dr joachim osur expanding access to medical abortion: building on two decades of experience lisbon,...
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Dr Joachim OsurExpanding Access to Medical Abortion: Building on Two Decades of Experience
Lisbon, PortugalMarch 2-4, 2010
Use of Medical Abortion Through Pharmacy Outlets
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Pharmacists: The First Line of Defense
• Serve as the first source of health care to people throughout the worldoMain source among low income
populations
• Use of pharmacies as a source of care is increasingo Particularly among poor and uninsured
• Studies in Africa, LAC and Asia indicate gaps and opportunities
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Current situation in much of Africa
• Restrictive laws and lack of services in the formal health system impede access to safe abortion.
• Consistent demand for abortion has led to non-clinician providers including:- Herbalists - Traditional birth attendants- Women - Pharmacy workers (trained and untrained)
• Various methods of abortion are used by these providers:- Herbs - Various instruments - A number of medicines
• However: Communities that have been sensitized about misoprostol seem to abandon other methods in favor of misoprostol.
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Methods of Abortion in a Rural Community in Kenya
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Safety of Abortion in the Community
• At community level, the safety of the abortion is highly dependent on the source.
• It appears that misoprostol abortions by pharmacy workers may be the safest, possibly because pharmacy workers:o Refer to health care facilitieso Avoid invasive procedureso Desire to remain in business and maintain
social standingo Know how the drug works
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Relationship of Complications to Site of Abortion in a Rural Kenyan Village
Where Termination of Pregnancy Was Initiated
Complications Suffered by the Woman
TotalNone
Haemorrage not requiring transfusion death
Haemorr-hage
requiring transfusion
Pelvic infec-tion
Lower genital tract injury
Not known 6 1 1 0 1 0 9
Home 22 6 0 0 5 4 37
Clinic/hospital 39 23 0 0 3 3 68
Pharmacy 9 1 0 0 0 0 10
Herbal clinic 1 2 0 2 0 0 5
Herbalist's home
0 1 0 0 0 0 1
Total 77 34 1 2 9 7 130
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Not Yet Rain!
• A number of problems, however, dog the provision of medical abortion through pharmacies.
• A mystery client survey in Kenya showed :o Pharmacy workers have poor knowledge on
termination of pregnancyo Some have negative values and stigmatize
abortion• “Sorry sister. Try elsewhere”.
o For those who give misoprostol, doses of drugs dispensed are wrong in most cases
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Not Yet Rain!
• In Zambia and Kenya, most community pharmacies are not registered, hence:o Pharmacy worker capacity unknowno Knowledge of MA drugs may be lackingo Possible lack of support for training by MoH
and the pharmacy society
• Most community pharmacies are currently unable to give accurate information on use of misoprostol
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Reasons For Not Giving Information to Women Who Seek Abortion From Pharmacies
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Case Study: Kenya
• We collaborated with misoprostol distributor to: o identify and train pharmacy workerso ensure misoprostol always in stock
• Linkages were created between trained pharmacy workers and trained health facilities.
• Pharmacy workers see their role as:o Informing and referring womeno Prescribing misoprostol to the extent allowed by the
pharmacy boardo Ensuring supply of misoprostol to health facilities
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Case Study: Zambia
• In collaboration with pharmaceutical society, pharmacy workers were identified and trained.
• Pharmacy workers expressed concern that their role in abortion care had not been appreciated.
• Following the training, pharmacy workers decided they were going to:o Do on the job training for their colleagueso Come up with own scope of practice on abortion
including prescribing, referral, community educationo One pharmacist promised to follow up registration of
mifepristone
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Recommendations by Pharmacy Workers
• Formally recognize their role in abortion care• Offer values clarification• Provide full package of support and training:
o Community educationo Prescribing MA drugso Referralo Registration, supply and quality monitoring of MA drugs
• Educating, and mobilizing the community to access services through the pharmacy could improve the role of pharmacies in medical abortion and increase access to care through pharmacies.