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Knowledge and Inventory
Reproductive health, simply defined as a
Management of Misoprostol for
complete state of physical, mental and social Reproductive Health Services
well-being and not merely the absence of Amongst Community
disease or disorder of the reproductive process, constitutes a measure of the social and Pharmacists in Anambra and
economic well-being of any nation.1,2 Of the Delta States of Nigeria
various components of reproductive health, *Adinma ED1, Adinma JIB2
unsafe motherhood represented by maternal

Background: Misoprostol, a prostaglandin
infringement of the reproductive rights of analogue used in the management of a wide women and its address has over several years range of reproductive health disorders is safe, posed an intractable challenge to several inexpensive and easily administered. countries of the developing world.3 In Nigeria for Objective: To investigate the knowledge of
instance, the yearly maternal deaths of 59,000 misoprostol amongst Community Pharmacists women which constitute approximately 10% of from Anambra and Delta States, Nigeria, with the overall global maternal mortality statistics respect to its indications, contraindications, and have remained a great embarrassment to the side effects; and also evaluate their stocking and federal government and its benefactors alike. Two of the five major direct medical causes of Method: Cross-sectional, questionnaire based
maternal mortality viz obstetrics haemorrhage survey of 22 Community Pharmacists from and abortion, occupy prominent positions for the Anambra and Delta States, Nigeria. role they play in the causation of maternal Result: There were nine participants from
Anambra and 13 from Delta State. The majority were of urban location, 77.8% in Anambra and instance, is known to account for as high as 25- 76.9% in Delta State. There is significantly 30% of maternal deaths, while abortion and its higher knowledge of misoprostol, 88.9% and 100% respectively for Anambra and Delta complications have been implicated as the cause States, compared with current stocking and of maternal deaths to the magnitude of as high dispensing of the drug, 22.2% apiece, and as 50% in some countries.4,5 Reducing the 30.8% apiece respectively for the two States. burden of maternal mortality in resource poor Only two of the 6 listed indications for countries of developing world requires a wide misoprostol were recognized, each by one introduction of the application of simple, participant from Anambra State; while five were economical, yet safe and effective management recognized, each also, by one participant methods, of which misoprostol ranks high. from Delta State. No respondent from Delta Misoprostol is a synthetic prostaglandin E State recognized abortion treatment as an analogue originally developed and 1 approved globally for the prevention of peptic ulcer. The Only 40% respondents in Anambra State tablet which has no known adverse interaction recognized the contraindications, and 80%, of with other drugs is inexpensive and usually the side effects of misoprostol, while 80% and stable at room temperature and has long shelf 70% respondents in Delta State recognized the life.6, 7 The drug is effective in the treatment of contraindications and side effects respectively. early pregnancy failure, induction of second Conclusion: There is gap in knowledge and
trimester abortion, ripening of the cervix and inventory management of misoprostol for induction of labour.8-11 It is also used for the reproductive health problems' management treatment of post partum haemorrhage. Its use amongst Community Pharmacists. There is for obstetrics and gynecological indications is need for sensitization and advocacy program on however off label in most countries.
the use of Misoprostol for these health has over the years, been marketed in Nigeria as Key Words: Knowledge, Inventory
Cytotec for the treatment of peptic ulcer and has Management, Misoprostol, Pharmacists, Nigeria. only recently been approved for use by the Nigerian National Agency for Food and Drug Afrimedic Journal 2011;2(1):13-18
Administration and Control (NAFDAC) for the treatment of post partum haemorrhage. In Nigeria, the provision of maternal healthcare demographic characteristics of the respondents services is not restricted to skilled practitioners for the two States studied. There were nine alone, that is doctors and nurse-midwives, but participants in the Anambra State meeting, also to a wide range of practitioners, orthodox consisting of eight males and one female, while Delta State had 13 participants comprising nine pharmacists are an important group of maternal males and four females. The majority of the healthcare providers for the part they play, not respondents had practiced pharmacy for 21 years and above 7 (77.8%) in Anambra State reproductive healthcare medications but also in and 6 (46.2%) in Delta State and most of them routine consultations and treatment of some were based in urban location, 7 (77.8%) in reproductive health problems. This study investigates the knowledge of misoprostol The distribution by knowledge, usage, and amongst community pharmacists from Anambra availability of misoprostol/cytotec as shown in and Delta States of Nigeria, with respect to its Table II indicates that 8 (88.9%) and 13 indications, contraindications, and side effects. (100%) respectively of the participants in It also evaluates their stocking and dispensing pattern of the drug for the management of misoprostol. Only 2 (22.2%) pharmacists in reproductive health problems. Information Anambra State and 4 (30.8 %) in Delta State obtained from this study will determine whether have treated 5-10 patients with misoprostol over the 3 months preceding this study. Knowledge sensitization of health practitioners to an of misoprostol therefore is statistically increased use of this vital drug for reproductive significantly high compared with use, ever stocked, current stocking, and dispensing of the drug by the community pharmacists for both This is a Cross-sectional, questionnaire-based Anambra and Delta States. P <0.05 for each of survey of 22 Community Pharmacists attending a lunch meeting at two locations Nnewi in Table III shows the distribution by knowledge of indications, contraindications, as well as the side respectively of South-east and South-south effects of misoprostol. Of the 6 indications for Nigeria. The survey was carried out on 18th misoprostol listed in the questionnaire, only 2 June 2009 and 2nd September 2009 at Nnewi (post partum hemorrhage and abortion) were and Asaba respectively. The questionnaire recognized, each by one of the 9 respondents from Anambra State; and 5 were recognized, respondents with respect to their bio-social again each by only 1 of the 13 Community characteristics sex, duration and location of Pharmacists from Delta State. No respondent practice, and number of clients receiving from Anambra State recognized the treatment of misoprostol within three months preceding the peptic ulcer as an indication for the use of study; respondents' knowledge , usage , and misoprostol. Similarly, no community pharmacist availability of misoprostol/cytotec; and their from Delta State recognized the treatment of knowledge of indications, contraindications, and abortion as an indication for the use of side effects of misoprostol/cytotec. Data misoprostol. Of the 5 contraindications to the obtained were analyzed using Statistical Package use of misoprostol and 10 side effects of the for Social Sciences (SPSS) version 15.0, and drug listed in the questionnaire, only 2 displayed in Tables. Statistical comparison of (40.0 %) of the contraindications and as high as variables was made where necessary using Chi- 8 (80 %) of the side effects were recognized by respondents in Anambra State while 4 (80 %) recognized by respondents in Delta State. Afrimedic Journal 2011;2(1):13-18
Afrimedic Journal 2011;2(1):13-18

incomplete abortion and other reproductive health related problems.13-15 The reproductive management of Misoprostol for reproductive healthcare practitioners are therefore expected health services was undertaken for a total of 22 to have considerably clear knowledge and usage pharmacists practicing in two States of Nigeria. of this life saving drug. This unfortunately is not Most of these Pharmacists practice in urban the case amongst the community pharmacists centres and had done so for more than 20 participating in this study evident from the very years, they are therefore expected to have built high number of pharmacists, 7 (53.8%)-11 up a reasonably large clientele. The findings (84.6%) and 5 (55.6%)-7 (77.8%) respectively from the questionnaire studies were interesting. from Delta and Anambra States that failed to In spite of a considerably high knowledge of respond to the knowledge of the indications, misoprostol amongst the pharmacists, only a contraindications, and side effects of the drug. paltry 2 (22.2 %) and 4 (30.8 %) from Anambra Of the 6 indications for misoprostol listed in the and Delta States respectively were currently questionnaire, only 2 (post partum hemorrhage stocking misoprostol, and in fact had prescribed and abortion) were recognized, each by one of the drug for as few as only 5-10 patients over the 3 months preceding the study. The poor Similarly, 5 of the 6indications listed were stocking and prescription of misoprostol by recognized, again each by only 1 of the 13 community pharmacists may indicate an unclear community pharmacists from Delta State. It is Reports from studies conducted both in Africa and Europe have highlighted the undoubtful efficacy of misoprostol in the treatment of Afrimedic Journal 2011;2(1):13-18
to put in place, a sensitization and advocacy Anambra State recognized the treatment of program on the use of misoprostol for the peptic ulcer as an indication for the use of management of reproductive health problems, misoprostol even though the drug has been not just for community pharmacists, but also for approved for that purpose in Nigeria for a long all other cadres of health professionals involved time. In addition, none of the community in women's health management in the country. pharmacists from Delta State recognized the This advocacy and sensitization program efforts treatment of abortion as an indication for the can be enriched through the development of use of misoprostol. These are important findings misoprostol treatment and dosage protocol and when combined with the similar scenario presented to the responses to the knowledge of America.18 In the words of Weeks et al “If we side effects and contraindications to the use of can develop practical training programs and misoprostol, attest unequivocally to the lack of treatment protocols for use in rural areas, then clear information on this very important drug the use of misoprostol could potentially lead to a major reduction in abortion-related maternal healthcare professionals. The reason for this morbidity and mortality”. 13 This statement is no may not be far-fetched and can be considered in less applicable to abortion management as it is the light of the fact that it is only recently that to other similarly important practical obstetric misoprostol had been approved for use in problems such as post partum hemorrhage. reproductive health management treatment of REFERENCES
post partum hemorrhage, by Nigerian National 1. Fathalla MF. Promotion of Research in Human Reproduction: Global Needs and Perspectives. Control (NAFDAC). Progesterone antagonist Mifepristone, has been reported to have a high 2. Adinma ED, Adinma JIB. Reproductive Health efficacy (92% - 99%) for complete abortion in anImmutable Factor to the Socio-economic addition to an excellent safety profile.16, 17 It has Development of Nations: Focus on Nigeria. Afr J also been employed as a standalone medical abortifacient for the treatment of various types 3. Adinma JIB. An Overview of the Global Policy of abortion and in fact, many other reproductive health problems.10, 11 Its convenience to use is Reproductive Right: The Nigerian Perspective. Tropical Journalof Obs/Gyn, 2002; 19 (suppl 1) administration orally, sublingually, vaginally, and 4. Rebecca J, Cook JD, Dickens BM, Andrew FO, CONCLUSION
Wilson, Scarrow SE. Advancing Safe Motherhood Observations from this study, in spite of the through Human Rights. WHO 2001; 5: 12-13. relatively small sample size of community 5. Centre for Reproductive Rights Regarding pharmacists surveyed, undoubtedly depict a Maternal Mortality in Nigeria Universal Periodic yawning gap in information and therefore knowledge and inventory management profile 6. Moreno-Ruiz NL, Borgatta L, Yanow S, Kapp on the use of the vital drug, misoprostol, for the management of reproductive health problems Mifepristone for Early Medical Abortion. amongst this important group of healthcare International Journal of Obs/Gyn 2007, doi: deplorable reproductive health indices in Nigeria 7. Yap-Seng Chong, Lin Lin Su, Arulkumaran S. have continued to be a source of worry to the Misoprostol: A Quarter Century of Use, Abuse government, non-governmental organizations and Creative Misuse. Obstet Gynecol Survey and the generality of the Nigerian people alike. This situation calls for all hands on deck, towards a total commitment to the harnessing and mobilization of all efforts towards the reversal of the undesirable trend. There is need Afrimedic Journal 2011;2(1):13-18
9. American College of Obstetricians and Miscarriage: Non-surgical Uterine Evacuation of Administration Labeling on Cytotec (Misoprostol) Abortion (Published Erratum Appears in BMJ Use and Pregnancy. ACOG Committee Opinion 1993; 306: 1303). BMJ 1993; 306: 894-895. on Obstetrics Practice, vol. 283. Washington, 15. Sahin HG, Sahin HA, Kocer M. Randomized Outpatient Clinical Trial of Medical Evacuation 10. El-Rafaey H, O'Brien P, Morafa W, Walder J, Rodeck C. Misoprostol for Third Stage of Labor. Miscarriage (Published Erratum Appears in Eur J Contracept Reprod Healthcare 2002; 7: iv) Eur J Contracept Reprod Healthcare 2001; 6: 141- Misoprostol and Pregnancy. N Engl J Med 2001; 16. The Population Council. Medical Methods of 12. Saxena P, Salhan S, Sarda N. Role of SublingualMisoprostol for Cervical Ripening to Abortion in Developing Countries: Consensus VacuumAspiration in First Trimester Interruption Statement. Contraception 1998; 58: 257-259. ofPregnancy. Contraception, 2003; 67/3: 213- 17. American College of Obstetricians and Gynecologists. Medical Management of Abortion. 13. Weeks A, Alia G, Blum J, Winikoff B, Ekwaru ACOG Practice Bulletin. Clinical Management P, Durocher J, Mirembe FA. Randomized Trial of 18. Faúndes A, Cecatti J, Conde-Agudelo A, Aspiration for Incomplete Abortion. American Escobedo J, Rizzi R, Távara L, Velasco A. College of Obstetrics and Gynecologist 2005; Misoprostol Use in Obstetrics and Gynecology. FLASOG, Latin American Federation of Obs/Gyn 14. Henshaw RC, Cooper K, El-Refaey H, Smith 1Department of Community Medicine, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
2Department of Obstetrics and Gynecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria

Afrimedic Journal 2011;2(1):13-18



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