Assessing the Medication Abortion Drug Dispensing Practices of Private Sector Chemists through Mystery Client surveys in Nepal.

Research Report.

SUMMARY: Unplanned pregnancies remain a common problem in Nepal, despite a decline in the total fertility rate from 5.1 births per woman in 1984-1986 to 2.6 births in 2008-2010. Specifically, 27.5% of currently married women of reproductive age (WRA) have an unmet need for family planning.1Furthermore, maternal morbidity and mortality due to unsafe abortions remain high, with estimates that about half of maternal deaths are due to unsafe abortion. While the Department of Health services (DoHS) Annual Report 2010/11 found that 95,306 women received safe abortion services during the 2010/11 fiscal year, unsafe abortions remain a significant problem in Nepal for reasons including lack of knowledge about legalization of abortion and availability of safe abortion services, inadequate access to safe abortion services, high cost of services, reluctance or fear of utilizing the services in time, poor supportive environments, and social stigma. To reduce unsafe abortions and increase access to safe abortion services through medication abortion (MA), PSI/Nepal's Women's Health Program (WHP) has collaborated with the Family Health Division/Ministry of Health and Population (MoHP). PSI/Nepal's program aims to increase awareness of MA as a safe abortion method through various behavior change communication (BCC) activities including a mass media campaign, community-based interpersonal communication (IPC), community-based advocacy meetings, and informal household level meetings. PSI/Nepal is also involved in the social marketing of the first legally registered safe abortion drug in Nepal, Medabon (mifepristone and misoprostol), and is currently distributing Medabon to government authorized health facilities and retail outlets in the country. In February 2013, PSI/Nepal conducted a Mystery Client (MC) survey with 260 chemists to gather information about MA dispensing practices and counseling behavior amongst chemists. Two scenarios were developed to represent different types of possible clients: in Scenario A, the wife is 6-7 weeks pregnant and in the Scenario B the wife is 13-14 weeks pregnant. Thekey findings of the study are as follows: With regards to provider behavior, in Scenario A, 14.6% of chemists refused to give the MA drug without a prescription; whereas in Scenario B, 65.4% of chemists refused to give drugs due to the gestational period. In both scenarios, more than 90% of chemists inquired about the gestational period/last menstrual period (Scenario A, 92.3%; Scenario B, 92.7%). More chemists recommended a doctor's visit for MCs in Scenario B (30.8%) compared to Scenario A (16.2%). In both Scenarios, more than one quarter of chemists recommended getting a pregnancy test first (Scenario A, 28.1%; Scenario B, 25.8%). When it came to MA drug cost, there was a variation from Rs 425to Rs 2500.More than half of the chemists (51.1% in Scenario A and 53.2% in Scenario B) offered the MA drug at aprice of Rs 500 to Rs 1000. Only 5% of the chemists, in both Scenarios, sold the MA drug for less than Rs 500, among which 71.4% sold Medabon. In terms of the MA drug recommended by chemists, 22% recommended separate packs of Mifepristine and Misoprostol in Scenario A, and 6.3% in Scenario B. Regarding MA drug (Mifepristine + Misoprostol) combination packs, about 50% of providers recommended them to clients in both scenarios (54.0% of providers recommended to clients in Scenario A and in54.4% in Scenario B).Medabon as a MA drug was recommended by 20.0% chemists in Scenario A and 19.0% chemists in Scenario B. Counseling is an important indicator for measuring the quality of service provided by a chemist before dispensing the MA drug to a client. The study showed that in Scenario A, out of 87.8% of chemists counseled on MA drug regimens, only 75.8% counseled clients about the drug regimen correctly. Similarly, out of 88.1% chemists who provided counseling on the route of administration, only 80.7% of chemists did so correctly. More than two-thirds (72.0%) of chemists counseled on possible side effects that may be seen during an abortion. In Scenario B, the complete counseling process could not be observed as per the scenario given. The chemist was expected to refer clients to the SAS center for more information. The study observed that only 30.8% of chemists counseled clients to visit the doctor and 43.5%referred them to SAS sites after confirming the gestation period. Furthermore, 30.4% of chemists dispensed MA drugs to clients whose gestation periods were over 9 weeks. In terms of quality of care, chemists were evaluated based on perceived behavior and quality of counseling provided to the clients. More than half (50.4%) of clients expressed that the chemist's overall behavior was satisfactory, and above one quarter (27.3 %) of clients felt that the chemist was patient and explained everything clearly. The study showed that use and display of MA related communication materials were low in pharmacy shops in both Scenarios. Only 5.4% chemists showed MA leaflets to the clients while counseling on the MA drug, of which 3.1% gave out the MA leaflets while dispensing the drug. The study results will be used to improve and adopt new approaches in private sector chemist training and Provider Behavior Change Communications (PBCC)2 activities.