Victoria Satchwell was desperate when she called the fifth pharmacist asking them to dispense abortion pills for an almost 10-week pregnant client. The woman is a 19-year-old rape victim living in Vredefort, a small farming town in the Free State. Over two days, Satchwell’s team spoke to four pharmacists and they all refused to dispense. Some cited moral reasons, while others simply said they don’t stock misoprostol. There are two common ways of medical abortion. Home-use misoprostol treatment, the cheaper option, is recommended for up to 10 weeks of pregnancy, while the more effective combined regimen of mifepristone and misoprostol is recommended for up to 13 weeks in South Africa, according to the National Clinical Guideline for Implementation of the Choice on Termination of Pregnancy Act. Misoprostol-only treatment costs around R180, while the combined regime costs around R640. “She was very close to the cut-off date, which is 10 weeks. So we called pharmacists and they told us they weren’t going to help for religious reasons”, says Satchwell.  Tele-health service for at home abortion She leads Abortion Support South Africa, a tele-abortion service launched in February 2023. The organisation provides online consultation for women seeking an abortion and connects them to a healthcare professional registered with the Health Professionals Council of South Africa (HPCSA). The healthcare professional assesses the woman’s situation and based on eligibility, prescribes abortion pills that have to be collected from a pharmacy, with a script.  Vredefort has two pharmacies. One did not pick up the call and the other said they would not dispense as they “don’t want to get involved with that.” Satchwell then tried Parys, the nearest city. One pharmacist hung up on Satchwell after saying they don’t keep stock.  Another pharmacist said she wouldn’t dispense due to moral reasons. After Satchwell explained that they were working with a rape victim with severe financial constraints, the pharmacist said they don’t stock abortion pills because unused medicines would expire – misoprostol comes in a box of 60 tablets and a prescription for medical abortion is usually 16 tablets.  As a last resort, Satchwell contacted the fifth pharmacy on her list. Speaking to the pharmacist, she told her four other pharmacists had denied provision of the service and they needed her help. “I was almost in tears about this. This was the fifth one I called, and I just unloaded, ‘No, you have to help this woman!’”, Satchwell tells Health-e News.   The last pharmacist agreed to dispense but it took four days for the woman to gather the R50 taxi fare to get to Parys, where the pharmacy is located. The delay pushed her beyond the 10-week recommended gestational age for medical abortion using misoprostol, and Abortion Support advised her to seek clinical care.  Dr Margit Endler, a consultant in obstetrics and gynaecology at Karolinska Institutet and an adjunct senior researcher in UCT’s School of Public Health and Family Medicine, told Health-e the effectiveness and safety of medical abortion decrease progressively as gestational age increases. “There’s a risk of heavy bleeding, incomplete abortion or continuing pregnancy. However, in this case, the four days wouldn’t make a big difference as the WHO recommends medication abortion at home for up to 12 weeks.  She says Abortion Support might have suggested 10 weeks so they do not deviate from South African guidelines.  Satchwell says the woman told Abortion Support that she was able to travel but not whether she ended up having a successful abortion. Since February, Satchwell and her colleagues at Abortion Support have contacted 184 pharmacies on behalf of 196 patients asking pharmacists to dispense misoprostol. Around 40 per cent of pharmacists refused to dispense despite being shown a prescription by a  healthcare professional. Satchwell says the vast majority of the pharmacies cite religious or moral reasons or simply say they do not stock common abortion pills.  It’s typically easy for a pharmacist to order abortion pills from medicine wholesalers the day of or even purchase them from nearby pharmacies, says Jackie Maimin, CEO of the Independent Community Pharmacy Association (ICPA), a non-profit association representing 1 100 independent community pharmacies.  Abortion rights in laws and government policies The National Clinical Guideline for Implementation of the Choice on Termination of Pregnancy distributed in 2020 defined the parameters of ‘refusal to care’ when it comes to abortion, 24 years after abortion was legalised in South Africa.  It’s stipulated that only the direct termination of pregnancy (TOP) provider can refuse care, while ancillary staff such as reception, ward clerks and other healthcare professionals involved in the general care of a patient such as a pharmacist may not refuse to provide abortion care under any circumstances. This means that the pharmacists who rejected Satchwell’s request to dispense abortion pills were acting against government policies and potentially breaking the law. South Africa has one of the most liberal abortion laws in the world with abortion rights protected under the Choice on Termination of Pregnancy Act 92 of 1996 (CTOP). The law allows women less than 13 weeks pregnant to end the pregnancy without any given reasons, 13 to 20 weeks under specific conditions such as socioeconomic status and more than 20 weeks if her or the foetus’ life is in danger.  A direct TOP provider who refuses care based on personal beliefs must refer the individual to a colleague or facility that is able to offer abortion services.  The guideline also requires keeping a record of the clinical detail of the patient, the referral process and the name of the clinician who refused services. Additionally, healthcare professionals who are reluctant to provide TOP services must inform their facility manager in writing when applying for a position in the facility. Satchwell says she did not choose to report the pharmacists because she hopes to take “an awareness approach.” She says together with the ICPA, they are drafting guidelines and hosting webinars to inform pharmacists of abortion laws and tele-abortion.  Lack of awareness of abortion law has serious consequences  There has never been … Continue reading Pharmacists think it’s illegal to dispense abortion pills: worrying consequences