WOMEN, MEN AND ABORTION PILL AN ANTHROPOLOGICAL APPROACH OF REPRODUCTIVE HEALTH ISSUES IN CAMBODIA RESEARCH REPORT OCTOBRE 2012 Researcher: Leakhena ITH Royal University of Phnom Penh Principal Investigator & senior researcher: Pascale HANCART PETITET, Institut de Recherche pour le Développement, UMI 233 & Institut Pasteur du Cambodge Co Principal Investigator: Thérèse DELVAUX, Institut de Médecine Tropicale d Anwerp Funded by: European Society for Contraception &Reproductive Health 1
I. EXECUTIVE SUMMARY This study aimed to explore both women s reproductive lives and social practices surrounding medical abortion in Cambodia. Specific Objectives were: - To examine the social impact of access to medical abortion drugs in women s reproductive health experiences- - To explore women s and their partners knowledge related to access and use of medical abortion drugs - To describe caregivers and pill sellers discourse and attitudes toward abortive pill use - To find out the constraint and the opportunities of caregivers and pills sellers in providing abortive pills and dealing with post abortion care. Methods We conducted in depth interviews in two health centers* prescribing medical abortion drug Medabon in capital city Phnom Penh and at Tackmao province; in Informal sector of care in capital city (Private pharmacy, small private clinic) and in Informal sector of care out in the province (Private pharmacy, market). To speak in quantitative terms we interviewed 25 women; 6 men (partners of interviewed women); 8 caregivers in two health centers and 4 pill seller/ caregivers in two sites of informal sector of care. Notes:Medabon is a combination of 200 mg mifepristone (1 c); 800 µg misoprostol (4 tab x 200 µg).* The two health centres were run by Marie Stopes International (MSI) an international non- governmental organization (NGO)working in reproductive health and active in Cambodia Key findings Medical abortion drugs in Cambodia Medabon The cost of Medabon in the market is about 3.5 US$ per kit. The cost when purchased in a pharmacy is about 10 to 15 US$ per kit. The cost at MSI health facilities is 20 US$ per kit including medical consultation, counseling and post abortion care. 2
Chinese pill According to information provided by pharmacists, Chinese abortion pill contains two types of pharmacological substances: mifepristone and misoprostol. According to the instructions for use of products that we have purchased, mifepristone (6 tablets 25mg or a total of 150 mg) must be associated with misoprostol (3 tablets X 0.2 mg or a total of 600 µg) to terminate a pregnancy of less than 49 days after the last menstrual period. According to pharmacists, the drug cannot be used beyond 50 days of pregnancy. Moreover, the quality of the products differs according to their price. One tells us that it takes 20 US$ for a "number one quality 100% safe ", 15 US$ for a drug with inferior efficacy estimated by the interlocutor at 80%. For others, the100% efficacy could be achieved with a 10 US$ pill. Finally, according to their statements, many other abortive drugs are sold in drugstores and in Chinese pharmacies. Caregivers providing medical abortion at MSI clinics: Successful practice but not an easy role The two MSI clinics we visited provide comprehensive family planning counseling and clinical services (including condoms, oral contraceptives, emergency contraception, injections, IUDs, implants, tubal ligation and vasectomy). They also provide pregnancy tests, safe abortion (medical and surgical), pre-natal and post-natal care, diagnosis and treatment of reproductive tract infections/ sexually transmitted diseases, and voluntary HIV testing and counseling. Marie Stopes also offers special male sexual health services. Moreover, Marie Stopes Clinics pay particular attention on ensuring that women who come for safe abortion services are encouraged to take up a modern family planning method to avoid the dangerous cycle of repeated abortions. The objective of the MSI team is that 80% of women who get abortion services will be given modern family planning method when she will come for post abortion consultation. Most of caregivers knew that while working at MSI they will have to provide abortion services to a number of clients. However, they were scared of providing abortion service up to twelve weeks of pregnancy. Post abortion care: 70-80% of the women who got medical abortion at MSI clinics came back for medical follow up within two weeks after taking abortive pill. Most of caregivers felt personal or religious concerns about providing abortion services. They usually overcame it as they had no other choice if they want to keep their job. They also felt that doing so they contribute to improve women reproductive health. 3
Pill sellers: Various levels of knowledge related to medical abortion All pill sellers knew that Medabon pill combines two kinds of drugs, namely mifespristone to be taken the first day and misoprostrol to be inserted into the vagina on the second day. They also knew that Medabon is allowed to be used within the first 63 days of pregnancy. Also the pill sellers we met knew the normal side effects of Medabon. According to them, Medabon was safe and effective for abortion, and well cheaper than surgical abortion The level of knowledge among pharmacists we met was not homogeneous. Some of them did not attend any medical training whereas other had been trained as medical doctor. Besides selling abortive pills, pill sellers were also used to give advices on contraceptive methods to their clients and to sell them various contraceptive methods: oral contraceptives, Depoprovera injection or condoms. They also give advises on natural (seasonal) method such as calendar or withdrawal. Women: Overall satisfaction? Twenty women received Medabon at MSI clinics, including counseling and post abortion services. Five women bought Medabon from pharmacists, pill sellers, and midwifes. The women who received abortion services at both MSI clinics were more knowledgeable on issues related to medical Abortion and surgical Abortion service than those who received service at pharmacies. Women did not mention any problem related to the insertion of misoprostol tablets in the vaginal. Moreover, sometimes their partner helped inserting them. Although women were told that the body effects of taking abortive pills (Medabon ) will be similar than what they are used to experiment during menstrual period they perceived it differently. From their point of view, medical abortion was associated with bleeding period for one month. They felt also that medical abortion is not always the best option as it leads to higher percentages of unsuccessful abortions than surgical abortion. The women who did not get successful abortion at MSI clinic were not requested to pay for curettage fee. However they had to pay for ultrasound examination and for medicines. 4
The number of women using contraception increased following the abortion process. Women s partners: health Some success for male involvement in reproductive Among 6 women partners we met, 4 never used any contraceptive methods. After their wife got medical abortion, 2 decided to use calendar method and condoms, 2 decided to use oral contraceptives. Through information they received by their wife, five women partners knew that after taking abortive pills the physical effects are similar than menstrual period. Women partners knew the location of abortion services from various sources: The ONG RHAC is providing reproductive health information in newspapers and they are used to listen medical news on radio. They also got information from their neighbors, relative and friends. Most men accompanied their wife for medical consultation and abortion. Some women partners knew clearly about their wife health problem and help their wife if they could. Sometimes partners helped their wife to insert the tablets in the vagina. 5
ANNEX: RESEARCH PROTOCOL 1. STUDY DESIGN In anthropology, the main investigation methods are based on a qualitative approach. The ethnographical enquiries require observation of social situations in their context and the conduct of in-depth interviews with informants. Moreover, anthropologists are aware that the quality of the relationship the researcher is able to develop with the informant has a great impact on the quality of data collected. For these reason, our data collection was based on face-to-face semi structured interviews with informants. Also each informant could at any time stop an interview or refuse to answer to any question. The study has been based on ongoing ethnographical research (including in depth interviews, focus groups and observations) in private and public, formal and informal health settings in Phnom Penh. Besides, we studied medical abortion representations and practices from the perspective of women in various social settings. Additional were collected through the networks of International organizations working in Cambodia on abortion issues in general and on medical abortion in particular. 2. STUDY SETTING & POPULATION We conducted in depth interviews: 1. One health center prescribing (Medabon ) in capital city Phnom Penh: Marie Stoppes Clinic at Chbar Apov, Phnom Penh 2. One health center out in the province where is available (Medabon ): Marie Stoppes Clinic at Tackmao. 3. In Informal sector of care in capital city (Private pharmacy, small private clinic) 4. In Informal sector of care out in the province (Private pharmacy, market) Additional data were collected: a. In headquarters of national FP/RH programme (NMCHC) b. In international organizations involved in medical abortion (Family Health International; Marie Stopes International; Population Services International) 6
3. STUDY PROCEDURES- SAMPLING STRATEGY To speak in quantitative terms we interviewed: 10 women in each health institution (total: 20) 10 women outside health institution 6 men (partners of interweaved women) 4 caregivers in each health institution (total: 8) 2pills seller/ caregivers in the informal sector of care in two sites (total :4 ) 5 stakeholders Inclusion/ exclusion criteria: In order to be eligible, participants were aged 18 or older and willing to participate following an informed consent. Interviewed women were using or having used medical abortion pills within the last 6 months; Partners were identified by the interviewed women. Interviewed providers were prescribing medical abortion pills. Sampling strategy: Interviewed women were selected randomly within each health institution sites. Our existing social network was mobilized to identify women using the informal sector of care. All providers directly involved and prescribing (Medabon ) at the health institution sites were interviewed. If we found that more than four providers were directly involved or prescribing (Medabon ), four of them were selected according to the higher number of prescriptions of (Medabon ) made within the last 6 months. Interviewed stakeholders at national and international organizations were also interviewed. 4. DATA COLLECTION The in-depth interviews followed a semi-structure questionnaire format, with both closed and open-ended questions, to ensure key, standard information be obtained. Also researchers had some freedom to follow any interesting 7
lines of enquiry. Data were collected by Leakhena Ith and Pascale Hancart Petitet. Issues investigated were as follow: Clients and their partner Specific Objectives were: - To examine the social impact of abortive pill access in women s reproductive health experiences - To explore women s and their partners knowledge related to abortive pill access and use We investigated: - Biography / Contraceptive itinerary / and circumstances related to medical abortion use - Advantages/ disadvantage of medical abortion/ surgical abortion/ contraceptives method - Knowledge related to medical abortion practices and services - Medical abortion experiences, with whom, how do they know where to go, which practices (details), which cost, relation with the caregiver, outputs (case studies) - Additional data provided by the informant Caregivers and pill sellers perspectives Specific Objectives were: - To describe caregiver and pill sellers discourse and attitudes toward abortive pill use - To find out the constraint and the opportunities of caregivers and pills sellers in providing abortive pills and dealing with post abortion care. We investigated: - Advantages/ disadvantage of medical abortion/ surgical abortion/ contraceptives method - Knowledge related to medical abortion practices and services (where and how they were trained, where and how they get the abortive pill, how they use it) 8
- Constraints and opportunities for care givers in giving medical abortion access and services (in formal and informal sector of care). - Experiences in providing medical abortion services (case studies) - Additional data provided by the informant Stakeholders perspectives Specific Objectives were: - To examine stakeholders representations related to medical abortion; - To describe the stakeholders constraint and opportunities in providing safe medical abortion services. We investigated: how) - History of medical abortion access in Cambodia (when, by whom, - Advantages/ disadvantage of medical abortion/ surgical abortion/ contraceptives method - Professional experiences in providing medical abortion policies and services (case studies) 5. DATA ANALYSIS All qualitative information were transcribed and translated in English in Microsoft Word (Version 2007) and were analyzed using content analysis, following an inductive coding method. 6. ETHICAL CONSIDERATIONS The study protocol was approved by the National Ethical Committee for Health Research (NECHR) in Cambodia, by the Institutional Review Board at the Institute of Tropical Medicine, Antwerp and the Ethical Committee at the University of Antwerp in Belgium. 9