Unwanted pregnancies are common among women of reproductive age in Nigeria and a significant number end in abortion. Each year, between 2015 and 2019, nearly three million pregnancies were unintended. Forty-eight percent ended in abortion.
Many of these abortions are unsafe and some result in severe maternal morbidity or death. The main reason for this is that dismissal is legally permitted in Nigeria only if a woman’s life is in danger. This drives women to seek clandestine abortions by unqualified providers using inappropriate methods.
But abortions have become relatively safer since the emergence and increasing availability of medical abortion, especially misoprostol. Misoprostol was approved in Nigeria in January 2006 for the treatment of postpartum haemorrhage. Evidence suggests that Nigerian women are beginning to access and use it safely to induce their own abortions.
A recent study showed that 94% of women who used misoprostol – which they obtained from drug sellers (pharmacists and patent medicine sellers) in Lagos State – would have completed their abortion without further action.
In Nigeria, patent and patent medicine sellers are retail outlets without formal pharmacy training that retail orthodox pharmaceuticals for profit. Pharmacies are regulated in Nigeria.
Having uncomplicated abortions using misoprostol is a positive development for Nigerian women. It promotes their health and prevents unnecessary deaths from unsafe abortion. In addition, the confidentiality offered by the method protects women’s health and saves lives. It also has the ability to reduce the social stigma and financial cost of resolving an unwanted pregnancy through abortion.
In sum, in the context of restrictive abortion laws, promoting access to misoprostol as a harm reduction strategy is a lifeline.
In our study, we assessed the quality of care provided to women who obtained misoprostol for abortion from drug vendors (patent medicine vendors and pharmacies) in 2018 in six local government areas of Lagos State, southwestern Nigeria. Our study highlighted the need to understand drug sellers’ knowledge about the provision of medical abortion and the extent of information they provided to their customers. This is important to ensure the effectiveness of medical abortion.
Drug sellers are not the only suppliers of misoprostol. But most women prefer to hang out with them. Understanding the quality of care provided during the abortion process is therefore critical to ensuring that women are able to manage abortions themselves safely and effectively.
Our study therefore sought to determine whether the quality of abortion care differed according to the type of drug seller. Our research involved collecting information from drug sellers as well as women who had purchased the drug.
Our results show that women are more likely to obtain a medical abortion from patent medicine vendors than from pharmacies. In addition, there are differences in the socioeconomic characteristics of women who seek care from patent medicine vendors versus pharmacies. Abortion drugs are usually paid for out of pocket by women. Thus, we hypothesize that women who may have lower purchasing power or prefer to pay less are more likely to visit patent medicine vendors than pharmacies. Patent medicine vendors generally have lower prices and are easily accessible.
When assessing the quality of care, we looked at three main areas: the technical competence of the medicine seller, the information provided to customers, and the customers’ experience of care.
We looked at these areas from the perspective of drug dealers, as well as women.
We selected local government areas that had at least one higher education institution. We hypothesized that areas with higher education institutions would have a larger market for misoprostol due to the concentration of young women with secondary or higher education, a population that has an estimated incidence of relatively higher abortion rate in Nigeria.
The field activities were organized into two main components.
The drug vendor study included two categories of drug vendors – registered pharmacies and patent and proprietary drug vendors. Those who reported selling misoprostol-containing drugs were selected.
The second component concerned women who obtained these drugs from drug vendors to terminate a pregnancy.
We included 126 drug sellers while 386 women responded to the three prospective interviews during the study.
We explored the consistency between drug sellers’ and women’s reports of the quality of care received. The aim was to shed light on the potential mismatch between the nature and the way in which information is given, intended, received and used.
Our results suggest that, in general, more women seek safe abortion care from patent medicine vendors than from pharmacists. Additionally, we found that drug sellers’ knowledge of medical abortion was suboptimal. And there was a gap in the knowledge and information they are supposed to give to women who got a medical abortion from them.
Anecdotally, pharmacy staff are considered better providers. But our results suggest that there was no difference between the technical knowledge of patent medicine sellers and that of pharmacy staff regarding the prescription of medical abortion.
Importantly, however, a greater proportion of patent medicine vendors reported receiving on-the-job training on safe abortion and post-abortion care than pharmacy staff. Regulators and other stakeholders should consider this a top priority.
We also found that women received better quality of care from patent medicine vendors compared to pharmacies. They said they received more specific information about the types of drugs they were prescribed, how to use them, and what to expect after using the drugs.
In an abortion-restricted setting like Nigeria, local pharmacies and vendors of patent medicines continue to play a major role in providing medical abortion, including misoprostol.
Drug sellers – especially patent medicine sellers – are often the most accessible frontline health workers in many communities in Nigeria. In some settings, they may indeed be the only healthcare provider immediately available to patients.
Our results confirmed that drug sellers are important providers within the health system. That the members of the community trust them. And that they can provide essential reproductive health care, including medical abortion.
Our evidence suggests that they are an important part of the healthcare system and can provide the same quality of care as pharmacies, if not better. Moreover, women trust them. But the strength of patent medicine vendors is particularly underutilized in public health strategies compared to formal pharmacies.
To expand access to sexual and reproductive health care products and services, Nigeria should systematically train and integrate them into programs and interventions. This has already been done with community health workers and traditional birth attendants for maternity care.
There is also a need to build the capacity and skills of patent medicine vendors in the dispensing and administration of medical abortion drugs. This would be an important harm reduction strategy. In addition, the skills of frontline providers need to be improved.
Dr. Onikepe Owolabi was at the Guttmacher Institute at the time of this research and continues to collaborate on this data with them.
Akanni Ibukun Akinyemi, Professor, Obafemi Awolowo University
Akinrinola Bankole, Senior Researcher, Guttmacher Institute
Melissa Stillman, Research Associate, Guttmacher Institute
Onikepe Owolabi, Public Health Researcher, Guttmacher Institute
Temitope Erinfolami, PhD Candidate, Obafemi Awolowo University