The Use of Manual Vacuum Aspiration in the Treatment of Incomplete Abortions and Post- Abortion Care in Malawi
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Malawi is a small landlocked country in the south-eastern part of Africa with a population of about 18 million people. It is a poor country with an impoverished health system. Consequently, it has one of the highest maternal mortality ratios in the world. Unsafe abortion is one of the top five causes of maternal deaths worldwide; in Malawi it is also estimated to be the cause of up to a quarter of all maternal deaths. Even though there are ongoing discussions, induced abortions at the moment are only legal in Malawi when needed to save a pregnant woman’s life. Nevertheless, it is estimated that there are around 140,000 induced abortions performed in the country every year. This leads to many complications that have to be dealt with by an already impoverished health system. Retained products of conception left inside the uterus, which is referred to as an incomplete abortion, is one of the most common complications after an abortion. It can lead to hemorrhage, infections, sepsis and potentially death if left untreated. Manual vacuum aspiration (MVA) is a safe and cheap method of treating incomplete abortions. Even though it is the recommended surgical treatment method, its use in Southern Malawi has decreased over the last few years while that of curettage increased. This trend is inconsistent with the World Health Organization (WHO) guidelines and those of International Federation of Gynecology and Obstetrics (FIGO) and the Malawi Ministry of Health ─ all clearly state that vacuum aspiration is the recommended surgical method for treating incomplete abortions in the first trimester. A descriptive study on the use of MVA in the Southern part of Malawi was conducted first. It showed that the use of MVA was still low. Nevertheless, there were major improvements at the Mangochi District Hospital in the 2013-2015 period that peaked to 70% of first trimester abortions in 2015. Furthermore, there was a 10% decrease in hospital-based maternal mortality during the same time period and no abortion-related deaths occurred due to abortion in 2015. In the other hospitals MVA use remained low, fluctuated, or did not exhibit a comparable decline in maternal mortality. This indicated a need for intervention to enhance MVA use in the treatment of incomplete abortions. The intervention was training health personnel in conducting MVA in three public hospitals in the southern part of Malawi, specifically at the Queen Elizabeth Central Hospital, the Chiradzulu District Hospital and the Chikwawa District Hospital. Two hospitals where no intervention was carried out were also included as controls. The intervention study was successful and resulted in a 21.3% increase after one year of MVA use. Subsequently, focus group discussions were conducted with the health personnel to explore their perception of the training and use of MVA in post abortion care. The focus group sessions revealed that the participants appreciated the intervention, but still had obstacles in conducting MVA, such as broken equipment and lack of support from management. These issues need to be dealt with by the Ministry of Health and hospital leaders in order to make any improvements sustainable and establish clinical routines compatible to national and international guidelines.