06:28pm Wednesday 23 October 2019

Can incomplete abortion be treated more safely and less expensively?

Incomplete abortion is one of the main causes of obstetric complications in Malawi. Surgical management with curettage is the most common treatment, despite WHO’s recommendation to use manual vacuum aspiration (MVA). Researchers are looking to see whether training health personnel in MVA can increase the use of this method.

In Malawi today, abortion is generally illegal and punishable by up to 14 years’ imprisonment. Malawi is not alone, as access to abortions is limited in the majority of the world’s nations. In Malawi, abortion is permitted if the pregnancy poses a danger to the mother’s life. However, there is ongoing debate on expanding the law to allow for abortion in cases of rape and incest, if the pregnancy will cause severe psychological or physiological harm to the mother, or if the foetus is severely malformed. Nonetheless, due to conservative forces in Malawian society, general legalisation is not likely to be passed until far into the future.

“In addition to the personal tragedy unsafe abortion can cause for an individual woman and her family, it also adds a burden to health personnel and large costs to the health service system. The more cheaply and safely this treatment can be performed, the better,” says PhD student at the Norwegian University of Science and Technology, Maria Lisa Odland. Ms Odland is based in Blantyre, Malawi for 12 months and will be collecting data for her PhD.Unsafe abortion

Due to the fact that abortion is illegal, many women turn to desperate means to end their pregnancy. Induced abortion performed by individuals without the necessary skills and in the absence of minimal medical standards is called unsafe abortion. Unsafe abortions result not uncommonly in incomplete abortions, which can cause severe complications and death. A nurse at a Malawian district hospital says, “Many women come to the hospital with complications after an incomplete abortion. Even though the women don’t tell us how come they’ve got the bleeding, we frequently see signs of unsafe abortions.”

Chemical treatment (Misoprostol) is the most commonly used treatment for incomplete abortion, including in many African countries. This option has not previously been available in Malawi due to conservative opposition. There is a fear that Misoprostol could be deliberately used to induce abortion. Health facilities in Malawi are left with no other option than manual treatment.

Why is MVA used less frequently?
A common complication following abortion is that not all of the tissue and products of pregnancy have been removed or expelled from the uterus. If not treated through some form of uterine evacuation, this can lead to heavy bleeding, sepsis (blood poisoning) and ultimately death. According to WHO, the preferred surgical treatment for incomplete abortion is the use of a handheld syringe to empty the uterus. This is called manual vacuum aspiration (MVA), and can be performed using local anaesthesia.

However, researchers have recently shown that MVA is used less frequently than the alternative surgical procedure, dilatation and curettage (D&C). In fact, the use of MVA is actually decreasing at several Malawian health institutions that have been studied.[i] D&C has to be performed by a physician, requires general anaesthesia and is considered to entail greater risk of complications such as infection, bleeding and perforation of the uterus. In addition, this method is estimated to be more expensive.[ii] The question is thus: If MVA is considered to be cheaper and less risky, why is it employed less often? Can this trend be reversed?

MVA training at Queen Elisabeth Central Hospital in Blantyre: Research Collaborator and Gynaecologist Gladys Gadama teaching a medical intern the ten-step procedure of MVA using a vacuum syringe and a model vagina. (Photo: Åse-Marit Kristiansen)

Course implementation at three hospitals

Maria Lisa Odland and her collaborators are training various types of medical professionals, including midwives, physicians and clinical officers, in the MVA procedure at three different hospitals in Malawi. The purpose of the training is to improve post-abortion care and consequently improve maternal health outcomes at Malawian hospitals. They are using a simple training module for MVA in low-resource settings which has been developed by the global non-governmental organisation (NGO), Ipas. Ipas is dedicated to ending preventable deaths and disabilities from unsafe abortion. In addition, Ms Odland is recording the use of MVA at three test hospitals and two control hospitals to see whether training leads to increased use of MVA.

Qualitative research: PhD student Maria Lisa Odland (second from left) and her supervisor, Professor Elisabeth Darj, conduct focus group interviews with nurses and health officers (physicians) at the Chiradzulu District Hospital in Southern Malawi. (Photo: Åse-Marit Kristiansen)

Ms Odland and Professor Darj are conducting qualitative interviews with focus groups in order to find out more about the perceptions and attitudes of health personnel towards such training, with the aim of shedding light on the end results. They want to know not only whether such training is efficient, but also why or why not. The ultimate goal is to provide constructive input to the Malawian Ministry of Health on the efficiency of the MVA training module and on which factors have an impact on the use of MVA at Malawian hospitals. This is important information for determining whether implementation of a national training programme would be feasible in the future.

Title of PhD project: The use of manual-vacuum aspiration in the treatment of incomplete abortions and post-abortion care in Malawi (244672)

Funding: NOK 3.2 million

PhD candidate: Maria Lisa Odland

Supervisor and project leader: Professor Elisabeth Darj

Project Owner: Norwegian University of Science and Technology (NTNU)

Collaborators: College of Medicine and Kamuzu College of Nursing, University of Malawi.



Written by:
Åse-Marit Kristiansen

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