Despite the legalization of abortion in Nepal in 2002 and subsequent expansion of services, unsafe abortion is still common and exacts a heavy toll on women, as documented in the 2016 study, "Abortion Incidence and Unintended Pregnancy in Nepal." Access to safe abortion care is especially limited in remote areas where trained providers and equipment are scarce. Given that 76% of Nepali women live in rural areas, providing medication abortion through pharmacies could increase access to care for the most vulnerable women.

Medication abortion using mifepristone and misoprostol tablets is safe and effective for ending pregnancy during the first trimester and can be provided without laboratory tests, ultrasound or sterile equipment. In Nepal, medication abortion is legally available at government-certified health facilities, but pharmacies are not eligible for government certification for abortion provision (those participating in this study received temporary certification).

In 2015, the authors conducted in-depth interviews with 19 pharmacy-based workers, including pharmacy owners and auxiliary nurse-midwives, in two districts of Nepal-Chitwan and Jhapa. They found that most pharmacy owners and workers are comfortable with their knowledge about medication abortion and proud of the services they provide. "The providers felt that women faced significant barriers to abortion access under the existing system and viewed provision of medication abortion as a service to women and their community," noted the authors.

The study participants reported that pharmacies have distinct advantages over government health centers because their clients typically travel shorter distances, benefit from private consultations and do not have to explain the visit to family members or friends. Unmarried women, in particular, can benefit from pharmacy-based services because they face significant barriers to receiving abortion care and might otherwise resort to unsafe abortion methods. Moreover, pharmacies remain
a first point of contact for many women who are seeking abortions in settings where access to care is limited.

Participants endorsed integrating pharmacies into formal, legal abortion networks to expand access to medication abortion and ensure access to safe services. Such integration would also streamline the process of referrals from pharmacies to clinic-based providers. For example, a formal referral system would enable pharmacy workers to refer women to a government health facility for an ultrasound when gestational age is unclear, or for follow-up in the event of abortion complications or an incomplete abortion. Participants also felt that, because standards of care are often updated and improved, legalization could provide avenues for ongoing training to help them keep up with the latest medical protocols.

Taking into consideration the viewpoints of key stakeholders will be critical if medication abortion services are to be expanded beyond traditional clinical settings. Study findings on the provision of medication abortion in pharmacy settings can help ensure its success and sustainability and inform efforts to make medication abortion more widely accessible in Nepal and other low-income countries.

"Pharmacy Provision of Medication Abortion in Nepal: Pharmacy Owner and Worker Perspectives," by Goleen Samari, Mahesh Puri, Rebecca Cohen, Maya Blum and Corinne H. Rocca, appears in International Perspectives on Sexual and Reproductive Health and is currently available online.