MA provision by pharmacy

workers: Scale, quality

and strategies to improve

provision practices

Katy Footman, Marie Stopes International

Marie Stopes International 1

Background

• Pharmacies are often a first,

preferred source of health care due

to convenience, privacy, anonymity,

low costs.

• Very little data available but what

we have suggests MA purchased

from pharmacies is growing trend.

• Potential to reduce morbidity and

mortality associated with unsafe

abortion.

• But women need adequate

information and counselling to be

able to use MA drugs effectively.

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Systematic review methods

Aims: to describe the scale and practice of pharmacy provision of MA; to assess

the effectiveness of interventions aiming to improve the scale and/or quality

Timeline: November 2015

Databases: MEDLINE, Web of Science, POPLINE, Embase, Global Health and

WHO Reproductive Health Library. Hand-searching websites of six organisations

involved in MA research and provision in LMICs. Snowballing on references.

Search terms: range of terms related to abortion + range of terms related to

pharmacies, drug sellers, or self-medication were used.

Inclusion criteria: outcomes met the review objectives; study design used

quantitative primary data collection methods; published between 1st January 1990

and 1st October 2015; in English, Spanish or French language; LMIC setting;

published peer-reviewed journal articles and grey literature.

Data extraction: double-extracted using standardised template.

Quality assessment: double graded using standardised checklist

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Search results

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Citations identified in database search (N=2989)

Full text evaluated (N=61)

Excluded (N=2932): Duplicates, non LMICs, not related to medical abortion

Excluded (N=40) Not related to pharmacy provision of MA (N=18) Sample of women visiting hospital for PAC (N=7) Not primary data (N=3) Not related to MA (other aspects of reproductive health) (N=3) Intervention study with no baseline data to extract (N=2) Language (N=1) Qualitative studies (N=6)

Studies identified through database search (N=21)

Title and abstract screening

Studies identified through hand-searching and contacts with experts (N=4)

Studies included in the review (N=25)

Where has research been conducted?

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2 or 3 high quality studies

2 medium-high quality studies

2 medium-low quality studies

1 medium-high quality study

1 medium-low quality studies

1 low quality study

No studies

Availability of MA

• Globally, provision of abortifacients

by pharmacies was common

without prescription.

• Considerable variation by setting

and over time.

• Mifepristone less widely available

• Ineffective abortifacients also

commonly provided.

• Variation also by methodology

used.

• Pharmacies reported demand for

MA was common.

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0% 20% 40% 60% 80% 100%

Bangladesh, 2015*

India, 2015^

India, 2015*

Bangladesh, 2014^

South East Asian city, 2014^

South East Asian city, 2014*

Vietnam, 2012*

Vietnam, 2012^

India, 2005*

Dominican Republic, 2012*

Mexico, 2011^

Mexico, 2009^

Argentina, 2007^

Latin American city, 2006*

Latin American city, 2006^

Kenya, 2016^

Zambia, 2015^¥

Zambia, 2015^Ɨ

Senegal, 2015*

Tanzania, 2013*

Nigeria, 2013^

Ghana, 2012^

Nigeria, 2010^

Kenya, 2009*^

Bars show % pharmacies offering misoprostol-only.

*Survey, ^Mystery client

Knowledge and

counselling

• Knowledge of, or counselling on, an

effective regimen for the drug most

commonly sold is rare.

• Knowledge of the correct regimen did

not always translate into accurate

advice to mystery clients.

• Mystery clients rarely advised on

what to do in case of complications.

• Referrals not commonly offered.

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0% 20% 40% 60% 80% 100%

India, 2015*

India, 2015^

India, 2015^

Bangladesh, 2015*

Nepal, 2015*

Bangladesh, 2014^

South East Asian city, 2014^

India, 2005*

Mexico, 2011^

Mexico, 2009^

Latin American city, 2006^

Latin American city, 2006*

Kenya, 2016*

Zambia, 2015^¥

Senegal, 2015*

Zambia, 2015^Ɨ

Tanzania, 2013*

Ghana, 2012^

Bars show % pharmacy workers knowing/advising the correct MA regimen for drug most commonly sold. *Survey, ^Mystery client, Ɨ Zambia 2015, 2009 data, ¥ Zambia 2015, 2011 data.

Interventions to improve scale or quality

Nature of

intervention

Nature of

evaluation

Result: intervention successful? Overall

quality

grade

Zambia

2015

One day training Pre-post, no

comparison

Increase in referrals (47%-68%)

Information provision (55%-75%) &

selling misoprostol (9% - 32%).

Low

Bangladesh

2015

Training, in-

pharmacy

detailing & call

centre

Post-intervention

survey,

comparison with

control group

Increased odds of knowing correct

miso-regimen among miso-sellers if:

- used call centre (aOR 2.01);

- received training (aOR 1.89);

- received detailing (aOR 1.73).

Medium

Nepal 2015 Two day training

+ 1 day

refresher course

10 months later.

Pre-post,

comparison

group in different

region

Improvement in :

- knowledge of regimen (22% to 88%

(I) vs 23% to 41% (C))

- identifying complete abortion in

intervention group (65% to 77% (I),

51% to 49% (C)).

Medium

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Conclusions

Research on MA availability in

pharmacies is needed

Provision appears to be widespread,

but often with poor knowledge and

provision of information

Providing training and information can

improve knowledge and practice

More evidence is needed on what

works for improving quality of MA

provision and safety of self-

administration

But how?

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MSI pilot to assess client outcomes after self-

managed MA

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• Pharmacy workers recruit client into

study using standardised script &

voucher.

• Pharmacy workers reimbursed USD

12.70, women reimbursed USD 1.15.

• Client instructed to send an SMS with

voucher ID to call center

• Immediate phone back from call

center & follow up interview arranged

• Follow up phone interview after 2

weeks

• Most pharmacies willing to take part

but low continuing commitment.

• Majority of clients were recruited from

a small number of pharmacies

• Initial enrolment was main barrier to

representative sample:

Overall response rate = 30%

Follow up rate = 87%

• Final sample: 109

• Other challenges: self-reported

outcomes

Next steps:

Lessons learned:

• Pharmacy staff reimbursement important but more monitoring needed

• Immediate contact by phone facilitated recruitment

• Inclusion of all pharmacy staff needed

Future attempts needed:

– In settings where misoprostol-only is commonly provided

– With measures to improve recruitment process – more convenient, less

potentially threatening

– Ongoing reimbursement of pharmacy staff rather than one-off payment?

– Expanding number of pharmacies to increase client numbers

– Investing in hiring research assistants to be based in pharmacy

– Alternatives - recruitment of women accessing hotlines/call centres

– Validation of measures of self-reported complications/outcomes also needed.

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Thank you

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