The use of medical treatment with misoprostol in the management of incomplete abortions in Malawi

The use of medical treatment with misoprostol in the management of incomplete abortions in MalawiUnsafe abortion is a major cause of maternal morbidity and mortality in Malawi. Vacuum aspiration and misoprostol are safe recommended methods to treat abortion complications, still old-fashioned curettage is mostly used in Malawi. This study aimed to increase the use of misoprostol in the treatment of incomplete abortions in Malawi.Malawi is a low-income country in Sub-Saharan Africa with a population of almost 20 million, rapidly increasing. Even though the country has made progress in reducing its maternal mortality, the annual decrease in maternal mortality ratio has plateaued and is still high at 381 per 100,000 births. Unsafe abortion is still a major contributor to maternal mortality and morbidity in the country, even though Malawi has made major efforts to try to increase the uptake of family planning. As a consequence, Malawi also has one of the highest treatment rates for abortion complications in the world. The most common complication after abortions and miscarriages is the retained product of conception left inside the uterus. So-called incomplete abortions may lead to haemorrhage, sepsis and, worst case scenario, death if left untreated. Incomplete abortions can be treated medically with misoprostol or surgically with vacuum aspiration or sharp curettage. Misoprostol and vacuum aspiration are the safest and recommended methods, but in Malawi, curettage is still used in most cases. This is despite curettage being more costly, needing a surgeon and general anaesthetic, and having a higher risk of complications such as bleeding, infection and uterus perforation. Manual vacuum aspiration is a safe and recommended method that is also used. Still, it has many barriers, such as being time-consuming and broken equipment. Misoprostol, on the other hand, is safe, cheap, and easy to use. Still, it was used in only 1% of the cases in a previous study. Known reasons for this are lack of experience with the drug, worries about its efficiency, and the leadership not supporting its use. In this study, we wanted to see if a training intervention would efficiently increase misoprostol use at selected hospitals. It was designed as a quasi-experimental study with three intervention sites and two control sites. Records from all women treated for incomplete abortions were reviewed before and one year after the intervention at all the sites. All women treated with misoprostol came to follow-up visits one week after the treatment and filled in questionnaires about their experience with using the drug. A selection of women were also interviewed about their experiences. Additionally, focus group discussions and in-depth interviews were conducted with healthcare workers to explore their perceptions and experiences with using the drugs. The intervention successfully increased the use of misoprostol from 22.8% to 35.9% in the intervention sites. The district hospitals were primarily responsible for the increase as they went from not using misoprostol to using it in almost 40% of the cases. The feedback from the women receiving misoprostol was also positive, with over 90% of the women being satisfied with the treatment. The healthcare workers were also happy as the drug decreased their workload, and they would prefer it to using surgical methods. Some healthcare workers were still concerned about the drug being inefficient. To conclude, using misoprostol in the treatment of incomplete abortins is safe and accepted by women and healthcare workers in Malawi, and a training intervention is efficient in increasing its use. Stakeholders and policymakers should further upscale the use of the drug by doing training, ensuring the availability of the drug in healthcare centres, and encouraging its use. This will help reduce complications and costs in post-abortion care in Malawi.

The use medical treatment with misoprostol in the management of incomplete abortions in MalawiUnsafe abortions are common in Malawi, leading to many complications such as incomplete abortions. Misoprostol is a cheap and safe way to treat incomplete abortions to avoid further complications but it is rarely used in Malawi. In this study, we did a training intervention to increase misoprostol in the treatment of incomplete abortions in Malawi.The maternal mortality is still high globally, especially in Sub-Saharan Africa, and unsafe abortion is a major cause. In Malawi, abortion is only legal to save a pregnant woman's life. Still, it is estimated that around 140,000 induced abortions are performed every year, with most of them being unsafe. The country has one of the highest maternal mortality ratios in the world, and unsafe abortion is the cause of up to 25% of these deaths. Additionally, Malawi has high treatment rates for abortion complications. It is essential to make post-abortion care as cheap, safe and efficient as possible to benefit women and Malawi's already impoverished health system. The most common complication after an abortion is retained products of conception left inside the uterus, which can lead to bleeding, infections and potentially death if left untreated. So-called incomplete abortions are more common after unsafe abortions and can be treated surgically or medically. The recommended treatment methods by the WHO are either manual vacuum aspiration (MVA) or medical treatment with misoprostol in the first trimester. Still, previous studies have shown that most incomplete abortions in Malawi are treated with old-fashioned sharp curettage despite national and international guidelines. Curettage has more complications, such as bleeding, infections, perforation and infertility, and is also more costly as the procedure requires an operating theatre, general anaesthetics and a surgical provider. Both misoprostol and MVA are associated with fewer complications and are much cheaper than curettage since they can be done by nurses and do not require general anaesthetics. Previous efforts to increase the use of MVA through training interventions have been successful. However, the successful implementation of MVA has also faced many barriers, such as broken equipment and a lack of support from the leadership. Hence, increasing the use of misoprostol would be the best way to improve post-abortion care in Malawi going forwards. It is cheaper and easier than MVA and is the first-line treatment in Norway and many other countries, but it is rarely used in Malawi. In this study, we did a simple training intervention on using misoprostol to treat incomplete abortions at three hospitals in central Malawi. We also added two control hospitals where no intervention was done. Data was collected on all women treated for incomplete abortions before and one year after the intervention. All women given misoprostol were followed up and filled out a questionnaire on their experience with the treatment. Interviews were also done with a sub-sample of the women treated for incomplete abortions and with the healthcare workers giving the treatment. One year after the intervention, the proportion of misoprostol used to treat first-trimester incomplete abortions had significantly increased at the intervention sites to 35.9%. The control sites had no such increase, and the use remained low at 13.6%. Most women (94%) were happy with the treatment and would recommend it to other women. Healthcare workers also saw many benefits in treating incomplete abortions with medical treatment as it was easier and quicker. In conclusion, misoprostol is an accepted and safe way of treating incomplete abortions in Malawi, and a simple training intervention effectively increased its use. Implementation on a larger scale is recommended to improve post-abortion care in Malawi, and potentially other countries.