Exploring the availability and accessibility of medication abortion pills without a prescription: a mystery client study of pharmacies in Mumbai, India

Abstract

Abstract Background In India, mifepristone was introduced in 2002 for use with misoprostol as medication abortion and is currently approved for use up to nine weeks of gestation. Even though a prescription from a clinician is officially needed to obtain this regimen, many abortion seekers try to obtain medication abortion pills directly from pharmacies without one. The availability of medication abortion in pharmacies varies widely across states. We conducted a mystery client study in Mumbai, Maharashtra to assess the availability of, accessibility of, and pharmacy worker dispensing practices related to medication abortion pills. Methods We developed two mystery client profiles: one of an unmarried woman and the other of her male partner. In October 2023, both mystery clients separately visited each pharmacy to purchase medication abortion pills without a prescription. The mystery clients asked for medications that could “bring back menstruation” after a positive urine pregnancy test and then let the interaction unfold organically. We documented each encounter and analyzed these interactions using descriptive statistics and for content and themes. Results We visited 112 pharmacies for a total of 224 encounters. Medication abortion pills were in stock in only 12 pharmacies (11%) during at least one mystery client visit. In 79% (n = 178) of the visits, pharmacy workers asked mystery clients to see a clinician and in 23% (n = 51) of the visits pharmacy workers indicated that stocking or selling medication abortion pills was banned or illegal. A number of pharmacy workers mentioned that medication abortion pills are over-regulated and requirements for stocking and selling pills are cumbersome. Conclusions Although mifepristone/misoprostol can be dispensed by pharmacies in India, medication abortion pills appear to be available, with or without a prescription, in very few pharmacies in Mumbai. Pharmacy dispensing could support affordable medication abortion care, but overregulation has led to a decrease in the availability of these pills, which may create barriers to timely access to care for abortion seekers. There is a need to engage with pharmacy workers about the legal and regulatory status of mifepristone/misoprostol and identifying ways to eliminate overregulation appears warranted.