The use of manual-vacuum aspiration in the treatment of incomplete abortions and post-abortion care in Malawi

Abortions can be spontaneous or induced, either way complications may occur. Abortion is legal in many parts of the world, however in some countries only in order to save a woman's life. Ironically, this is where most complications appear. Due to the fact the abortions are illegal many women seek to desperate means to end their pregnancy. Induced abortions performed without the necessary skills and in an environment that does not conform to the minimal medical standards are called unsafe abortions. Every year several thousand women die due to pregnancy-related causes, such as unsafe abortion, one of the main causes of obstetric complications and maternal mortality. This is a large problem sub-saharan Africa, in countries such as Malawi where the maternal mortality is high. A common complication after abortion is retained products of conception in the uterus. If this is not treated by some sort of uterine evacuation, it can lead to heavy bleedings, septicemia and ultimately death. Evacuation of the uterus can either be medical or surgical. The drug, misoprostol is not used much in Malawi, as it could be used to induce abortions, which is illegal. The preferred method according to the World Health Organization is to use a handhold syringe to empty the uterus, this is called manual vacuum aspiration (MVA), and can be done in local anesthesia. In the western world electrical vacuum aspiration is used. In this project we trained medical professionals, such as midwives, doctors and clinical officers, to do MVA, in order to increase this treatment after abortions and improve maternal health in Malawi. The data collection phase of the study was between April 2016 and April 2017, which is the time period the PhD-student spent in Malawi. All patient files from the gynecological wards at the intervention hospitals from 2013 to April 2016 were reviewed to obtain baseline data before the training. The training sessions were performed in March/April 2016 and post training data has been collected from May 2016 through April 2017. Control hospitals where no training was performed was also added. Data has been collected on almost 12 000 patients. Focus group discussions with the health workers were performed in April 2017. The 1st paper was published in the International Journal of Environmental Research and Public Health, February 2018 regarding the use of MVA in the years leading up to the intervention. The use of MVA was still low in all the hospitals except for one, where they were now treating 70% of the first trimester abortions with MVA. This hospital also had 10% decrease during the same time period from 2013-2015. Similar findings, where the use of MVA has lead to a drop in maternal mortality has been reported in Tanzania as well. The 2nd paper was published in BMJ Global Health, July 2018. The simple training intervention was successful with at 21% increase in the use of MVA at the intervention hospitals a year after the training. There was only a 3% increase at the control hospitals during the same time period. The 3rd paper was published in BMC Reproductive Health, February 2019, presenting the results from the Focus Group Discussions. The health personnel enjoyed the training and felt more comfortable doing after the intervention. However, they still had obstacles to doing MVA such as lack of equipment and lack of support from the management. Data was presented at the European Congress of Tropical Medicine and International Health (ECTMIH) with two oral and one poster presentation. The PhD-student arranged a symposium on abortion and post-abortion care at the conference. She arranged a similar symposium and had an oral and post presentation at the Global Health Conference in Oslo April 2018. She was the leader of the committee for the national PhD-conference, which was organized at Sørmarka this year. She had an oral presentation at the FIAPAC conference in Nantes September 2018. Here she was given the award for best young FIAPAC researcher. The PhD-student attended a course in Sexual Health and Reproductive Rights at the University of Oslo in February 2018. This course, the ECTMIH and the Global Health conference were all funded by the Norwegian Research School of Global Health, in which the student is a board member for the second year in a row. A follow up study on the unmet need of contraception in Malawi was done in October 2017, and the PhD-student supervised a medical student who wrote her student thesis on the subject. A paper will be submitted to International Journal of Environmental Research and Public Health in 2019. These studies show the possibility to improve womens health in Malawi. The PhD-student defended her thesis the 18th January 2019.

This project implemented recommended practice and improved the quality of health services in post abortion care in Malawi. The use of MVA increased after a context tailored training program. Health workers appreciated the possibility of task-sharing, reducing the workload for doctors, by nurses doing MVA. It has strengthened the collaboration between Norway and Malawi. The project entailed local researchers, in data collection, intervention and manuscript writing, and has thus built capacity, competence and practical confidence to conduct MVA among Malawian health professionals.

The Norwegian Research Council calls for proposals supporting high-quality research, which will contribute to sustainable improvements in health and equity for vulnerable groups in low income countries. Malawi is one of the poorest countries in the world, with limited resources and a deprived health system. As a consequence the country has one of the highest maternal mortality rates in the world. It is estimated that 3000 women in Malawi die due to pregnancy-related complications, and unsafe abortion is one of the main causes of this. Unsafe abortion a common practice, as abortion is illegal. Incomplete abortion is a complication and need to be treated by uterine evacuation. Manual vacuum aspiration (MVA) is a safe, less expensive surgical procedure with less complication after evacuation of the uterus, compared to dilatation and curettage (D&C). Further the procedure can be performed in local anesthetics by midwives and clinical officers and not only by physicians. This three year PhD project will perform an intervention, by training health personnel at three hospitals in using MVA. A pre/post assessment will be conducted to estimate the efficiency of the training, regarding preferred use of MVA or D&C. Furthermore a qualitative study will be added to explore the health personnel's experiences after the training and views on using MVA. This project is a part of an established international collaboration between NTNU and the University of Malawi. By local and international dissemination of the results, it will contribute to knowledge for policy makers of the country. Furthermore it will strengthening the newly started research group of Global Health at NTNU, in line with the strategy of the Medical Faculty and with the Norwegian governments intention of improving global health research.