortion using misoprostol. Abuja, Nigeria; yinka. abiola@ PMVs’ best practices around the gmail. com Methods We conducted a retrospective provision of abortion care may help descriptive analysis of anonymised logbook data ensure the quality of services received Received 11 November 2020 collected from 141 Nigerian PMVs who provided by clients. http://jfprhc.bmj.com/ Revised 30 March 2021 Accepted 5 April 2021 misoprostol for abortion to 4924 clients between February 2015 and July 2018. We conducted a the provision of abortion care may help ensure descriptive analysis of self- reported misoprostol the quality of services received by clients. dispensation practices with data from a cross- sectional survey of PMVs (n=120) from June 2016 to December 2018. We collected data on INTRODUCTION women’s experience obtaining misoprostol from Medication abortion, or the use of pills on September 25, 2021 by guest. Protected copyright. 37 PMVs through a cross- sectional survey of to end a pregnancy, is a safe and effec- women (n=260) from 4–19 June 2018. tive method that is increasingly available Results For clients where the misoprostol dose worldwide. World Health Organization dispensed was recorded (n=3784), 86% of (WHO) guidelines recommend the use of clients were given 800 μg or more misoprostol, mifepristone- misoprostol for medication © Author(s) (or their pain medication (97%) and a contraceptive abortion or, in settings where mifepris- employer(s)) 2021. Re- use method (92%). Most clients with an outcome 1 permitted under CC BY- NC. No tone is not available, misoprostol alone. commercial re- use. See rights recorded in the logbook (n=4431) had a Where abortion is legally restricted or and permissions. Published by complete abortion (86%). Almost all women access to services is limited, individuals BMJ. reported that they would return to the PMV for may seek mifepristone and/or misoprostol To cite: Adojutelegan YA, future services (99%). directly from a pharmacy or drug shop Coughlin AJ, Shellenberg K, Conclusions The majority of PMVs dispensed and self- manage their abortion. WHO et al. BMJ Sex Reprod Health misoprostol in appropriate dosages and provided Published Online First: [please guidelines support self- management with include Day Month Year]. clients with information on drug administration mifepristone- misoprostol when access doi:10.1136/ and methods of contraception. Interventions to a trained provider is available but, bmjsrh-2020-200955 designed to improve PMVs’ best practices around given limited evidence, does not endorse Adojutelegan YA, et al. BMJ Sex Reprod Health 2021;0:1–9. doi:10.1136/bmjsrh-2020-200955 1 BMJ Sex Reprod Health: first published as 10.1136/bmjsrh-2020-200955 on 10 May 2021. Downloaded from Original research self- management with misoprostol alone.1 Evidence designed to improve comprehensive abortion care on people’s experience obtaining misoprostol or by PMVs across three states in Nigeria from 2015 mifepristone- misoprostol directly from pharmacies or to 2018. PMVs were selected from a sampling frame drug sellers is limited.2–4 developed through a physical search of PMV shops Abortion in Nigeria is legally allowed only to save and snowball recruitment. Ipas recruited PMVs for a woman’s life.5 However, a study conducted in 2012 the intervention if they were a nurse/midwife, commu- reported an annual incidence of 1.25 million abor- nity health extension worker (CHEW) or community tions.6 More recent data estimate nearly 1.8 million health officer (CHO) with a current practising license. abortions annually or 41.1 per 1000 women aged Participants were required to operate a patent medicine 15–49 years; when including the experience of respon- shop; be willing to attend training; already dispense dents’ closest confidantes, the number of likely abor- or sell misoprostol and be willing to dispense and sell tions in Nigeria rose to 2.7 million.7 Nigeria has one misoprostol for abortion post- training; and provide of the highest maternal mortality rates in the world contraceptive services to willing clients. All partici- and unsafe abortion is a major contributor to maternal pants attended a 3- day course training on abortion morbidity and mortality.8–10 and post- abortion misoprostol regimens, screening, Given Nigeria’s restrictive abortion law, access to safe eligibility and contraindications, expected and poten- abortion services is limited in public hospitals where tial adverse effects, complications and follow-up care. care is relatively affordable.6 Instead, individuals seek The intervention had 183 participating PMVs. Each care elsewhere, including by purchasing medications PMV was trained on medication abortion provision directly from pharmacies or drug sellers. In Nigeria, using misoprostol and were linked with misoprostol patent and proprietary medicine vendors or PMVs suppliers and trained clinicians for referral and treat- play an important role in the provision of basic health- ment of complications. Participants were required care services11 12 including reproductive health,13–16 to record details about care provided to clients who though knowledge of their role in abortion care is received misoprostol in a logbook without any client’s limited.3 PMVs are persons without formal training in personal information (Figure 1S). pharmacy who sell orthodox pharmaceutical products in retail for profit. Many PMVs are known to have Project design and data collection medical training, though this is not a requirement, and The intervention included two components: (1) assess- they often operate from shops.12 ments of PMV’s post- training knowledge and practice Misoprostol was first registered in Nigeria in 2006 undertaken as part of routine monitoring and evalua- for the treatment of postpartum haemorrhage.17 A tion with (A) review of client logbooks maintained by survey conducted in pharmacies and drug outlets in PMVs during the intervention and (B) a cross- sectional Lagos and Abuja in 2006 found misoprostol not well survey of PMV knowledge, attitude and practices known or widely available.18 Over a decade later, around misoprostol provision and (2) a cross- sectional research suggests misoprostol is more widely sold in survey of women who purchased misoprostol from a http://jfprhc.bmj.com/ drug outlets and is increasingly used for abortion.3 19 selected group of the trained PMVs. In 2014, the national task shifting guidelines allowed PMVs to stock misoprostol for the management of Review of logbook service records postpartum haemorrhage.20 Mifepristone was regis- Online supplemental figure 1S describes the interven- tered in Nigeria in 2017 and is increasingly available tion sample. Ipas trained 183 PMVs and 146 trained and used for abortion care. PMVs collected data prospectively on their misopr- Given the high unsafe abortion rate and evidence of ostol dispensation. Three PMVs who did not dispense on September 25, 2021 by guest. Protected copyright. misoprostol availability and dispensing for abortion by misoprostol for induced abortion and two PMVs with PMVs, from 2015 to 2018 Ipas worked with Nigerian incomplete logbook records were excluded from the Ministry of Health officials in three states to improve analysis. Logbook data from 141 vendors collected from PMVs’ knowledge about and provision of misoprostol 1 February 2015 to 1 July 2018 are reported here. for comprehensive abortion care The present study uses monitoring and evaluation data collected during this Assessment of PMV knowledge and practice of provision of misoprostol intervention to: (1) document the post- training knowl- for abortion edge and practices for the provision of misoprostol for During the intervention, PMVs maintained a logbook abortion by participating PMVs and (2) assess the expe- recording the dispensation of misoprostol including riences and satisfaction of women who