Evaluation of the Medical Abortion Kit Dispensing Practices of Community Pharmacies in Kathmandu Valley, Nepal

The risk of unsafe abortion lies mainly in the developing countries like Nepal. Medical abortion is use of medicines to terminate pregnancy. Mostly invalid pregnant women are ready to afford high cost without proper counseling due to social stigma and fear of family and society which is in scene among various community pharmacies in Nepal. Thus, this study was conducted in Kathmandu valley of Nepal to evaluate medical abortion kit dispensing practices of community pharmacies (CPs). Semi-structured types questionnaire was used as the instrument for data collection. Data collection was done through simulated patient via simple random sampling technique in 102 pharmacies. Out of six brand of medical abortion kit available in Nepalese market, 32% is unregistered product. It is found that 78% of the CPs used to sell in higher price than labeled price. Most of the CPs did not ask the general (screening) questions and also most of them counseled only about drug dosing and common side effects and price but neither of CPs referred (suggest to visit) to trained abortion service provider. The study discloses that CPs has been practicing the dispensing of medical abortion kit illegally and no proper screening and counseling was done. CPs are providing only profit oriented services which may be due to lack of skilled human resources in CPs.

services available throughout the countries there is a need for skilled service providers, adequate equipment, and essential drugs. Abortion was legalized in Nepal under the 11 th amendment to the Country Code (Muluki Ain) in March 2002 and approved by government of Nepal in September 2002. It empowers women's rights to control over and decide on their unplanned pregnancies [3]. According to the health point of view, abortion is the cessation of pregnancy and is "legal under certain conditions in almost all countries, ninety six percentages of countries recognizing a risk to a mother's life as legal basis for abortion" [4]. Medical abortion or abortion by orally administered regimens of mifepristone and misoprostol has recently been accepted worldwide as an effective and safe option for early abortion [5]. It is proven fact that there is still a need of expanding safe abortion clinics to provide medical abortion services to venerable group of people without doing surgical abortion procedures [6].
Medical abortion has become an alternative process of terminating pregnancy in first trimester by prostaglandins and anti-progesterone. Safe Abortion guidelines states that use of medical abortion drug (mifepristone and misoprostol) up to nine weeks, nine to twelve weeks, and after twelve weeks of gestation. In all three conditions mifepristone 200mg is followed by misoprostol l800μg (microgram) is needed to administer either through vaginal or sub sublingual route. Initially mifepristone is taken then after twenty-four to forty-hour misoprostol must be give through above mentioned route. There may be need of misoprostol 400μg dose on the basis of patient conditions. Medical abortion shows ninety five percent success rates [7]. The percentage of pregnant women attending unqualified practitioner for unsafe abortion is also in higher number. Nepalese society still do not accept single mother concept, therefore due to social fear and fear of violation of abortion law, pre-marital pregnancies, illegal pregnancies are subjected to more unsafe abortion. Mostly invalid pregnant women are ready to afford high cost due to social stigma and fear of family and society.
In order to maintain prestige the pregnant women take medicine secretly. For this reason, the dispenser are cheating the customer in the price by charging up to five thousand to a medicine which cost three hundred only [8]. The selling of the medical abortion kit without providing adequate information has been widely practiced in the community pharmacies.

Research design
In this study design, general medication order procedure was concurrently used with pharmacists/Assistant pharmacist/ Person involved in dispensing of drug in community pharmacies of different area of Kathmandu valley.

Research setting and population
The study was conducted in community pharmacies of certain

Result
The findings of this study included availability of different brands names, availability of registered and unregistered brands, cost variation among same brands and different brands, screening performed by CPs and their counseling practices. The study was conducted in total of 102CPs in which 70% of the people involved in dispensing of medicine were male. A total of 6 brands of the medical abortion pills by 6 manufacturing companies were found.
Among these 68% of the brands were found to have registered

Discussion
A survey among factory labor in Nepal has shown that sexual activity between unmarried young male and female with nonregular partner was more in practice. One out of five unmarried male and one out of eight unmarried female teenagers were sexually active [9]. Thirty three percent of pregnancies are unplanned, among currently married women of reproductive age in Nepal [10]. In neighboring India, where abortion is legal, the total abortion rate was estimated to be 0.06 in 1978 [11]. In America.
The percentages of abortion service centers are lowered by twenty percent tin Hospital based service provider and in rural area since 1982 [12,13]. Methotrexate with Misoprostol was used for medical abortion in early pregnancies in the mid-1990s.And more recently mifepristone has been used for non-surgical abortion [14].
Mifepristone is approved for such use in most of Europe [15] and has been used for more than a decade in France, Sweden and Great Britain [16,17]. Before the US Food and Drug Administration (FDA) approved drug for use as a medical abortifacient in 2000, it was used in clinical trials in US [18].
In earlier day in Nepal, more emphasis was given on spreading information regarding legal changes to law enforcement authorities, to aware everyone that women should no longer be imprisoned on abortion charges [19,20]. Non-government Organization has been carrying out local level awareness about abortion law, policies, by using different types of media. In this studies total of six brands of the medical abortion pills of six manufacturing companies were taken and data was collected with self-made structured questionnaire.
The questionnaire was asked being as simulated patient and data was collects in the different heading like availability, registration of brands, and cost variation of brands, price distribution, and possible question asked during dispensing. The findings of study are discussed in the result section.

Conclusion
Total of 112 community pharmacies were selected among them 10 community pharmacy were not involved in dispensing of medical abortion kit. In remaining 102 community pharmacies, 32% were from unregistered brands which were found during study period.

Limitation
Study was conducted in certain areas of the Kathmandu valley and may not be the representative of whole nation. Study time was limited and so sample size could not be extended. Thus, finding of study could not be generalized.