The knowledge of emergency contraception and dispensing practices of Patent Medicine Vendors in South West Nigeria

Abstract

Patent Medicine Vendors (PMVs) can play a critical role in increasing access to emergency contraceptive pills (ECPs) in developing countries, but few studies have examined their knowledge and dispensing practices. Using cluster sampling, the authors selected and interviewed 97 PMVs (60.8 per cent female) in Oyo and Ogun States of Nigeria to assess their knowledge, dispensing practices, and referral for ECPs. About one-third (27.8 per cent) of respondents were not aware of ECPs, and only half knew that ECPs could prevent pregnancy. Forty per cent had ever dispensed ECPs. Reasons proffered by those who do not dispense ECPs included barriers from the State Ministry of Health, police, other regulatory agencies, and religious beliefs. Only 50.5 per cent have referral arrangements for clients. Strategies to increase access to ECPs through PMVs include training on counseling techniques and referral, effective government regulation, and community involvement. Where unsafe abortion is a major cause of maternal mortality, these strategies offer protection for many women in the future.

Full text

AUTHOR COPY
Original Article
The knowledge of emergency contraception
and dispensing practices of Patent Medicine
Vendors in South West Nigeria
Mojisola M. Fayemi
a,
*, Olufemi L. Oduola
a
,QueenC.Ogbuji
a
,
Kehinde A. Osinowo
a
,AdejokeE.Oyewo
a
,and
Olabimpe M. Osiberu
b
a
Association for Reproductive & Family Health, Qtr 815A, Army Officers Mess
Road, Ikolaba, P.O. Box 30259 Secretariat Post Office, Ibadan, Oyo State, Nigeria.
E-mail: ope3m@yahoo.com
b
Center for Research in Reproductive Health, 10 Cinema Road, Sagamu, Nigeria.
*Corresponding author.
Abstract Patent Medicine Vendors (PMVs) can play a critical role in
increasing access to emergency contraceptive pills (ECPs) in developing
countries, but few studies have examined their knowledge and dispensing
practices. Using cluster sampling, the authors selected and interviewed 97
PMVs (60.8 per cent female) in Oyo and Ogun States of Nigeria to assess their
knowledge, dispensing practices, and referral for ECPs. About one-third (27.8
per cent) of respondents were not aware of ECPs, and only half knew that ECPs
could prevent pregnancy. Forty per cent had ever dispensed ECPs. Reasons
proffered by those who do not dispense ECPs included barriers from the State
Ministry of Health, police, other regulatory agencies, and religious beliefs. Only
50.5 per cent have referral arrangements for clients. Strategies to increase access
to ECPs through PMVs include training on counseling techniques and referral,
effective government regulation, and community involvement. Where unsafe
abortion is a major cause of maternal mortality, these strategies offer protection
for many women in the future.
Journal of Public Health Policy (2010) 31, 281–294. doi:10.1057/jphp.2010.14
Keywords: emergency contraceptive pills; Patent Medicine Vendors; dispensing
practices; oral contraceptives; pregnancy; Nigeria
Introduction
Every year women experience 66 million unintended pregnancies
and more than 500 000 deaths from pregnancy-related causes.
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Ninety-nine per cent of these deaths occur in developing countries.
1
Approximately one in every five pregnancies in Nigeria is unintended
and nearly one-third of women of reproductive age have had
an unwanted pregnancy at some point in their lives.
2
Lack of
access and low utilization of family planning services in developing
countries contribute to the high rate of unintended pregnancies;
3
only 10 per cent of sexually active women in Nigeria ever used any
modern contraceptive method.
4
In Nigeria, unsafe abortion is often the result of an unwanted
pregnancy, which is frequently owing to low contraceptive use.
5
Induced abortion is illegal, and a criminal offense, unless the woman’s
life is threatened by the pregnancy. Yet an estimated 760 000
abortions occur annually and a quarter lead to complications.
6
Women usually obtain induced abortions clandestinely, and fre-
quently these are unsafe, accounting for 72 per cent of all deaths in
young women under age 19
7
and 20 000 of the estimated 50 000
annual maternal deaths in Nigeria.
8,9
Thus, unsafe abortion is the
single largest contributor to maternal mortality.
Emergency contraceptive pill (ECP) is an effective method for
preventing unintended pregnancy if a woman has unprotected sex,
whether consensual or as a case of sexual assault.
10
ECP is most
effective within the first 24 hours,
11
but can be effective 120 hours
after unprotected sex or contraceptive failure.
10
ECPs remain
inaccessible across much of the world, as both supply and demand
constraints undermine potential clients’ abilities to effectively use the
method. This is particularly true in developing countries where
limited commodity supplies, provider incompetency, and misinfor-
mation coalesce to restrict the availability of ECPs.
12
In Nigeria there are two main commodity procurement channels.
The United Nations Population Fund procures all public sector
contraceptives on behalf of the government. The Society for Family
Health (SFH), a social marketing program, provides the significant
proportion of contraceptives dispensed by the private sector.
13
Nigeria’s Federal Ministry of Health did distribute EC pills in
government health facilities for a short period in 1999, but
discontinued this almost immediately owing to concerns about low
demand and its use as a primary birth control method.
13
Conse-
quently, the private sector has played the central role in introducing
and promoting ECPs.
Fayemi et al
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Pharmacies and patent medicine stores (PMS) serve as important
access points for ECPs. In Nigeria, the distinction between PMS and
pharmacies is important: usually a qualified pharmacist manages the
pharmacy but a Patent Medicine Vendor (PMV), who may have little
knowledge about the commodities, manages the PMS.
14
Thus a
PMV in this context is likely to be a person without formal pharmacy
training who sells pharmaceutical products on a retail basis for
profit. Although this does not designate the PMV as a health-care
provider, PMV enterprises are the primary sources of drugs for both
urban and rural populations.
15,16
According to the National Drug Law in Nigeria, PMVs may
dispense over-the-counter (OTC) drugs, but restrictive and conflict-
ing policies guide provision of oral contraceptives. The National
RH/FP Policy Guidelines and Standards of Practice requires basic
medical examinations and prescriptions for the provision of oral
contraceptives; PMVs may not initiate, but may re-supply oral
contraceptive pills. However, under the National Drug Policy for
Nigeria, Patent Medicine Dealers are neither allowed to initiate nor
resupply ECPs, including pills for oral consumption.
17,18
Despite this
restriction, several studies have documented that especially for young
people the preferred sources of contraceptives are PMS.
19,20
The
reasons include geographical accessibility, shorter waiting times,
more reliable drug stocks, longer hours of service, greater confiden-
tiality, lower cost, and no separate charge for advice.
21,22
Unfor-
tunately, the PMVs may not be aware of the correct dosage or
duration of treatment.
23
Notwithstanding some outcomes of the negative consequences of
obtaining drugs from the PMVs (likely inability to provide accurate
information regarding the mechanism of action and side effects),
they may be strong advocates of emergency contraceptives and create
awareness in more people than health workers in hospitals
and family planning clinics have been able to do.
24
Studies in India
and Bangladesh have demonstrated that paramedics and commu-
nity workers could provide ECPs as OTC drugs as efficiently as
physicians.
25,26
In Nigeria, studies have documented the knowledge and prescrib-
ing attitudes about ECPs among professional health-care work-
ers,
27,28
but there is a dearth of information on the knowledge and
dispensing practices of PMVs. Thus, the objective of this study is to
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assess PMVs’ knowledge and ECP dispensing practices. The results
will support review of policies and conceptualization of education
initiatives to increase access and quality of ECPs services in
Nigeria – and elsewhere.
Methods
We conducted this survey in four and five communities selected by
cluster sampling in Ibadan North and Sagamu Local Government
Areas (LGAs) in Oyo and Ogun states, respectively. Ibadan North
LGA has a population of 308,119; Sagamu LGA has a population of
255,885.
29
The Pharmaceutical Units of the Federal and State Ministries of
Health (SMOH) provide oversight functions and license all
registered PMVs. According to the 2008 records at the Pharmaceu-
tical Units of the SMOH, a total of 64 and 71 PMVs were licensed to
dispense drugs in Ibadan North and Sagamu LGA, respectively.
We selected 48 PMVs from Ibadan North and 49 PMVs from
Sagamu LGAs for the study.
To assess PMV demographic characteristics (professional history,
training experience, knowledge of, and ECP dispensing practices,
average monthly clientele and categories of clients who request
ECPs, ECP promotion activities, experience of stock out, and referral
arrangements), we administered semi-structured questionnaires. The
survey followed standard ethical guidelines. Respondents’ consent
was obtained before questionnaire administration and their anon-
ymity protected by ensuring that individual identifiers did not exist
in the instruments or in the electronic data set. For analyzing data we
employed the Statistical Package for Social Scientists.
Results
Demographic characteristics of respondents
The demographic characteristics of respondents appear in Table 1.
All were located in the urban sector; all were storeowners, with one
exception. More females (60.8 per cent) participated in the survey.
Respondents’ ages ranged from 23 to 55 years and more than half
(53.6 per cent) had secondary education.
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More than one quarter (26.8 per cent) engaged in other occupations
including (in order of frequency): nursing, teaching, accounting, trans-
portation business, and farming. A larger proportion (45.4 per cent)
reported to have made a profit of between US$32 and $65 monthly.
Table 1: Demographic characteristics of respondents
Demographic characteristics Number (%) of respondents (n=97)
Gender
Male 38 (39.2%)
Female 59 (60.8%)
Marital status
Single 7 (7.3%)
Married 88 (90.7%)
Widow/Widower 1 (1.0%)
No response 1 (1.0%)
Educational qualification
No formal education 1 (1.0%)
Primary 9 (9.3%)
Secondary 52 (53.6%)
Tertiary 31 (32.0%)
Professional 1 (1.0%)
No response 3 (3.1%)
Religion
Christianity 60 (61.9%)
Islam 37 (38.1%)
Engagement in other occupations
Yes 26 (27.8%)
No 70 (72.2%)
Duration of practice as a Patent Medicine Vendors
Less than a year 1 (1.0%)
1–5 years 26 (26.8%)
5–10 years 38 (39.2%)
More than 10 years 32 (33.0%)
Net profit per month
a
Under $32 32 (33%)
Between $32 and $65 44 (45.5%)
Between $65 and $130 12 (12.4%)
Between $130 and $194 5 (5.2%)
Above $259 1 (1%)
No response 3 (3%)
a
Exchange rate of 155 to $1.
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Professional history
A third had practiced as PMVs for more than 10 years, almost 40 per
cent had practiced for 5–10 years.
Most (92 per cent) learned the trade: (73 per cent) through
apprenticeship, a few (9.5 per cent) while working in pharmaceutical
companies, and (5.9 per cent) during nurses’ training or under
supervision of medical practitioners (3.6 per cent); only 2.4 per cent
inherited the trade. A few others (5.6 per cent) did not specify their
means of becoming involved in the trade.
Training experience
Most (67 per cent) reported having had formal training to improve
their practice. About 30.1 per cent jointly mentioned the SMOH and
Association for Reproductive and Family Health (ARFH), an
indigenous NGO, as organizers of such trainings and 14.4 per cent
mentioned only ARFH. About 16.5 per cent also participated in
training organized by the National Association of Proprietary
Patent Medicine Dealers, by the National Agency for Food and
Drug Administration and Control (NAFDAC) (7.2 per cent),
by pharmaceutical societies (6.2 per cent), by the SFH, or other
NGOs (6.2 per cent).
Reports of those trained differed with respect to content add-
ressed: for 21 per cent, breast cancer, for 17.5 per cent, drug abuse
and duties of PMVs, for 16.5 per cent restrictions on dispensing
drugs, for 10.3 per cent family planning, for 8.2 per cent contra-
ceptive use, for 4.1 per cent fake drugs, for 3.1 per cent drug expiry
date, for 3.1 per cent new development in pharmacy procedures, for
3.1 per cent HIV/AIDS, and for 1.0 per cent other health issues.
Knowledge of ECPs
Most (72.2 per cent) affirmed knowing about a modern family
planning method that could be used within 3 days after sexual
experience (Table 2); but, when respondents were asked about
having heard of ECPs before the conduct of the survey, one fewer
had.
On further probing, only half (46.4 per cent) of the sample
described ECP as a drug for pregnancy prevention, 8.2 per cent said
it is a drug used after sex, and 3.1 per cent mentioned a brand name
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of ECP – ‘Postinor’. One respondent reported that ECPs reduce
abortion and two simply said ‘it is effective’. One said only the ECP
is a ‘family planning method’, two that it is a menstrogren, and
another that EP forte (menstrogen and EP forte are taken to correct
menstrual irregularities). As a way of describing the efficacy of ECP,
one respondent stated that it is safe, able to delay ovulation, and that
it must be prescribed.
Dispensing of ECPs
About two in five (40.2 per cent) of the PMVs had ever sold ECPs:
79.5 per cent of this proportion still sold ECPs at the time of the
study (Table 2). Sources of ECP supply (in order of frequency)
include: pharmaceutical companies, SFH (an NGO), and open, local
Table 2: Distribution of respondents according to knowledge and dispensing of ECPs
Variables Number (%) of respondents (n=97)
Knowledge of modern family planning methods that can be used within 3 days after sexual
experience
Yes 70 (72.2%)
No 26 (26.8%)
No response 1 (1.0%)
Awareness of ECPs
Yes 69 (71.1%)
No 28 (28.9%)
Have you ever sold ECPs?
Yes 39 (40.2%)
No 58 (59.8%)
Do you still sell ECPs?
Yes 31 (32.0%)
No 66 (68.0%)
Average quantity of ECPs sold per month
Less than 5 packs 12 (12.4%)
5–10 packs 8 (8.2%)
11–20 packs 7 (7.2%)
21–70 packs 3 (3.1%)
71 pack and > 1 (1.0)
Not applicable 66 (68.1%)
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outdoor markets. Average numbers of ECPs sold per month ranges
from 5 to 71 pieces.
For the PMVs that did not dispense ECP, reasons proffered (in
order of frequency) include: barriers from the SMOH, the police,
religious beliefs, National Drug Law Enforcement Agency (NDLEA),
and NAFDAC. Others include side effects, low demand for the
product, and product out of stock.
About 43.2 per cent reported a clientele of fewer than 20 people
monthly; one quarter (25.3 per cent) had 20–100 clients, and 6.3 per
cent had a 100 or more clients monthly.
Categories of clients who request to purchase ECPs
On the basis of a review of the PMVs’ records, the category of clients
who requested ECPs within a month preceding the survey included
young in-school girls (20.6 per cent), young in-school boys (4.1 per
cent), young out-of-school girls (16.5 per cent), young out-of-school
boys (6.2 per cent) (Table 3). About 14.4 per cent of clients who
Table 3: Characteristics of clients who request to purchase ECPs from Patent Medicine
Vendors
Variables Number (%) of respondents who
cited each category
Categories of clients who requested ECPs
Young school girls 20 (20.6%)
Young school boys 4 (4.1%)
Young out-of-school girls 16 (16.5%)
Young out-of-school boys 6 (6.2)
Adult men 6 (6.2%)
Adult women 24 (24.7)
Proximity of clients’ residence to PMV store
Within the neighbourhood 21 (21.6%)
Nearby communities 7 (7.2%)
Distant communities 6 (6.2%)
Could not respond to question 63 (64.9%)
Clients who procure ECPs with prescription
Yes 14 (14.4%)
No 20 (20.6%)
Could not respond to question 63 (64.9%)
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procured ECPs from PMVs with prescriptions had been referred (in
order of frequency) by private hospitals, health workers, government
hospitals, and other PMVs.
Experience of ECP ‘stock out’ (lack of supplies)
More than half (53.1 per cent) of PMVs who currently dispense
ECPs had a stock out at some time. Among those, 59 per cent sought
resupply from pharmaceutical companies, and 11.8 per cent from
colleagues.
Arrangements to refer ECP clients to other sources
About half (50.5 per cent) reported having arrangements to refer
ECP clients to other sources. Referral points (in order of frequency)
include family planning clinics, pharmacies, other PMS, private and
government hospitals.
Monthly, 28.9 per cent of the respondents referred fewer than
10 ECP clients. One in 10 PMVs referred 10–50 ECP clients;
2.1 per cent PMV referred more than 100 ECP clients.
Ability to disseminate information on ECP in the community
Most of the PMVs (73.2 per cent) were sure that they could
disseminate information on ECPs in their respective communities.
The motivation to disseminate this information stemmed from (in
the order of frequency): sense of duty as a PMV, the importance of
ECPs to prevent unwanted pregnancy, the life-saving quality of
ECPs, people wanting to know more about pregnancy prevention,
and the fact that ECP will reduce abortion rate.
About one quarter reported that they could not talk freely about
ECP in their communities. Reasons (in order of frequency) include: it
is against their religious beliefs, Ministry of Health does not permit
them to sell the commodity, lack of interest, it promotes promiscuity,
and fear of harassment by regulatory agencies.
Discussion
In Nigeria, unsafe abortion remains a leading cause of maternal deaths
because access to contraceptive services remains low and abortion
laws remain restrictive.
5
Recent studies offer strong evidence that
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increasing contraceptive usage can reduce induced abortion rates
30
and could prevent up to 35 per cent of maternal deaths.
3
Thus,
increased access and use of contraceptives through community-based
initiatives is a key strategy
31
and PMVs can play a significant role.
In Nigeria, the PMVs’ educational level is usually not specified in
laws licensing their practice, although by convention, the minimum
educational attainment has been primary schooling.
32
In this study,
more than half of the PMVs had secondary education or more. The
higher educational level is likely to contribute to PMVs’ abilities to
provide accurate information to clients and to appropriately dispense
ECPs. To enhance competence of PMVs, it may be necessary to review
the laws and increase the educational level required for practice.
Survey results call into question the ability of PMVs to provide
accurate information for clients having had unprotected sexual
intercourse (consensual, sexual assault, or condom rupture), as about
one-third of the respondents were not aware of ECPs and only half
knew ECPs could be used for pregnancy prevention. This is similar to
the findings from a study conducted in Ibadan, Nigeria where more
than half of the professional health-care workers were not aware that
combined oestrogen/progestin or progestin – in the form of pills –
can be used as emergency contraception.
27
The SMOH and NGOs
should increase awareness about ECPs among community-based
distribution agents
26
and PMVs to ensure proper dissemination of
information to potential clients.
Nigerians’ negative cultural disposition to providing contracep-
tives to young people makes them wary of public health institu-
tions.
26
The advantage of the PMS for young people, including the
higher number of females, may relate to their need for anonymity,
which the PMVs provide, but which public health institutions deny.
This information is particularly relevant because young persons
(15–24 years) have the greatest incidence of unwanted pregnancy
and unsafe abortion.
14
Given the reasons cited for PMVs not being able to talk freely
about ECPs and supply shortages, women who need to access
information and ECPs appear to face religious, attitudinal, supply
and regulatory, or policy barriers.
In Nigeria, the PMVs are approved by the Federal Ministry of
Health to dispense OTC drugs and surveillance occurs at three key
levels: supervision by the Pharmacy Inspection Committee to ensure
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PMVs are licensed and only dispense unexpired OTC drugs,
supervision by NAFDAC to ensure they dispense only registered
OTC drugs, and supervision by the NDLEA to ensure PMVs do not
sell psychoactive drugs. Punitive measures available to authorities
include sealing of the PMV stores and confiscation of their products.
Governmental bodies, using existing authority and procedures, can
enhance the capacity of the PMVs to ensure they provide accurate
EC information and services.
As only half of the PMV respondents reported arrangements to
refer ECP seekers to the formal health-care system, it will be
important to enhance these links, especially in cases of sexual assault,
because the women clients may need counseling, HIV post-exposure
prophylaxis, and permanent family planning methods.
Conclusion
This study demonstrated that PMVs can play a critical role in
enhancing access to ECPs’ services. PMVs may require training on
counseling techniques, service provision, and referral. Key factors for
improving their services include reducing the opportunities for PMVs
to supply sub-standard drugs through a combination of more
effective government regulation, PMV Association self-regulation,
and community involvement.
Acknowledgement
This study was conducted by Association for Reproductive and
Family Health and Center for Research in Reproductive Health,
Nigeria with support from Population Council, Kenya and New
York. We commend Professor O.A Ladipo, Mrs G.E Delano, and
Professor A Adekunle who reviewed the manuscript and all
respondents from the Nigerian Association of Patent and Proprietary
Medicine Dealers.
About the Authors
Mojisola M Fayemi, MPH, is a public health educator experienced in
the implementation of Reproductive Health and HIV/AIDS beha-
vioral change interventions.
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Olufemi L. Oduola, MPH, is a public health promoter and educator
experienced in design of project evaluations especially in reproduc-
tive health.
Queen C. Ogbuji, PhD, is a medical sociologist with nursing/
midwifery background. She has participated in several HIV and
reproductive health research programs and contributed local and
international publications.
Kehinde A Osinowo, MPH, specializes in managing sexual and
reproductive health programs, including those focused on adolescent
reproductive health, safe motherhood, training capacity develop-
ment, and reproductive health policies.
Adejoke E Oyewo, BNSC, is a nurse, midwife who has contributed
to improving the quality of reproductive health care. In 2009 she was
a fellow at the West African College of Nursing.
Olabimpe M Osiberu, MSc, is a nurse, midwife who has served in
managerial, research, and administrative posts. She has published
locally and internationally.
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