Objective: This study aimed to measure and aggregate process indicators of the quality of care associated with informal dispensing of medication abortion (MA) pills, misoprostol with or without mifepristone, by pharmacies and chemist shops in three Nigerian states and one Indian state, capturing technical competence, information given to clients, and client experience. It also aimed to assess disparities in the local availability of MA pills by the socio-demographic characteristics of reproductive-aged women living in the communities served by these outlets.

Methods: Using a simulated client approach, trained male and female clients visited a total of 92 pharmacies and chemist shops across three Nigerian states and 127 pharmacies in one Indian state, posing as clients seeking MA pills without a prescription. After each visit, clients completed a self-administered electronic questionnaire recording what staff told them about drug use, side effects, warning signs, and follow-up care. Guided by the WHO’s 2022 abortion care guideline, the authors scored facilities on process indicators grouped into three domains: technical competence, information voluntarily given to clients, and client experience, and linked these findings to survey data from reproductive-aged women (ages 15–49) living in the same communities, collected by Performance Monitoring for Action (PMA).

Results: In the Nigerian states (51%) and about one-third in the Indian state (32%) offered MA pills, most often the misoprostol-only regimen in Nigeria and the combination regimen in India. Technical competency scores were low in both settings (18% in Nigeria, 34% in India), and scores for information given to clients unprompted were even lower (about 5% and 6%), while client experience scores were high in both places (around 90%). Accurate guidance on drug administration, timing between pills, and warning signs of complications was frequently missing, and women with no education in Nigeria and the poorest women in the Indian state were significantly less likely to live in communities where MA pills were available. The authors conclude that access to MA pills in the retail market must be paired with adequate guidance on their use to support the most favorable health outcomes.