Predictors of prior unsuccessful pharmacy abortion attempts among women presenting for abortion in government certified clinics in Nepal

Abstract

Objective Although abortion in Nepal is broadly legal and free of charge, many women seek abortion care outside the legal system, including from pharmacies. We evaluated the prevalence of, and factors associated with, prior unsuccessful abortion attempts among women presenting to 14 randomly‐selected government approved abortion health facilities across Nepal. Methods Eligible participants were recruited in 2019 by trained research staff from certified abortion facilities. Participants (n = 1160) completed research staff‐administered baseline surveys. We used multivariable mixed‐effects logistic regression models to evaluate factors associated with having attempted pharmacy abortion prior to coming to the health facility. Results Almost one in seven (14%) women had tried to end their pregnancy before presenting to a participating clinic, often (9%) using medication obtained from a pharmacy. Women who lived farther from the clinic (aOR 1.28 per log hours travel time, 95% CI 1.10–1.49) and who reported financial difficulty in accessing the clinic (19% vs. 10%, aOR 2.10, 95% CI 1.20–3.70) had increased odds of having tried to access abortion through a pharmacy. Conclusion Integrating pharmacies into the legal network of abortion providers may improve access to safe care, particularly for rural women with financial and practical travel limitations.

Predictors and experiences of seeking abortion services from pharmacies in Nepal

“…Although pharmacy provision of medication abortion pills is not formally permitted under the Nepal Safe Motherhood and Reproductive Health Rights Act of 2018, many people seek abortion pills through pharmacies and may only seek clinical care when they are unable to get such pills or experience an incomplete abortion [ 3 ]. Our small study of women who sought abortion pills directly from a pharmacy shows that pharmacists are capable of complying with the rules around gestational age screening and that many also provide critical information about what to expect in terms of symptoms and when to seek follow up care.…”

“…Our primary outcome of interest was whether the participant received or was denied an abortion from a pharmacist. Additionally, a number of sociodemographic variables were included in this analysis based on previous studies in this setting [ 1 , 3 , 5 , 6 ]: age (years), marital status (married, never married, divorced/separated, or widowed), caste (Brahmin, Chhetri, Thakuri, Hill Janajati, Terai Janajati, Dalit, other specified), highest level of formal and non-formal schooling attained (no schooling, some non-formal, primary, secondary, or higher), employment status (yes/no), and number of children (0, 1, 2, 3 or more). In addition, we created an objective measure of socioeconomic status using asset variables to determine each participants’ wealth quintile, by creating a score from a set of assets validated in Nepal previously [ 8 ].…”

“…Above 10 weeks only trained physicians can perform abortions, using manual vacuum aspiration, medical induction and/or dilation and evacuation. Although common, off-label or over the counter sales of MA drugs at pharmacies are not legally permitted in Nepal [ 3 ]. As per the policy–both providers and place to obtain abortion services needs to be certified by the government.…”

“…MA typically does not require laboratory tests, ultrasound, or sterile equipment, which are particularly challenging to access in rural low-resource settings. The Nepal Demographic and Health Survey (2016) reported that MA accounted for 70% of all abortions in Nepal, and 19% of these MA were obtained from a pharmacy [ 3 , 7 ]. Though they lack legal authority to prescribe and dispense, many pharmacies in Nepal stock MA [ 1 ].…”

“…In addition to needing quantitative information about who seeks care in pharmacies and women’s experiences receiving MA from pharmacies in Nepal, we do not know if women are receiving MA from pharmacies and what factors are associated with being denied. We know from our work recruiting women seeking abortion from certified clinics [ 3 ], that almost one in ten had previously sought abortion care from pharmacies and either did not get the wanted MA pills or the pills they received were not effective in ending their pregnancy, thereby necessitating a trip to a clinic. In this paper, we present data from a longitudinal study among women who sought MA from pharmacies in Nepal.…”