1. Dr Joachim Osur Expanding Access to Medical Abortion: Building on Two Decades of Experience Lisbon, Portugal March 2-4, 2010 Use of Medical Abortion Through Pharmacy Outlets

2. Pharmacists: The First Line of Defense Serve as the first source of health care to people throughout the world o Main source among low income populations Use of pharmacies as a source of care is increasing o Particularly among poor and uninsured Studies in Africa, LAC and Asia indicate gaps and opportunities

3. 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.

4. Methods of Abortion in a Rural Community in Kenya

5. 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 facilities o Avoid invasive procedures o Desire to remain in business and maintain social standing o Know how the drug works

6. Relationship of Complications to Site of Abortion in a Rural Kenyan Village Where Termination of Pregnancy Was Initiated Complications Suffered by the Woman Total None Haemorrage not requiring transfusiondeath Haemorr- hage requiring transfusion Pelvic infec- tion Lower genital tract injury Not known6110109 Home226005437 Clinic/hospital3923003368 Pharmacy91000010 Herbal clinic1202005 Herbalist's home 0100001 Total77341297130

7. 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 pregnancy o 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

8. Not Yet Rain! In Zambia and Kenya, most community pharmacies are not registered, hence: o Pharmacy worker capacity unknown o Knowledge of MA drugs may be lacking o 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

9. Reasons For Not Giving Information to Women Who Seek Abortion From Pharmacies

10. Case Study: Kenya We collaborated with misoprostol distributor to: o identify and train pharmacy workers o 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 women o Prescribing misoprostol to the extent allowed by the pharmacy board o Ensuring supply of misoprostol to health facilities

11. 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 colleagues o Come up with own scope of practice on abortion including prescribing, referral, community education o One pharmacist promised to follow up registration of mifepristone

12. Recommendations by Pharmacy Workers Formally recognize their role in abortion care Offer values clarification Provide full package of support and training: o Community education o Prescribing MA drugs o Referral o 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.

13. Visit us online at www.ipas.org/medicalabortion or write to medicalabortion@ipas.org