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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 16  |  Issue : 2  |  Page : 90-94

Misoprostol for treatment of incomplete abortions by gynecologists in Nigeria: A cross-sectional study


1 Department of Obstetrics and Gynaecology, University of Abuja/University of Abuja Teaching Hospital, Abuja, Nigeria
2 Department of Obstetrics and Gynaecology, Federal Medical Centre, Nguru, Yobe State, Nigeria
3 Department of Obstetrics and Gynaecology, Federal Medical Centre, Umuahia, Abia State, Nigeria

Date of Submission11-Jun-2019
Date of Decision11-Sep-2019
Date of Acceptance20-Sep-2019
Date of Web Publication19-Nov-2019

Correspondence Address:
Dr. Godwin O Akaba
Department of Obstetrics and Gynecology, University of Abuja/University of Abuja Teaching Hospital, Abuja
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njbcs.njbcs_12_19

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  Abstract 


Introduction: Misoprostol is approved for treatment of incomplete abortion in Nigeria, but subjective evidence suggests that it is seldom used by gynecologists in Nigeria for this indication. The purpose of the study was to determine the rate of utilization of misoprostol for treatment of incomplete abortion by gynecologists in Nigeria and perceived barriers to its use for this indication. Materials and Methods: This was a cross-sectional study of gynecologists who attended the 2017 Society of Gynaecology and Obstetrics of Nigeria, Conference held in Sokoto state, Nigeria as well as a retrospective review of Post abortion care services in three Nigerian tertiary hospitals for a period of one year (1 January-31 December, 2017). Results: Misoprostol was used in the treatment of first trimester abortions in 19/343 (5.5%) compared to manual vacuum aspiration (MVA) 324/343 (94.5%) in the tertiary hospitals. The major perceived barrier in the utilization of misoprostol for treatment of first trimester incomplete abortion was the preference of MVA to misoprostol by the provider (32%) and was followed closely by not being sure of the brand of the misoprostol (31%). Other reasons included that misoprostol was not effective (6%), side effects (8%), high cost (5%), unavailability (1%), not conversant with dosage regimens (1%), and others (16%). Overall, 51% of responders confirmed that they do not have a written onsite protocol for the management of first trimester incomplete abortions in their institutions. Conclusions: There is poor utilization of misoprostol, barriers to its use, and absence of protocols/guidelines for the treatment of first trimester incomplete abortions in most gynecological departments of Nigeria's public health institutions. It is expedient for gynecologists in Nigeria to put in place processes that ensures translation of evidence-based research findings into practice and policies towards improving maternal health in Nigeria.

Keywords: Misoprostol, Nigeria, post abortion care


How to cite this article:
Akaba GO, Abdullahi HI, Atterwahmie AA, Uche UI. Misoprostol for treatment of incomplete abortions by gynecologists in Nigeria: A cross-sectional study. Niger J Basic Clin Sci 2019;16:90-4

How to cite this URL:
Akaba GO, Abdullahi HI, Atterwahmie AA, Uche UI. Misoprostol for treatment of incomplete abortions by gynecologists in Nigeria: A cross-sectional study. Niger J Basic Clin Sci [serial online] 2019 [cited 2019 Dec 12];16:90-4. Available from: http://www.njbcs.net/text.asp?2019/16/2/90/270997




  Introduction Top


Abortions which is defined as the loss of pregnancy before the age of fetal viability is an important contributor to maternal morbidity and mortality especially in developing countries like Nigeria where access to safe abortion care services are limited by several factors including unavailability of trained personnel for provision of services as well as restrictive abortion laws.[1]

An incomplete abortion can result from either spontaneous or induced pregnancy loss and occurs when products of conception are not completely expelled from the uterus.[2]

Post abortion care (PAC) which is a package of related interventions for the management of complications of spontaneous and induced abortions aims to reduce maternal morbidity and mortality as well as improve women sexual and reproductive health.[3] One of the essential elements of PAC is the emergency treatment of incomplete abortions and other complications of spontaneous or unsafely induced abortions.[3],[4]

Misoprostol is an evidencebased, safe, effective and acceptable alternative to manual vacuum aspiration (MVA) for uterine evacuation in the first trimester of pregnancy[4],[5],[6],[7],[8],[9] and has an advantage of being easy to administer by both doctors and midlevel providers thereby helping to increase access to safe abortion care services.

A previous study led by Society of Gynaecology and Obstetrics of Nigeria (SOGON), a professional body for all gynecologist in Nigeria had accessed the feasibility of hospital, patients and provider acceptability on the use of misoprostol for treatment of incomplete abortion in Nigeria and had reported that hospitals, patients and clients were satisfied with the use of misoprostol for treatment of incomplete miscarriage as it was safe, efficacious and easy to administer.[10] Subsequently misoprostol was added to the essential drug list of Medicines by the Federal Ministry of Health (FMOH) in Nigeria for this indication in 2010.[11]

Despite the overwhelming literature on its safety, efficacy and relevance in scaling up PAC services in Nigeria,[10] the use of misoprostol for uterine evacuation particularly by gynecologist who provide research evidences, train other health workers and drive policy changes on maternal and reproductive health services in Nigeria appears to be low.

This study was designed with the objectives of ascertaining the rate of utilization of misoprostol for treatment of incomplete abortions by gynecologists in Nigeria, document possible barriers to its use for this indication by gynecologists in Nigeria, and determining the availability of departmental protocols/guidelines for management of abortions in tertiary and secondary health facilities.

Findings from this study would help in addressing the perceived barriers to utilization of misoprostol for treatment of incomplete abortions in Nigeria's public and private health institutions.


  Materials and Methods Top


This was a crosssectional study that involved gynecologists who attended the Annual SOGON Conference that held from 19 to 25 November, 2017 as well as retrospective review of PAC services from 1 January 2017 to 31 December 2017 in three Nigerian tertiary health facilities.

A total of 126 pretested self-administered questionnaires developed specifically for this study were distributed by convenience sampling to consenting gynecologists at the conference, out of which 100 (79.4%) were duly filled and returned to the researchers and used for analysis for this study. The questionnaire was developed for the study and information relating to participants demographics (age and sex), type of facility (private, secondary, and tertiary), average number of uterine evacuations per month, estimate of proportion of uterine evacuation done using misoprostol, perceived barriers to utilization of misoprostol for first trimester treatment of incomplete abortion, onsite availability of protocol/guideline for treatment of incomplete abortion were collected. In addition, one of the questions sought to know the recommended dosage of misoprostol for management of first trimester miscarriage. A response of a single oral dose of 600 μg or a single sublingual dose of 400 μg was taken as the correct response. Persons who did not respond to this question or wrote a different dosage regimen were termed as not knowing the correct dosage regimen for management of first trimester abortion using misoprostol.

Towards validating the responses gotten from the participants regarding proportion of PAC that utilized misoprostol for uterine evacuation in obstetrics and gynecology departments in public health institutions in Nigeria, a retrospective review of PAC services from 1 January 2017 to 31 December, 2017 in the departments of obstetrics and gynecology of three Nigerian tertiary public health institutions located in three out of the six geopolitical zones in the country were carried out. The institutions involved were as follows: University of Abuja Teaching Hospital (North Central), Federal Medical Centre, Nguru (North East) and Federal Medical Centre, Umuahia (South East). They all provide specialist healthcare services and serve as referral centers in their locations. The department of obstetrics and gynecology in these centers provide maternity and reproductive health services to Nigerian women and are headed by consultant obstetricians and gynecologists.

The information collected were entered into a computer and data analysis were done using SPSS version 20.

Ethical approval for the study was obtained from the Health Research and Ethics committees of the University of Abuja Teaching Hospital, Gwagwalada, Federal Medical Centre, Nguru and Federal Medical Centre, Umuahia. Written informed consent was obtained from all participants that responded to the study questionnaire. Informed consent was not required for the retrospective review of PAC services provided in the hospitals.


  Results Top


A total of 100 out of 126 gynecologists completed the survey and returned the questionnaire giving a response rate of 79.3%.

Of the 100 persons surveyed, 65% were males while the remaining 35% were females. Majority were in the age bracket of 40-49 years (51%) with the mean age of responders being 44.5 years [Table 1]. Overall, 87% of responders worked in a tertiary hospital (while 59% of responders worked in the teaching hospitals, 28% worked at Federal Medical Centers), the remaining 8% and 5% worked at the General hospitals (secondary healthcare facilities) or private sector respectively [Table 2]. Only 65% of responders correctly stated the recommended dosage regimen of misoprostol for treatment of incomplete miscarriage in the first trimester. Cumulatively, in the responder's opinion, the mean number of uterine evacuations done at the sites per month was 28.2 out which the mean percentage done using misoprostol was 3.6%.
Table 1: Demographic characteristics of gynecologists surveyed

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Table 2: Type of facility were gynecologists worked

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The major perceived barrier in the utilization of misoprostol for treatment of first trimester incomplete abortion was the preference of MVA to misoprostol by the providers (32%). This was followed closely by providers not being sure of the brand of the misoprostol (31%). Other reasons included that misoprostol was not effective (6%), side effects (8%), high cost (5%), unavailability (1%), providers not conversant with dosage regimens (1%), others (16%). The latter included reasons like misoprostol was associated with more bleeding, time to uterine evacuation was longer with misoprostol and most patients would still require MVA [Table 3].
Table 3: Perceived barriers to the use of misoprostol

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Overall, 51% of responders confirmed that they do not have a written onsite protocol for the management of first trimester incomplete abortions in their institutions while the remaining 49% confirmed availability of a written protocol in their various institutions [Table 4].
Table 4: Availability of departmental protocol for management of first trimester miscarriage

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Regarding whether patients should be offered misoprostol as an option of treatment during counseling, 41% agreed, 21% disagreed, 18% strongly agreed, 8% strongly disagreed, while 12% were undecided.

Recommendations for increasing utilization of misoprostol for PAC included creation of awareness on safety and efficacy of misoprostol for PAC, increased advocacy, development of institutional guidelines/protocols and training of providers.

From the retrospective review, a total of 386 patients were managed for complications of miscarriages out of which 343 patients had first trimester incomplete miscarriages. The mean age of the women was 30.45 years while the mean gestational age was 10.6 ± 3.2 weeks. Misoprostol was used in the treatment of first trimester miscarriages in 19/343 (5.5%) compared to MVA 324/343 (94.5%).


  Discussions Top


Misoprostol a prostaglandin E1 analogue is endorsed by several organizations including World Health Organization for the treatment of first trimester miscarriage. Its inclusion in the 5th Edition of the Essential Medicines list by Federal Ministry of Health in Nigeria in 2010 was a mark of the Federal government of Nigeria's support for the use of misoprostol for this indication by health workers.[11] Despite these endorsements and recommendations, utilization of misoprostol in obstetricians and gynecologists led units in Nigeria as well as the availability of onsite protocols for the management of first trimester incomplete abortion in most gynecological units in Nigeria seems to be low as highlighted in this study.

A retrospective review of PAC cases managed in four hospitals in Botswana showed that only 8.1% of cases where managed with misoprostol.[12] This poor utilization of misoprostol for PAC is comparable to findings from our study in which the mean percentage of cases managed by misoprostol was 3.6% and 5.5% in the opinion of participants and from retrospective review respectively.

A previous study that explored barriers to provision of PAC in a district hospital in Uganda also reported poor use of misoprostol in PAC. The reasons for this included lack of knowledge among providers, no hospital guidelines and a lack of available drugs in the health facilities.[13] This is similar to our findings where 35% of participants did not correctly remember the dosage for misoprostol in PAC and 51% did not have a written protocol or guideline in their institutions for treatment of abortions.

As defined by the Institute of Medicine, clinical guidelines are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”[14] Their use has been associated with improved health outcomes as it allows for uniform management of patients with similar conditions. Additionally, it empowers patients to make more informed healthcare choices and to consider their personal needs and preferences in selecting the best option. Benefits to the healthcare workers include update in knowledge on the subject matter and enhancement of clinical audits.[15] These benefits are yet to be fully achieved in Nigeria due to dearth of National and institutional guidelines for management of most obstetrics and gynecological conditions.

Recently, the Federal Ministry of Health in realization of the unavailability of a uniform standards of care and guideline for PAC, developed a training manual for PAC in Nigeria in partnership with several stakeholders for use by, as well as training of healthcare workers in Nigeria.[16] This document also stressed the role of misoprostol in the management of first trimester abortion and should be considered for all patients meeting the criteria for its use. The document unfortunately is yet to receive the desired attention in Nigeria's public health institutions. Efforts should be made by gynecologists to ensure availability of protocols and guidelines for management of this important contributor to maternal morbidity and mortality in their various departments.

Preference for MVA by the provider was the major reason for nonuse of misoprostol in this study even though previous studies comparing safety and effectiveness between MVA and misoprostol for treatment of incomplete miscarriages in Nigeria and other countries concluded that misoprostol was as effective as MVA.[7],[8],[9],[17],[18] A previous study that investigated provider knowledge, attitude and treatment preferences for early pregnancy loss also reported obstetricians and gynecologists preference for MVA compared to misoprostol for treatment of early pregnancy loss. The study additionally noted that belief by provider that patients would not accept treatment with misoprostol was negatively associated with its use.[19] The reliance on the preference of the provider for the choice of treatment for patients needing PAC as well as other reproductive health services is now obsolete with the advent of the concept of “patient centered care”.

The concept of patient-centered care lays emphasis on the patient rather than the provider in decision making and preference to a treatment option. It endorses the need to respect patients' preferences and values, psycho-physiological comfort, the importance of communication and the need to provide support and coordinated care that is inclusive of the patient and her family.[20] It has been found to improve quality of healthcare in other climes and should therefore be an integral element in the provision of health services in Nigeria. This concept should also be readily taught to undergraduate and postgraduate medical doctors and midwives as well as during trainings and workshops related to improving quality of care to patients in Nigeria.

The challenge of not being certain of the genuineness of the misoprostol medications was a concern for about one third of persons surveyed. This was an important barrier to utilization of misoprostol for PAC in this study. It is possible that these providers had had unsuccessful uterine evacuations or unremarkable experiences with counterfeit medications. There have been reports of counterfeit misoprostol as well as other medications in the past in Nigeria.[21] Counterfeit drugs result to treatment failures as well as huge economic burden to the society.[22] There is a need for relevant agencies like the National Drug Law Enforcement Agency and the Federal Ministry of Health in Nigeria to address this barrier more so that misoprostol is also important in the prevention and treatment of postpartum hemorrhage which is a leading cause of maternal mortality in Nigeria.

The strength of the study lies in its use of retrospective review of PAC in Nigerian hospitals to validate the responses regarding percentage of uterine evacuations using misoprostol on the questionnaire.

Although both responders' opinion and result of retrospective review affirmed low utilization of misoprostol for PAC, generalization of the results of this study may be limited by the reason that majority of the cases of incomplete abortions managed at the tertiary hospitals are usually complicated and may not meet clinical criteria for use of misoprostol, for uterine evacuation necessitating the use of MVA in these cases.


  Conclusions Top


There is poor utilization of misoprostol and absence of protocols/guidelines for the treatment of first trimester incomplete abortions in most gynecological departments of Nigeria's tertiary health institutions. Barriers to utilization of misoprostol by Nigerian gynecologists include preference to MVA and not being sure of the brand of the misoprostol. Gynecologists in Nigeria are major stakeholders in matters relating to reproductive health and rights of women. The non-utilization of misoprostol for uterine evacuation by majority could jeopardize the benefits of increasing women's access to safe abortion care services as non-specialist doctors, general practitioners and midlevel providers who look up to them for leadership and guidance may be discouraged by this practice. Gynecologists in Nigeria must therefore put in place processes that ensure translation of the evidence-based research findings into practice and policies towards improving maternal and perinatal health in Nigeria.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Yaya S, Amouzou A, Uthman OA, Ekholuenetale M, Bishwajit G, Udenigwe O, et al. Prevalence and determinants of terminated and unintended pregnancies among married women: Analysis of pooled cross-sectional surveys in Nigeria. BMJ Glob Health 2018;3:e000707.  Back to cited text no. 1
    
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Melese T, Habte D, Tsima BM, Mogobe KD, Nassali MN. Management of post abortion complications in Botswana-The need for a standardized approach. PLoS One 2018;13:e0192438.  Back to cited text no. 12
    
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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