‘It’s a very complicated issue here’: understanding the limited and declining use of manual vacuum aspiration for postabortion care in Malawi: a qualitative study

Abstract

Malawi has one of the highest maternal mortality ratios in the world. Unsafe abortions are an important contributor to Malawi's maternal mortality and morbidity, where abortion is illegal except to save the woman's life. Postabortion care (PAC) aims to reduce adverse consequences of unsafe abortions, in part by treating incomplete abortions. Although global and national PAC policies recommend manual vacuum aspiration (MVA) for treatment of incomplete abortion, usage in Malawi is low and appears to be decreasing, with sharp curettage being used in preference. There is limited evidence regarding what influences rejection of recommended PAC innovations. Hence, drawing on Greenhalgh et al.'s (2004. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Quarterly 82: 581-629.) diffusion of healthcare innovation framework, this qualitative study aimed to investigate factors contributing to the limited and declining use of MVA in Malawi. Semi-structured interviews with 17 PAC providers in a central hospital and a district hospital indicate that a range of factors coalesce and influence PAC and MVA use in Malawi. Factors pertain to four main domains: the system (shortages of material and human resources ; lack of training, supervision and feedback), relationships (power dynamics; expected job roles), the health workers (attitudes towards abortion and PAC; prioritization of PAC) and the innovation (perceived risks and benefits of MVA use). Effective and sustainable PAC policy must adopt a broader people-centred health systems approach which considers all these factors, their interactions and the wider socio-cultural, legal and political context of abortion and PAC. The study showed the value of using Greenhalgh et al.'s (2004. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Quarterly 82: 581-629.) framework to consider the complex interaction of factors surrounding innovation use (or lack of), but provided more insights into rejections of innovations and, particularly, a low-and middle-income country perspective.

Incidence of induced abortion in Malawi, 2015

“…Although use of manual vacuum aspiration (MVA) for treatment of incomplete abortion is recommended by WHO and favorable to use of dilation and curettage (D&C) [34], recent studies have documented declining MVA use in PAC in selected hospitals in Malawi [35]. In our study, when asked how treatment for abortion complications could be improved, 74% of HFS respondents said “have more commodities available” while 64% said “have more trained people available” (data not shown), which supports findings from a qualitative study of PAC providers to understand declines in use of MVA in recent years [36]. Addressing availability of equipment, providing regular training, and addressing staff shortages could improve PAC in Malawi [36].…”

“…In our study, when asked how treatment for abortion complications could be improved, 74% of HFS respondents said “have more commodities available” while 64% said “have more trained people available” (data not shown), which supports findings from a qualitative study of PAC providers to understand declines in use of MVA in recent years [36]. Addressing availability of equipment, providing regular training, and addressing staff shortages could improve PAC in Malawi [36]. …”

Evaluating the quality and coverage of post-abortion care in Zimbabwe: a cross-sectional study with a census of health facilities

“…A study in Malawi found various reasons for low uptake of MVA use and continued preference for curettage (a procedure no longer recommended by the WHO). These included lack of training, supervision, feedback and reliable supplies; health worker's attitudes towards PAC; and provider's perceived personal benefits and risks of MVA, such as preferring curettage because they are more familiar and comfortable with it [26]. Ethiopia serves as a successful example of increasing the availability and quality of abortion services after legal reform and major efforts by the Ministry of Health including development and dissemination of evidence-based guidelines; training and task-shifting to midlevel providers; and integrating postabortion contraception into existing reproductive health services [16].…”

Policy, law and post-abortion care services in Kenya

“…Adopting appropriate technologies can also reduce hospital stay, the cost of treatment and strain on resources, and increase the safety of PAC services [ 30 ]. This must be complemented by provider willingness to adopt these technologies [ 31 ]. Essential supplies, including pain medication and antibiotics, improve patient experience with care [ 32 ], leading to positive perceptions on quality of care, so increasing community trust in services offered and prospects of future utilization [ 11 , 33 – 35 ].…”