Dr Joachim Osur MISOPROSTOL AT GRASSROOTS

Drug Availability Misoprostol is registered for PUD in almost all countries. As a result not strictly controlled. Not always bought on prescription. Long shelf life – 7 years No special storage conditions Affordable

Availability in Chemists in Nairobi

Can Pharmacists Help Women in Need? A number of pharmacy workers lack knowledge of how to terminate pregnancy. While the majority have heard of or sold Misoprostol, they still suggest ineffective remedies for pregnancy termination.

What Would They Provide For Termination of Pregnancy

Can Pharmacy Workers Help Women? Most pharmacy workers were ready to sell the drug in confidence to mystery clients When interviewed, they insisted on patients having a prescription.

On Interview: Pharmacy Workers Say They Ask for Prescriptions

Can Pharmacy Workers Help Women? Even where there is a will to help, knowledge of dosing is seriously lacking. Wrong dosing could lead to complications: Under dose – no termination or incomplete abortion Failed termination can lead to foetal malformations Overdose – more side effects, uterine rapture in advanced pregnancy.

FrequencyPercent OD„2055.6% „ % 400 µg stat25.6% According to prescription38.3% BD719.4% BD *5/712.8% BD 800 µg12.8% Stat dose12.8% Total362.8% Doses Recommended by Pharmacy Workers

Can Pharmacy Workers Help Women? A number of pharmacy workers give information on the Misoprostol (even if it is wrong information) Others do not give any information for a variety of reasons.

Reasons For Not Giving Information to Women

Importance of Use of Misoprostol at Pharmacy/Community Level Urugway harm reduction model has shown that use of Misoprostol at community level reduces complications, mortality.

OUTCOME N% Illegal abortion (but under safer conditions: misoprostol) 41261% Continued with the pregnancy173% Spontaneous abortion/other pathologic pregnancies233% They were not pregnant91% Abortion conducted under legal conditions41% No data available (did not return for the “after visit")21031% TOTAL675100% What Women Chose to Do After Counseling (Urugway Harm Reduction Model)

Since 2001 the Maternal Mortality Rate in Urugway due to unsafe abortion among women in Public Hospitals decreased by 87%

Since 2001, the number of women arriving at the Emergency Room of the Public Hospital who had to be referred to the Intensive Care Unit decreased by 79%

Legal Challenges Abortion still generally restricted in most of Africa. Anglophone countries have similar laws- inherited from the British. Sections of abortion law may impact on community use of MA for termination of pregnancy.

Legal Challenges A person is not criminally responsible for performing in good faith and with reasonable care and skill a surgical operation upon any person for his benefit, or upon an unborn child for the preservation of the mother’s life, if the performance of the operation is reasonable, having regard to the patient’s state at the time and to all the circumstances of the case. MA is not a surgical procedure but the principle of good faith and reasonable care and skill still applies.

Legal Challenges Any person who unlawfully supplies to, or procures for any person any thing whatever, knowing that it is intended to be unlawfully used to procure the miscarriage of a woman whether she is or not with a child, is guilty of a felony and is liable to imprisonment for three years The community supplier of MA drugs should have certification by MOH or other agencies Broad interpretation of the law is necessary so as to spell out legal indications for abortion.

Legal Challenges Any woman who, being with child, with intent to procure her own miscarriage, unlawfully administers to her self any poison or any noxious things, or uses any force of any kind or uses any other means whatever, or permits any such a thing or means to be administered or used on her is guilty of felony and is liable to imprisonment for seven years Countries need to compile adequate evidence to support the scientific use of MA. National standards and guidelines are needed for guidance on MA use both at facility and community levels.

Conclusion Misoprostol is easily available in pharmacies This is a window of opportunity for saving women from crude forms of abortion Women have been accessing Misoprostol to terminate pregnancies Information given to women by pharmacy workers is not always accurate. Wrong advise on usage of the drug is worrying.

Recomendations There is need to train pharmacy workers on pharmacological agents for termination of pregnancy. Use of pharmacies as a channel for Misoprostol could potentially reduce complications of unsafe abortion and should be encouraged. Laws and policies to protect the pharmacist and the woman needed.