Women’s Experiences with Self-Managed Misoprostol Abortions in Lagos State, Nigeria

In Nigeria, abortion is legally permitted only to save a woman’s life. However, medication abortion drugs, particularly misoprostol, have become widely available in recent years through Nigeria’s large market of formal and informal drug vendors. Little has been previously known about the experience of women seeking and obtaining misoprostol for an abortion, or about the drug’s safety and effectiveness in this context. Lagos is Nigeria’s most populous city and constitutes one of the largest markets for medication abortion in the country. This fact sheet presents new findings from a prospective study of 394 women aged 18–49 who self-managed an abortion using misoprostol obtained from a drug seller in Lagos State, Nigeria in 2018.

• Eighty-three percent of women participating in the study had confirmed their pregnancy with a positive pregnancy test.
• For 85% of women, this was their first experience terminating a pregnancy.
• Fifty-seven percent of women did not know about pills that could end a pregnancy before visiting a drug seller.
• Five percent of women in the study had attempted to end the current pregnancy prior to visiting a drug seller.

Information and services provided by drug sellers

• About three-quarters of study participants relied solely on the information given to them by the drug seller on how to use the medication.
• The majority of women reported that drug sellers attempted to assess their eligibility for medication abortion by asking for the date of their last menstrual period (79%) or if they had taken a pregnancy test (74%).
• One-quarter of women reported not knowing what kind of medication they had purchased; among those who did know, 97% reported receiving misoprostol and 3% received misoprostol in combination with mifepristone.
• The majority of participants were not provided with adequate, accurate information by drug sellers about how to administer the medication, how much to take and what to expect from the process.
• For instance, only 25% of participants were given information about the possibility of experiencing postabortion complications; 67% were told to anticipate bleeding and 35% were told to expect cramping.
• Fewer than one-third of women were told that they may need to use pain medication during the abortion process.

Self-reported postabortion complications

• The majority of women in the study did not report experiencing complications from the medication. However, 20% described bleeding that was heavy or prolonged enough to indicate medical assistance had been warranted, and 4% experienced symptoms suggestive of infection.
• Overall, 7% of participants reported wanting or needing medical care after taking the pills, and 6% sought care.
• Out of the 24 women who sought medical care, one woman reported receiving a blood transfusion and seven had a surgical procedure to complete the abortion. More than half had an ultrasound or were given pain medication.

Self-assessed completeness of abortion

• Fifty-four percent of women reported that they knew they were no longer pregnant because their period returned, 33% confirmed their abortion was complete by taking a pregnancy test at home and 25% reported that they no longer had symptoms of pregnancy. Twenty-four percent of women reported visiting a medical facility to confirm the completion of their abortion.

Women’s reflections on their use of misoprostol

• Nine percent of women reported that they would have attempted to induce abortion using unsafe methods had they not had access to misoprostol.
• Seventy percent of women in the study reported that they would use misoprostol in the future, should they experience another unintended pregnancy. Among those who would not use it again, 47% reported that they would not terminate another pregnancy.

Recommendations

• The Nigerian government, at both national and local levels, should work with drug sellers’ associations to improve the quality of medication abortion services, given the sellers’ critical role in providing misoprostol for abortion. Drug sellers should be routinely updated on recommended guidelines for the provision of medication abortion.
• In addition, drug sellers must be trained to share key information, such as what to expect during the abortion process, potential signs of complications and where to access medical care if clients want or need it. Written materials should also be provided to women seeking to purchase medication abortion in order to standardize the provision of accurate information by drug sellers.
• The data suggest that misoprostol obtained from drug sellers is effective at terminating pregnancy and that its retail availability provides an alternative for women who may otherwise use harmful methods to terminate an unintended pregnancy. The Ministry of Health should consider this method to be a harm reduction approach to prevent severe morbidity and mortality caused by unsafe abortion procedures.
• This study suggests that it is feasible to research women’s experiences using misoprostol for abortion, even in settings where abortion is highly restricted. Similar studies are needed in other settings (e.g., other regions and less urban areas) and among other demographic groups in Nigeria (e.g., young women and high-risk populations) to understand a broader range of women’s experiences obtaining misoprostol and their abortion outcomes after use.