Quality of care offered by health care retail markets for medication abortion self-management: Findings from states in Nigeria and India

Abstract

Dispensing of misoprostol and mifepristone by pharmacies and chemist shops for self-management of medication abortion (MA) fills a crucial gap in settings where abortion care by trained health professionals is not readily available. This promising service delivery pathway, endorsed by the World Health Organization (WHO), is hindered by concerns of poor-quality care. Simulated clients collected data on MA pill dispensing practices from 92 pharmacies and chemist shops in three Nigerian states and 127 pharmacies in an Indian state that we have anonymized. Guided by the WHO's abortion guideline, we measured process-related quality indicators such as medication use instructions, warning signs, and respectful treatment among other aspects. We aggregated indicators under three domains: technical competence, information given to clients, and client experience. Overall, 51% of facilities in the Nigerian states and 32% in the Indian state offered MA pills. Most dispensing facilities offered the misoprostol-only regimen in Nigeria (68%) and the combination regimen in the Indian state (83%). Among facilities offering MA pills, 26% in Nigeria and 78% in the Indian state provided correct instructions on route of pill administration. Accurate information on the appropriate interval between pill type in the combination regimen was low in Nigeria (27%) and the Indian state (14%). Excessive bleeding as a warning sign was discussed more frequently in the Indian (56%) versus Nigerian states (32%); other abnormal bleeding patterns were rarely mentioned. Aggregate technical competency scores were low at 18% in Nigeria and 34% in the Indian state, with highest scores for client experience at 90% and 91% respectively. Findings suggest that people using MA pills purchased from the retail market are not given accurate and adequate information for most effective self-use. If MA self-management remains outside regulatory boundaries, technical quality will remain sub-standard, imposing unnecessary costs to people, their health, and health systems.

Fig 1. Distribution of the quality of abortion care indicators by domain in the three Nigeria states (n = 47) and an Indian state (n = 41).

In both settings, performance was best on indicators related to client experience, with most room for improvement in the information given to clients domain. *Only if combination regimen offered; n = 15 facilities in Nigeria states, n = 35 facilities in the Indian state. NOTE: For technical competency, credit was given for correct information whether it was provided prompted or unprompted. For information given to clients, credit was only given for information provided unprompted.

Fig 2. Despite different legal contexts, quality of abortion care provided by pharmacies and chemist shops in Nigerian states (n = 47) and the Indian state (n = 41) were similar across domains.

Gender differences were not significant, but patterns differed.