Expanding Access to Medication Abortion through Pharmacies in Nepal
Abortion has been legally available in Nepal since 2004, but barriers to accessing safe care still exist, particularly in areas with limited access to clinical services. Expanding provision of medication abortion (MA) to the pharmacy setting is a promising avenue to reach women with safe abortion care.
Currently, abortion can be legally obtained at government-certified health facilities from trained doctor and midlevel providers in Nepal. Pharmacies offer benefits over hospitals and clinics, including accessibility, anonymity, and less costly services. They are often the first point of contact for women seeking abortion and are important sources of information and services. Pharmacies, however, are not authorized to provide MA and sometimes offer unsafe and ineffective abortion care. Safe delivery of MA in pharmacies is possible, but no data exist thus far on interventions for safe pharmacy provision.
This study is an innovative experiment to evaluate the safety, effectiveness, correctness of use, and acceptability of provision of MA in the pharmacy setting by midlevel providers, i.e. trained nurses and nurse midwives. The study will be a non-inferiority trial of the termination of pregnancies up to nine weeks gestation with medication by midlevel providers comparing two settings: (1) government-certified health facilities and (2) nurse-owned pharmacies without routine access to physician supervision, ultrasounds, bimanual exams or lab tests.
Our hypothesis is that high-quality pharmacy provision by trained midlevel providers will be as safe and effective as hospital and clinic provision. Results will be essential for promoting novel evidence-based care and legislation for increasing access to medication abortion, including, if appropriate, an expansion of MA provision outside of clinical settings. Favorable results can be leveraged to improve abortion access and safety through pharmacies in other low-income countries, including neighboring India.