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The knowledge and use of misoprostol among women in a Nigerian population

Background: Increasing the availability and accessibility of misoprostol in low resource settings has been advocated to reduce maternal deaths from primary postpartum haemorrhage (PPH). WHO recommends a strategy of antenatal distribution of misoprostol to pregnant women, for self-administration for the prevention of PPH, in settings where women are likely to give birth outside of a health facility or in the absence of skilled health personnel. The success of such strategies depends on the current knowledge and acceptability of misoprostol among women in such population. The aim of this study was that we assessed the knowledge and use of misoprostol among Nigerian women. Methods: It was a prospective cross-sectional population based survey in which 16445 consenting women, from randomly selected households and communities across the 20 local government areas (LGA) of Lagos state, had in-depth interview with the aid of an interviewer administered structured questionnaire to assess their knowledge and use of misoprostol. Data obtained were presented in frequency and proportions. Results: Thirteen per cent and 6.5% of the respondents were aware of drugs that could be used to terminate pregnancy and stop bleeding following childbirth, respectively. Only 5.2% of the women were aware of misoprostol, two-third (67%) of which knew it could be used to terminate pregnancy and 5% of women aware of misoprostol knew it could be used to reduce or stop bleeding following childbirth. Only 2.3% of the entire study population admitted to personal use of misoprostol. Conclusions: Knowledge about the safe, life-saving and effective use of misoprostol among Nigerian women is low. There is need to disseminate information about misoprostol especially in settings where women are likely to give birth outside of a health facility or in the absence of skilled health personnel.


INTRODUCTION
Misoprostol is a drug that was originally produced to prevent gastrointestinal ulcers. 1 It has gained widespread recognition for safety and effectiveness for its initial off-label uses in obstetrics and gynaecology, due to its uterotonic properties, to induce labour, prevent and treat PPH and manage abortion; clinical conditions that are the major drivers of the high maternal mortality rates in sub Saharan Africa. 2 Misoprostol is cheap and stable at room temperature and therefore particularly useful in resource-poor settings. 2 Its varied routes of administration include oral, vaginal, rectal, buccal and sublingual allowing for possible self-administration. WHO has recognized misoprostol as a life-saving drug, incorporated recommendations for its use into reproductive health guidelines on induction of labour, prevention and treatment of PPH and management of spontaneous and induced abortion and included it on the list of essential medicines. 2,3 The highest rates of maternal mortality worldwide remain domiciled in sub Saharan Africa largely due to contributions from PPH and unsafe abortion among other leading causes. 4 Increasing the availability and accessibility of misoprostol in low resource settings has been advocated to undoubtedly reduce maternal deaths from PPH. 5 In 2020, WHO recommended that in settings where women give birth outside of a health facility and in the absence of skilled health personnel, a strategy of antenatal distribution of misoprostol to pregnant women for self-administration is recommended for prevention of PPH. 6 Observational studies and evaluations have indicated that advance misoprostol distribution programmes can increase coverage of uterotonic use for PPH prevention, with very few reports of incorrect use of misoprostol or adverse events and improved health outcomes. [6][7][8] The use of any medication by an individual will definitely be directly related to the individual's knowledge of such medication. The success of currently recommended misoprostol distribution programs aimed at improving health indices and outcomes in any population is hinged on the knowledge and acceptability of misoprostol among women in that population. We therefore conducted a population based survey to assess the knowledge and use of misoprostol among Nigerian women.

Study design
The study was a community based population study.

Study area
The study was conducted in 20 LGA of Lagos State, Nigeria.
This was a population-based, prospective, cross-sectional survey in which 16,455 consenting women, in randomly selected enumeration areas across the 20 LGA of Lagos state, had in-depth interview using an interviewer administered, structured questionnaire designed for the study from January 2015 to December 2017. Designated enumeration areas were randomly selected in each local government. Households were identified and respondents, one woman per household, had questionnaire administered on them.
Inclusion criteria was women above 15 years of age while the exclusion criteria was women below 15 years of age.
The data obtained were analyzed using SPSS, version 22 and frequency and proportions were calculated for categorical variables. Tables and pie charts were used for graphical illustration.

RESULTS
Of the 16445 women in the survey, the proportion of respondents in each of the five year bands was fairly even across the age groups of 15-49 years. Less than 5% of the respondents were 50 years and above (Table 1). About half (54%) of the respondents had either attempted or completed secondary education, while less than 20% were university graduates. Majority were Christians and Muslims constituted a third (34.3%) of the study participants (Table 1).      Only 1063 (6.5%) were aware of drugs that could be used to stop bleeding following childbirth ( Table 2). The most commonly mentioned names of such drugs by the women who were aware were ergometrine, misoprostol and vitamin K. About 13% of the women knew of drugs used to terminate unwanted pregnancy ( Table 3). The drugs mentioned included postinor (mentioned by 41% of the respondents), duofem and misoprostol. A variety of other agents such as Andrews liver salt, ampiclox, lime and salt, antibiotics were also indicated as drugs that can be used to terminate unwanted pregnancy.
On awareness of misoprostol, 860 (5.2%) of 16445 women were aware of misoprostol (Table 4). Among those who knew and indicated its uses, two-thirds (67%) indicated that it could be used for termination of pregnancy, 13% said it could be used for regulating menstruation while 5% were aware it could stop bleeding following child birth.
Of the 860 women who were aware of misoprostol, 43.5% had used it before the survey ( Table 5). Half of the respondents who used misoprostol did not indicate what it was used for. About one in 5 had used the drug to terminate an unwanted pregnancy while 16% claimed they had used it for regulating their menstrual cycle.

DISCUSSION
The 16445 women who took part in the survey were fairly evenly distributed in proportions between the designated age groups from 20 to 49 years and about half (54%) of the respondents had more than primary level of education. We found that 13% and 6.5% were aware of drugs that could be used to terminate pregnancy and stop bleeding following childbirth respectively (Table 2 and 3). Stillman et al in Lagos, Nigeria observed that 57% of women did not know about pills that could end a pregnancy before visiting a drug seller. 9 This value reported by Stillman et al is lower than 77% found in our survey despite the fact that their study was also done in Lagos, Nigeria like ours. Our survey included a much larger number of women making our finding more likely representative of the entire population.
Only 5.2% of the respondents were aware of misoprostol, two-third (67%) of which knew it could be used to terminate pregnancy and a meagre 5% of women, aware of misoprostol, knew it could be used to reduce or stop bleeding following childbirth. The level of awareness about misoprostol in our survey is way lower than findings by Maternowska et al in Burkina Faso, who reported that about 2/3rd of respondents in their study knew misoprostol, though unsure of its dosing or how to use it, they were aware it could be used to empty the uterus for an abortion. 10 Like in our study, more women who were aware, could relate more to its use for an abortion than for its other medical uses. Also Rosing et al in New York found that 37% of respondents in their study admitted familiarity with the use of misoprostol as an abortifacient. 11 The discrepancy in our findings with that of Maternowska  Half of the respondents who used misoprostol did not indicate what it was used for. This may be due to the culture of secrecy in matters relating to termination of pregnancy stemming from the current legal and sociocultural restrictions on abortion in Nigeria. About one in 5 of the respondents who had used misoprostol indicated they had used misoprostol to terminate an unwanted pregnancy.
The limitation to this study was that not all women remembered the name of drugs they used.

CONCLUSION
In conclusion, findings from this survey suggest that adequate knowledge about the safety, life-saving and effective use of misoprostol among Nigerian women is low. There is need to disseminate information about misoprostol especially in settings where women are likely to give birth outside of a health facility or in the absence of skilled health personnel.