"You can do this at home and people won't find out": a qualitative exploration of women's experiences with the use of medication abortion drugs received directly from pharmacies in Nepal.

BACKGROUND: In Nepal, over two-thirds of abortion seekers use medication abortion drugs to terminate their pregnancies. However, fewer than half of all abortions occur in government-approved facilities. Although the government of Nepal discourages pharmacy sale of medication abortion drugs without a prescription, pharmacies account for one-fifth of all abortion services in the country. We conducted a qualitative study to gain insight into why women obtain medication abortion care through pharmacies and document their experiences. METHODS: Using a multi-modal recruitment strategy, we interviewed 25 women from three populous districts of Nepal's Koshi Province who had used medication abortion drugs purchased from pharmacies within the previous two years. We used ATLAS.ti 24 to manage our data and analyzed interviews for content and themes using inductive and deductive techniques. RESULTS: We found that confidentiality, convenience, cost, and connection led women to obtain medication abortion care from pharmacies. Many of our participants were unaware of the free services offered by government health centers or reported that they avoided these facilities due to privacy concerns and/or the perceived need for accompaniment. Most of our participants received the mifepristone/misoprostol regimen from pharmacies without a prescription but were charged more than the mandated maximum retail price. Although pharmacy workers informed women on how to administer the medications, they provided little or no counselling on side effects, complications, post-abortion contraception, or additional medications such as those for pain management. Despite confidence in their decision to terminate their pregnancies and their ability to self-diagnose the pregnancy, take the pills, and confirm completion of the abortion, some of our participants found the abortion process challenging due to insufficient counselling, variable costs, and the lack of pain medications. CONCLUSION: Women seek pharmacy-based medication abortion services for various reasons, including barriers within the health system that limit access to public sector abortion sites. Strengthening the role of pharmacies as medication abortion providers is crucial as they are in a position to enhance women's agency by providing accurate information, medically sound services, and appropriate referrals. Establishing policies and guidelines to formally integrate pharmacies as safe medication abortion sites in Nepal appears warranted.