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Malawi has a high maternal mortality rate, of which unsafe abortion is a major cause. About 140,000 induced abortions are estimated every year, despite there being a restrictive abortion law in place. This leads to complications, such as incomplete abortions, which need to be treated to avoid further harm. Although manual vacuum aspiration (MVA) is a safe and cheap method of evacuating the uterus, the most commonly used method in Malawi is curettage. Medical treatment is used sparingly in the country, and the Ministry of Health has been trying to increase the use of MVA. The aim of this study was to investigate the treatment of incomplete abortions in three public hospitals in Southern Malawi during a three-year period. All medical files from the female/gynecological wards from 2013 to 2015 were reviewed. In total, information on obstetric history, demographics, and treatment were collected from 7270 women who had been treated for incomplete abortions. The overall use of MVA at the three hospitals during the study period was 11.4% (95% CI, 10.7-12.1). However, there was a major increase in MVA application at one District Hospital. Why there was only one successful hospital in this study is unclear, but may be due to more training and dedicated leadership at this particular hospital. Either way, the use of MVA in the treatment of incomplete abortions continues to be low in Malawi, despite recommendations from the World Health Organization (WHO) and the Malawi Ministry of Health.
The study was designed to identify which methods were used to manage incomplete abortions for women seeking post-abortion care in public hospitals in the southern part of Malawi; this constitutes a follow-up to a previous survey [17]. We chose a retrospective descriptive design that involved reviewing hospital files for a chosen time-period. The study was conducted at two district hospitals, Chiradzulu and Mangochi, and the Queen Elizabeth Central Hospital (QECH). While the majority of post-abortion care cases are treated in public hospitals [13], the QECH is the referral hospital for the whole southern region of Malawi. Hence, a large number of women with incomplete abortions are treated at the QECH. All records from patients admitted in the three study hospitals were routinely stored after discharge and could be accessed by the clerk in charge at each hospital. All files from the female/gynecological ward, between 1 January 2013 and 31 December 2015, at the three hospitals were retrieved and reviewed. Women who had been treated for incomplete abortions were included. Fetal death up to 28 weeks of gestation is classified as a miscarriage in Malawi, and therefore all pregnant women in this category were included. Women admitted for all other reasons, as well as women who were not offered any post-abortion treatment at all, were excluded. Since complications after a spontaneous miscarriage and an induced abortion are hard to distinguish, and are mostly unreported, these cases were not separated. Manual vacuum aspiration should preferably only be used in the first trimester, and may potentially be used up to 14-weeks of gestation [18]. However, mothers of higher gestational ages were included, as many of these women may have had residual amounts of retained products that might have been treated with MVA if they had been examined properly prior to surgery. Data were taken from the female/gynecological ward records by a team of three research assistants, including nurses and midwives familiar with medical terms. The process was managed by a medical doctor, who also served as the principal investigator. The same data extraction tools were employed at all three study sites. Demographic data (residence, age, marital status, level of education, religion, and occupation), reproductive history (gravity, parity, number of children still alive, and gestational age), length of hospital stay, and type of evacuation were retrieved for each patient. Data collection was conducted during the period from 1 April 2016 to 31 May 2016. Data were analyzed using IBM SPSS Statistics version 22 (Armonk, New York, USA). Values are given as proportions (percent) with their 95% confidence interval (CI), and age is reported as the mean and standard deviation (SD). Ethical approval was granted by the local Malawian College of Medicine Research and Ethics Committee (COMREC) P.06/15/1748, and the Regional Committee for Medical and Health Research Ethics Central Norway (REC Central), 2015/455/REK. Permission to access individual patient records was granted by the District Health Officers at Mangochi and Chiradzulu District Hospitals, and the Head of the Department of the Obstetric and Gynecological ward at QECH. All patient information was anonymized and de-identified prior to analysis.
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