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Background: Abortion-related complications are among the common causes of maternal mortality in Malawi. Misoprostol is recommended for the treatment of first-trimester incomplete abortions but is seldom used for post-abortion care in Malawi. Methods: A descriptive cross-sectional study that used mixed methods was conducted in three hospitals in central Malawi. A survey was done on 400 women and in-depth interviews with 24 women receiving misoprostol for incomplete abortion. Convenience and purposive sampling methods were used and data were analysed using STATA 16.0 for quantitative part and thematic analysis for qualitative part. Results: From the qualitative data, three themes emerged around the following areas: experienced effects, support offered, and women’s perceptions. Most women liked misoprostol and reported that the treatment was helpful and effective in expelling retained products of conception. Quantitative data revealed that the majority of participants, 376 (94%) were satisfied with the support received, and 361 (90.3%) believed that misoprostol was better than surgical treatment. The majority of the women 364 (91%) reported they would recommend misoprostol to friends. Conclusions: The use of misoprostol for incomplete abortion in Malawi is acceptable and regarded as helpful and satisfactory among women.
This is a mixed methods study where quantitative and qualitative data were collected simultaneously from women receiving misoprostol for first-trimester incomplete abortion. A descriptive cross-sectional study design was used for the quantitative part of the study, and an explorative method with in-depth interviews for the qualitative part. A questionnaire and an interview guide developed in English and translated into Chichewa, a local language, were used to acquire information about women’s experiences and perceptions of misoprostol as treatment for first-trimester incomplete abortion at a one-week follow-up visit after treatment. A concurrent triangulation approach was chosen for more understanding and confirmation of the findings [29, 30]. The study was conducted in the central region of Malawi, in gynaecological wards of three government facilities, namely: Bwaila, Salima, and Mchinji district hospitals. District hospitals act as referral centres in their respective districts and provide free medical, surgical and supportive care to patients. The care provided to women with gynaecologic problems in these facilities include, among others, comprehensive emergency care and PAC. Bwaila hospital is located in Lilongwe, which is the capital city of Malawi; the other two hospitals are located in Lilongwe’s neighbouring districts. All women who returned for follow up between 18th August and 7th December 2020 at the three district hospitals, after being treated with misoprostol for first trimester incomplete abortion were eligible. Both convenience and purposive sampling methods were used. The survey was done with 400 participants altogether. We targeted 200 participants at Bwaila hospital because it is a larger facility with double the number of patients with incomplete abortions per month as compared to the other two facilities. We had 100 participants from each of the other sites. For the qualitative part, the first 24 women of different ages and number of pregnancies who had experienced misoprostol treatment for incomplete abortion were recruited from all 3 sites. The women were a subset of those who participated in the survey. Everyone was offered an opportunity to participate until after reaching data saturation. Those who were available and had the experience of being treated with misoprostol were asked to participate. All women treated for first trimester incomplete abortion with misoprostol, and who reported for a follow-up visit at one week in the study sites were eligible and asked to take part in the study. Women who had complications prior to treatment such as severe bleeding and those who did not give their consent were excluded. Data were collected from 18th August to 7th December 2020 using a pre-tested questionnaire with two open-ended questions and an interview guide. Data were collected to determine experiences and to explore perceptions of women who received misoprostol during their check-up visit. Data collection tools targeting the women were developed in English and translated into Chichewa. Data were collected in a local language (Chichewa) and then later translated into English. Codes were used to identify the participants. Interviews were conducted by trained research assistants (nurse/midwives) in a quiet room at the facility. The women were approached after they had been checked up, before going home. Recruitment and interviews were done on the same day. Face-to-face interviews were conducted with the women by the data collectors using interview guides. The interviews lasted for about 30 min each and were audio recorded. Data collection for the qualitative part ended after 24 interviews when no more new information was obtained; this was determined by repetitive information. For the quantitative part, data were collected through a survey with 400 participants. Research assistants used questionnaires on Android devices. The data were collected using forms generated by CSPro v7.0™ and were synched in a Dropbox by the data collectors immediately after the interviews. The research assistants were trained in the data collection and use of the android devices prior to the interviews to ensure that they were familiar with the data collection process. Quantitative data were exported from Dropbox and analysed using STATA 16.0 for detailed descriptive analyses. Descriptive statistics were computed from the demographic and other variables. The results are presented in tables and narratives. Reflexive thematic analysis using the inductive approach was used to analyse narrative data obtained from individual in-depth interviews [31]. The analysis of the qualitative data was ongoing throughout the data collection period. Transcription and translation were done immediately after each interview. The transcripts were checked after transcription and translation to ensure there was no misrepresentation of information. The scripts were read several times for familiarisation of data which was followed by the identification of codes. Coding aided organisation of the data according to the emerging concepts, then the codes were grouped under themes and sub-themes [31]. An example of the analytical process is presented in Fig. 1. The emerging themes and subthemes were revised and reported in a narrative format, illustrated by quotes, coded as responders 1 to 24. Analytical process The study was carried out following ethical rules and guidelines. Ethical clearance was obtained from the College of Medicine Research and Ethics Committee (COMREC)—Malawi (Ref: P.01/20/2924) and Regional Committees for Medical and Health Research Ethics (REK) – Norway (Ref: 141130 2019). Permission to conduct the study in the selected sites was obtained from Lilongwe (for Bwaila), Salima and Mchinji district health offices. Written informed consent was sought prior to data collection. Participants were given information pertaining to the study through an information sheet, which was read to them. Each participant was informed of the potential risks and benefits of participating in the study and was assured of privacy and confidentiality, as no names were used for identification. The participants were informed about how their data would be managed and that only the research team would have access to the data. The women were also informed that participation in the study was voluntary and that they were free to withdraw from the study at any point. In addition, they were informed that refusal to participate or withdrawal from the study would not affect their treatment at the facility.
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