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'It's a very complicated issue here': Understanding the limited and declining use of manual vacuum aspiration for postabortion care in Malawi: A qualitative study

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Malawi has one of the highest maternal mortality ratios in the world. Unsafe abortions are an important contributor to Malawi’s maternal mortality and morbidity, where abortion is illegal except to save the woman’s life. Postabortion care (PAC) aims to reduce adverse consequences of unsafe abortions, in part by treating incomplete abortions. Although global and national PAC policies recommend manual vacuum aspiration (MVA) for treatment of incomplete abortion, usage in Malawi is low and appears to be decreasing, with sharp curettage being used in preference. There is limited evidence regarding what influences rejection of recommended PAC innovations. Hence, drawing on Greenhalgh et al.’s (2004. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Quarterly 82 : 581–629.) diffusion of healthcare innovation framework, this qualitative study aimed to investigate factors contributing to the limited and declining use of MVA in Malawi. Semi-structured interviews with 17 PAC providers in a central hospital and a district hospital indicate that a range of factors coalesce and influence PAC and MVA use in Malawi. Factors pertain to four main domains: the system (shortages of material and human resources; lack of training, supervision and feedback), relationships (power dynamics; expected job roles), the health workers (attitudes towards abortion and PAC; prioritization of PAC) and the innovation (perceived risks and benefits of MVA use). Effective and sustainable PAC policy must adopt a broader people-centred health systems approach which considers all these factors, their interactions and the wider socio-cultural, legal and political context of abortion and PAC. The study showed the value of using Greenhalgh et al.’s (2004. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Quarterly 82 : 581–629.) framework to consider the complex interaction of factors surrounding innovation use (or lack of), but provided more insights into rejections of innovations and, particularly, a low- and middle-income country perspective.
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‘It’s a very complicated issue here’:
understanding the limited and declining use of
manual vacuum aspiration for postabortion care
in Malawi: a qualitative study
Sinead Cook,
1,2,
* Bregje de Kok,
3,4
and Maria Lisa Odland
5
1
Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK,
2
Department of Sexual
Health, Cardiff and Vale NHS, Cardiff Royal Infirmary, Cardiff, UK,
3
Anthropology Department, University of
Amsterdam, Amsterdam, The Netherlands,
4
Institute for Global Health and Development, Queen Margaret
University, Edinburgh, UK and
5
Norwegian University of Science and Technology, Trondheim, Norway
*Corresponding author. Department of Sexual Health, Cardiff Royal Infirmary, Newport Road, Cardiff CF24 0SZ, UK.
E-mail: sineadcook@doctors.org.uk
Accepted on 11 August 2016
Abstract
Malawi has one of the highest maternal mortality ratios in the world. Unsafe abortions are an im-
portant contributor to Malawi’s maternal mortality and morbidity, where abortion is illegal except
to save the woman’s life. Postabortion care (PAC) aims to reduce adverse consequences of unsafe
abortions, in part by treating incomplete abortions. Although global and national PAC policies rec-
ommend manual vacuum aspiration (MVA) for treatment of incomplete abortion, usage in Malawi
is low and appears to be decreasing, with sharp curettage being used in preference. There is
limited evidence regarding what influences rejection of recommended PAC innovations. Hence,
drawing on Greenhalgh et al.’s (2004. Diffusion of innovations in service organizations: systematic
review and recommendations. Milbank Quarterly 82: 581–629.) diffusion of healthcare innovation
framework, this qualitative study aimed to investigate factors contributing to the limited and declin-
ing use of MVA in Malawi. Semi-structured interviews with 17 PAC providers in a central hospital
and a district hospital indicate that a range of factors coalesce and influence PAC and MVA use in
Malawi. Factors pertain to four main domains: the system (shortages of material and human re-
sources; lack of training, supervision and feedback), relationships (power dynamics; expected job
roles), the health workers (attitudes towards abortion and PAC; prioritization of PAC) and the innov-
ation (perceived risks and benefits of MVA use). Effective and sustainable PAC policy must adopt a
broader people-centred health systems approach which considers all these factors, their inter-
actions and the wider socio-cultural, legal and political context of abortion and PAC. The study
showed the value of using Greenhalgh et al.’s (2004. Diffusion of innovations in service organiza-
tions: systematic review and recommendations. Milbank Quarterly 82: 581–629.) framework to con-
sider the complex interaction of factors surrounding innovation use (or lack of), but provided more
insights into rejections of innovations and, particularly, a low- and middle-income country
perspective.
Key words: Diffusion of innovations, low- and middle-income countries, Malawi, manual vacuum aspiration (MVA), people-
centred health systems, postabortion care
V
CThe Author 2016. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.
All rights reserved. For permissions, please e-mail: journals.permissions@oup.com 305
Health Policy and Planning, 32, 2017, 305–313
doi: 10.1093/heapol/czw128
Advance Access Publication Date: 10 September 2016
Original Article
Introduction
Malawi has one of the highest maternal mortality ratios in the world
(WHO et al. 2014). Unsafe abortion may contribute to around 18%
of Malawi’s maternal mortality (Bowie and Geubbels 2013), where
abortion is illegal except to save the woman’s life. Levandowski
et al. (2013) estimated 67 300 abortions were performed in Malawi
in 2009; over one-third required treatment for complications. Many
organizations, including WHO (2014) and Ipas (2011) emphasize
that for countries like Malawi to meet global maternal mortality re-
duction targets, unsafe abortion deaths must be reduced. The
Malawian Ministry of Health’s (2009) key strategies for tackling un-
safe abortion-associated mortality and morbidity are family plan-
ning to reduce unintended pregnancies and provision of
postabortion care (PAC). PAC aims to reduce mortality and long-
term morbidity attributable to unsafe abortion through provision of
emergency care, treatment of incomplete abortion by uterine evacu-
ation, counselling and contraception (Corbett and Turner 2003).
Some authors (Descher and Cohen 2003;Grimes 2006) argue that
increasing contraception usage and reducing legal restrictions to safe
abortion should be priorities as PAC only mitigates the conse-
quences of unsafe abortions. However, in Malawi significant abor-
tion law reform is not anticipated soon (Chikuse 2015) and
increasing contraception use will not eliminate unwanted pregnan-
cies ( ˚
A
0
hman and Shah 2011). Thus, unsafe abortions will continue
to occur and quality PAC remains essential to reduce morbidity and
mortality (Pattinson et al. 2006).
WHO (2012) recommends vacuum aspiration (electronic or
manual) or misoprostol for first-trimester uterine evacuation as part
of PAC. Manual vacuum aspiration (MVA) is recommended over
dilatation and sharp curettage (D&C) as it is associated with fewer
complications, shorter hospital stays (Tunc¸alp et al. 2010) and can
be performed by midwives or nurses as an outpatient procedure
(Grimes et al. 2006). MVA was introduced as a pilot to Malawi in
1994 (Leme et al. 1997) and rolled out with investments in facilities,
training and equipment in 2001 (Schenck-Ygleslae 2004). It is the
recommended treatment for first-trimester incomplete abortion and
is on the country’s standard equipment list; misoprostol is not cur-
rently recommended in national PAC policy (Ministry of Health
2009). However, in their strategic assessment of unsafe abortion in
Malawi (involving observations of facilities and key informant inter-
views), Jackson et al. (2011) found MVA is used infrequently, with
D&C being used in preference. Reasons suggested for this included:
a lack of MVA equipment, equipment being locked up to prevent its
use in inducing abortions and a lack of trained staff. Moreover, a re-
cent study found declining MVA use in three Malawian hospitals
during 2009–12 from 31.0 to 4.9%, with a corresponding increase
in D&C (Odland et al. 2014). Studies have shown MVA to be more
cost-effective than D&C in Malawi (Benson et al. 2015) and other
low- and middle-income countries (LMIC) (Johnston et al. 2007;
Maonei et al. 2014). Thus, increasing MVA use may improve the
quality of PAC without significantly increasing spending, crucial in
Malawi given its high poverty levels and minimal health budget
(World Bank 2014).
It is therefore important to investigate what contributes to the
limited and declining use of MVA in Malawi, and why Malawi’s
policy, which recommends MVA, does not translate into practice.
Scholars have used various theoretical approaches to attempt to
understand how clinical policies translate into practice. Some studies
from high-income countries have used behavioural theories which
analyse how individual factors affect transfer of clinical policies into
practice (Godin et al. 2008). The widely used ‘diffusion of innov-
ations’ theory (Rogers 2003) goes beyond this individualistic ap-
proach, by focusing on individual decision-making processes but
also recognizing the importance of communication and social net-
works for how and why organizations or groups adopt innovations
(new ideas or technologies) or not. The theory proposes individuals’
use of innovations is the outcome of a staged process: obtaining
knowledge and understanding of the innovation; persuasion; deci-
sion to use the innovation or not; implementation of the decision; re-
inforcement of the decision through observed outcomes. This
process diffuses throughout the organization (Rogers 2003).
Rejection of the innovation, as happened with MVA in Malawi,
may occur at any point and be passive (individuals or organizations
do not consider the innovation) or active (consideration followed by
a decision to not use or discontinue using the innovation).
Greenhalgh et al. (2004) contend that diffusion of innovations
theory still treats behaviours as the outcome of conscious, rational
and individual decision-making processes, rather than as the com-
bined result of individual, communal, organizational, economic and
social factors. Moreover, they argue that diffusion of innovations
theory treats diffusion as an overly simple and linear imitation pro-
cess. In reality, diffusion is more complicated due to the impact of a
myriad of contextual factors, including management structures,
local priorities and power dynamics and result in formal dissemin-
ation processes (e.g. staff training) co-existing with unplanned diffu-
sion processes. Greenhalgh et al. (2004) capture the complexity of
the diffusion process and the interplay of a range of contextual fac-
tors in their diffusion of healthcare innovation framework.
We build on Greenhalgh et al.’s (2004) framework since context-
ual issues will be particularly important for MVA use in Malawi,
given the general importance of social, cultural and political con-
texts for sexual and reproductive health programmes (WHO 2007).
As Greenslade et al. (1994) and Kulczycki (2009) argue, controver-
sies surrounding abortion and women’s reproductive rights
Key Messages
Numerous interconnecting factors influence the limited and declining use of MVA for postabortion care in Malawi.
Effective and sustainable postabortion care policy must adopt a broader, people-centred health systems approach which
considers all these factors, their interactions and the wider socio-cultural, legal and political context of abortion and
postabortion care.
Human factors and perspectives are key to understanding diffusion of innovations.
This study extends Greenhalgh et al.’s (2004) diffusion of innovation framework to the rejection of innovations and, par-
ticularly, low- and middle-income settings.
306 Health Policy and Planning, 2017, Vol. 32, No. 3
complicate the introduction of PAC innovations. Studies from a
number of LMIC examining implementation of MVA and PAC pro-
grammes found that various health system elements and social and
political issues, in particular abortion-related stigma, create chal-
lenges for the sustained implementation of MVA and PAC pro-
grammes (Tagoe-Darko 2013;Paul et al. 2014;Storeng and
Ouattara 2014). Therefore, the framework developed by
Greenhalgh et al. (2004) is particularly appropriate for the study of
the diffusion (or not) of MVA in Malawi. The framework highlights
that features of the wider context and health system interact
with the innovation adopters (health workers) and their relation-
ships and interactions with one another, and that all these factors to-
gether influence diffusion, dissemination and implementation of
innovations.
Furthermore, Greenhalgh et al.’s (2004) framework chimes with
the growing body of literature on people-centred health systems,
which emphasize that ‘software’ (ideas, interests, values, norms and
relationships) is at least as important as ‘hardware’ (technical, finan-
cial and material resources) for health system functioning (Sheikh
et al. 2014). Thus, this study will explore how hard- and software
related contextual factors affect PAC and the use of MVA.
Moreover, we explore these issues through the perceptions of
healthcare providers. After all, providers’ perceptions and under-
standings are key for policy implementation (Greenhalgh et al.
2004;Blaauw et al. 2006;Aniteye and Mayhew 2013).
Methods
This small-scale qualitative study primarily involved interviews with
health workers conducted by the first author in Chiradzulu District
Hospital and Queen Elizabeth Central Hospital (QECH). We se-
lected these two government hospitals because public hospitals pro-
vide the majority of PAC in Malawi (Kalilani-Phiri et al. 2015) and
the selection of a rural and urban site enabled exploration of poten-
tial differences between rural and urban facilities. Furthermore,
QECH is the largest referral hospital in Malawi and sees the major-
ity of women with abortion complications. Odland et al. (2014)
found Chiradzulu had the lowest use of MVA (7.4%) compared
with two other Malawian hospitals. Interviews were supplemented
by unstructured observations of care practices (but no direct inter-
actions with patients) made during the 4-week study period, to
provide contextual insights concerning organizational set up, re-
sources and staff dynamics. Observations were triangulated with
interview findings.
Through purposeful sampling, we included PAC providing
health workers of different cadres (doctors, nurses and clinical offi-
cers), genders and levels of experience and seniority, to capture a
wide range of views and understandings. We excluded practitioners
who were not currently involved in providing PAC, were not pre-
dominantly based in either hospital or were working in their current
position for <1 month. A total of 11 participants were interviewed
in QECH and 6 in Chiradzulu (Table 1).
We used semi-structured interviews rather than focus groups be-
cause PAC is a potentially sensitive topic and may involve criticizing
colleagues’ practices; individual interviews allowed participants to
speak more freely (Bowling and Ebrahim 2005). Interview topics
included experiences of, and perceptions towards, PAC and MVA.
During the study, small adaptions were made to interview questions
mainly to reflect locally used terms (e.g. ‘evacuation’ rather than
‘D&C’). Acknowledging the importance of reflexivity in qualitative
research, we reflected throughout the study on how participants’ per-
ceptions of the interviewer as female, foreign, white and a doctor and
our own preconceptions and values, might influence the findings. For
instance, our western liberal values according to which abortion is a
human and reproductive right could lead to overly negative interpret-
ations of less liberal attitudes amongst providers. Furthermore, the
interviewer had previous experience of both providing PAC in
Malawi and abortion care within the UK, which may allow personal,
as opposed to participants’ thoughts and experiences, to influence the
findings. Reflection on our own views and experiences led to a more
balanced interpretation of attitudes and preferences.
Informed written consent was obtained from all participants fol-
lowing a written and verbal explanation of the study and the inter-
viewer’s inability to directly improve PAC. They were advised that
their personal responses would remain confidential and anonymous,
that they were not obligated to participate, and could refuse to an-
swer a question or withdraw at any time. Nobody refused to partici-
pate. Permission was requested to digitally record the interviews;
one participant refused, so handwritten notes were taken. The
recordings were transcribed and thematic analysis performed (Braun
and Clarke 2006). The first author coded and arranged the data into
descriptive and analytical themes and sub themes; data and analysis
Table 1. Participants’ characteristics
Nurse Clinical officer Doctor
Number of participants 6 5 6
Hospital QECH: n¼3 QECH: n¼2 QECH: n¼6
Chiradzulu: n¼3 Chiradzulu: n¼3 Chiradzulu: n¼0 (No doctors from
Chiradzulu were interviewed, as they
are rarely involved in PAC)
Gender Female: n¼4 Female: n¼2 Female: n¼2
Male: n¼2 Male: n¼3 Male: n¼4
Seniority Nurse-midwife technician: n¼3
Senior nurse: n¼3
Clinical officer (independent practitioner
with 3 years training): n¼3
Senior clinical officer: n¼2
Junior intern (doctor in first year follow-
ing medical school): n¼1
Senior intern (second year doctor): n¼2
Registrar (doctor post-internship special-
izing in obstetrics and gynaecology):
n¼2
Consultant: n¼1
Length of time in
current position
1 month–15 years (<1 year: n¼3,
2–5 years: n¼2, 15 years: n¼1)
2 months–15 years (<1 year: n¼2, 1–7
years: n¼2, 15 years: n¼1)
2 months–5 years (<1 year: n¼3, 1–5
years: n¼3)
Health Policy and Planning, 2017, Vol. 32, No. 3 307
were discussed with the second author and compared with other
similar studies to enhance credibility and trustworthiness (Yin
2015). The analysis used a mixed deductive and inductive approach;
some codes (e.g. ‘monitoring and feedback’) were derived from
Greenhalgh et al.’s (2004) framework, whereas others emerged from
the data.
Ethical approval was granted from both Queen Margaret
University, Edinburgh and the College of Medicine Research and
Ethics Commitee, Malawi.
Results
The emergent themes are discussed later and displayed in the result-
ant conceptual framework (Figure 1), which builds on Greenhalgh
et al.’s (2004) framework. We categorized findings into four themes:
the system, relationships, health workers’ values and attitudes and
the innovation. The outer context impacts on all these areas; all
these factors together influence the provision of PAC and MVA
usage. One participant described this interaction of interdependent
factors, all influenced by the outer context: ‘it’s a very complicated
issue here’ (P.10, clinical officer, Chiradzulu).
The system
Greenhalgh et al. (2004) emphasize that numerous system features,
including hardware and organizational aspects, are key to the adop-
tion, diffusion and sustained use of innovations. Participants high-
lighted a number of such features as key barriers to MVA use. They
described the challenges of working with limited resources generally
but emphasized MVA instruments are a particular and increasing
problem. After initial donations, there has not been a reliable supply
to replace old and broken equipment.
So the problem we have is these things start as projects, some-
body develops an idea, after possibly looking at how successful it
was somewhere, but then comes incorporated, part of the system,
but how to continue without that capacity, it becomes a chal-
lenge. So that project goes away, there’s no supply of equipment,
so it goes naturally to extinction. (P.4, intern, QECH)
Participants explained that in the absence of MVA equipment, they
would perform D&C rather than delay the procedure. This ap-
peared to sometimes result in health workers automatically resorting
to D&C; they became used to there being no equipment.
In addition to shortage of physical resources, participants
emphasized the problem of staff shortages, particularly staff trained
in PAC. Patients requiring PAC are admitted to the gynaecology ward
in QECH and the female ward in Chiradzulu. Nurse shortages were
observed in both these wards, with often only one or two nurses cov-
ering up to 70 patients. Participants explained how staff shortages
lead to staff feeling overworked and demotivated, thus potentially af-
fecting quality of care. Participants noted that unsafe abortions con-
tribute to a large proportion of gynaecology admissions and some
thought the number of women presenting for PAC may be increasing,
which may be compounding feelings of being overworked.
Staff shortages may also affect MVA use. Nurse shortages were
felt to contribute to nurses trained in MVA not performing it as they
were engaged with other tasks.
We nurses we are in a shortage. So most of time we are concen-
trated in the ward, doing rounds, doing other things. While these
Figure 1. Conceptual framework developed from Greenhalgh et al.’s (2004) framework and the study’s findings
308 Health Policy and Planning, 2017, Vol. 32, No. 3
interns are assigned to do the assessment of the abortion patients.
So we just leave them to do. (P.1, nurse, QECH)
The junior interns, however, receive little of the practical on-the-job
training they require, again due to staff shortages.
So you find as an intern, it is put on the schedule that you are
going to do an evacuation, but there is nobody to guide... So the
junior, all he has in mind is theoretically this is how we do, in
terms MVA. (P.4, intern, QECH)
Doctors expressed concerns about the quality of on-the-job training;
interns might pass weaknesses down to juniors. Furthermore, senior
interns usually train juniors only in D&C, as they tend to be more
confident in D&C than MVA. Participants said this is leading to
MVA becoming a ‘forgotten skill’, as the next cohort feel even less
confident and are less likely to train others. However, in
Chiradzulu, clinical officers described good on-the-job training and
support. Some nurses had received MVA training, although often
some years ago, during a national programme. Participants from
both hospitals felt it important to have ongoing practical supervision
or regular refresher courses both to train more people and maintain
skills of those already trained.
A lack of follow-up and feedback were highlighted as additional
organizational issues. At QECH, women are not followed-up after
PAC, whereas at Chiradzulu they are advised to return after 2
weeks. Participants at QECH were concerned that without routine
follow-up, they would not know whether women experienced prob-
lems after treatment, and whether ‘what we have done is OK’.(P.4,
intern, QECH). Absence of feedback may limit the use of relatively
new procedures like MVA, about which staff may feel less secure.
Furthermore, a lack of monitoring of health workers’ perform-
ance was felt to contribute to poor care and low MVA use. One
nurse described how performance and MVA use was better when an
non-governmental organization was monitoring their performance
but when this ceased MVA use declined.
In the first maybe because we were being sponsored by
JHIEPEGO and what and they were supervising us... and they
were check listing, so people were doing it. (P.1, nurse, QECH)
Participants also felt that monitoring MVA rates is beneficial and
suggested that MVA usage increased in Chiradzulu following the
dissemination of results demonstrating it had the lowest usage be-
tween 2008 and 2012 (Odland et al. 2014). They attributed this to
appointing a PAC coordinator who organizes a MVA staff rota and
monitors supplies. Thus, leadership may be another organizational
factor affecting MVA rates.
Relationships
According to Greenhalgh et al. (2004), social networks, that is net-
works of communication and influence between colleagues and
friends, influence the diffusion of innovations. Thus, staff relation-
ships and dynamics need to be examined. At both hospitals, staff
have distinct and set roles and responsibilities. Junior interns pro-
vide PAC in QECH; senior interns described being ‘off the hook’
after completion of their junior internship. Nurses provide initial
and post-procedural care in QECH. Nurses perform the same role at
Chiradzulu but clinical officers and occasionally senior nurses con-
duct procedures. However, nurses perform MVA rarely and may
consider it as the clinicans’ duty, as one nurse indicated.
If we are given a chance to do it [MVA], we can do it, but accord-
ing to scope of practice in Malawi, it is the duty of the clinician.
(P.14, nurse, Chiradzulu)
On the other hand, one doctor described that following wide-
spread MVA training for nurses, doctors started perceiving MVA
as a nurse’s responsibility and D&C as a doctor’s responsibility.
Clear demarcations between nurses and doctors in terms of role
and status may have contributed to doctors discontinuing MVA,
which became seen as a simple innovation of lower standing, de-
signed for nurses.
Strictly delineated roles and responsibilities may also negatively
impact on patient care and teamwork if health workers do not con-
sider a particular task or patient as their responsibility, as one intern
explained:
we don’t really work as a team... It’s like when you work, you
do say ‘it’s OK, as long as I do this then it’s fine. If something
happens [to the patient], it won’t be on my side now, I have
cleared on my side, and then they are on that other side’.
The intern points to a distinction between ‘my side’, for which one is
responsible and ‘the other side’, for which one is not. The same intern
explained if a doctor is unable to find the correct senior doctor to help
them, others may refuse, as they do not consider it their responsibility.
So I asked them to assist, they said ‘no I am not on-call, you
need to inform the ones on-call’. I said ‘the patient is not well,
can you just assist?’ They said ‘no I can’t assist’. (P.6, intern,
QECH)
Whilst poor teamwork will affect the quality of care in general, we
can again see how it may particularly affect use of MVA, a relatively
unknown procedure about which the staff feel less confident.
Collaboration will be further impeded by strong hierarchal power
structures between cadres which were apparent in both hospitals but
particularly QECH. Nurses are perceived to have less power than
doctors.
The powers are mainly with the College of Medicine as com-
pared with the College of Nursing. So there’s an issue with super-
iority with that one. And the ones who are in charge of the
wards, they are the doctors, the consultants, so they have author-
ity. (P.4, intern, QECH)
This power differential also comes through in the description later; a
senior nurse described how she tries to help and train junior interns
in MVA when they are having difficulties.
If there is a problem then I come in and maybe just suggestion,
you can do this one, so then they do MVA. (P.1, nurse, QECH)
The use of the phrase ‘maybe just suggestion’ points to a lack of
assertiveness and power differentials, despite the nurse having
more experience than junior doctors and displays how MVA use
might be particularly hampered by these power differentials be-
tween cadres if nurses feel unable to speak up. Power differen-
tials between cadres also appeared to influence participants’
views on who should ideally perform MVA. Almost all partici-
pants agreed nurses, clinical officers and doctors should perform
MVA, but they described uterine evacuation as being primarily a
clinical officer or doctor’s responsibility, with nurses only provid-
ing services when doctors or clinical officers are unavailable to
reduce delays
Participants also described a strong hierarchy amongst doctors.
This appears to contribute to juniors’ fears to ask for help, as they
do not want to admit a lack of knowledge or are scared of being
shouted at.
Yeah so instead of teaching, they just shout at you as if, they just
put all the blame on you as if you have completed nothing, so,
Health Policy and Planning, 2017, Vol. 32, No. 3 309
anyway we are used [to it], because even when we are at [med-
ical] school it’s just the same things. (P.4, intern, QECH)
If MVA is expected to be carried out by relatively inexperienced
staff, hierarchical relationships and fears about being scolded rather
than supported may make staff less inclined to carry out MVA.
Health workers’ values and attitudes
Greenhalgh et al. (2004) note that the adopters’ needs, values and
goals matter for diffusion of innovations. They will be especially im-
portant for PAC related innovations given that abortion is a particu-
larly value-laden issue. Participants displayed a range of attitudes
towards providing PAC. They all agreed it should be an emergency
service and patients should be prioritized as they require urgent
treatment. However, participants held differing opinions on whether
PAC is actually prioritized in their hospitals. Some felt it is, as reduc-
ing maternal mortality is a national priority. However, others said
often PAC is not treated as a priority emergency service, resulting in
treatment delays.
They are kind of looked at on the lower side of care...emergency
obstetrics is taken like more of a priority than postabortal care.
That’s why even if, that’s why a lady who has signs of miscar-
riage or signs of abortion would come at night but then they
wouldn’t be attended to, but somebody in labour would be at-
tended to there and then. (P.10, clinical officer, QECH)
This suggests that outside the interview context, providers may at-
tribute less importance to PAC. Some health workers described
PAC as a ‘normal duty’, no different from other healthcare ser-
vices, others were very positive and passionate about providing
PAC. One nurse explained PAC was her main motivation to work
in gynaecology. Nurses appeared more enthusiastic about provid-
ing PAC than clinical officers and doctors, reflected in using
words such as ‘passion’, ‘great’ and ‘satisfaction’. Many health
workers found PAC satisfying as they considered it necessary and
life-saving care, and it seemed to provide them with heroic
feelings.
So I was just like: we saved her life. (P.3, nurse, QECH)
Furthermore, some participants described positive feelings about
helping and providing advice to women who they considered vulner-
able, such as teenagers. Some health workers also described feelings
of sadness or sympathy, towards both women who had spontaneous
and induced abortions, who may have a lack of support and long-
term complications, particularly infertility.
However, many health workers described finding PAC challeng-
ing due to their personal belief that induced abortion is immoral.
These feelings were influenced by religious beliefs and prevailing
community beliefs and norms. Participants explained that PAC is
often only associated with induced abortions by the public and there
tends to be negative attitudes towards these women, with people
considering them ‘sinners’ or ‘criminals’; these words and views
were often reflected by health workers. Many participants described
other health workers exhibiting discriminatory or judgemental atti-
tudes towards patients whom they suspected had induced abortions,
particularly in mission hospitals and amongst health workers who
don’t work directly in PAC.
Participants stated that this stigma surrounding abortion often
leads to women delaying presenting for care or not disclosing
induced abortions (or even pregnancies or miscarriages), resulting
in health workers feeling frustrated with these women. Staff short-
ages and perceived increasing rates of women presenting for PAC
may increase negative feelings towards these patients, who they
feel are increasing already heavy workloads by ‘opting’ to induce
abortions.
They [staff working in Outpatient Department] can shout at
them ‘why did you do this? You are creating a lot of job here,
you want us to be helping you this month and then next month
you are coming a lot of you! You come here with a lot of induced
abortion!’ (P.12, clinical officer, Chiradzulu)
A nurse also noted other staff feel PAC is facilitating abortions.
Although she did not agree, an intern did and therefore felt very
negatively towards PAC.
People are not afraid of getting pregnant, knowing that if they do
the abortion, someone at the hospital is ready to treat them. (P.5,
intern, QECH)
It is important to note, however, that negative views of abortion
could go together with a perceived obligation to provide care for all
women.
I believe that doing a abortion is a sin myself, but just because I
believe that it is a sin, it’s not like I say ‘because you did an abor-
tion I’m not going to help you’, I’m supposed to help everybody.
(P.5, intern, QECH)
One participant described this as creating an internal conflict of val-
ues, between their moral or religious views and the care they pro-
vide. Most participants felt their beliefs did not affect their care but
one thought it might.
The innovation
Knowledge and attitudes towards the innovation (MVA) are con-
sidered highly important for adoption and diffusion (Rogers 2003).
Although the literature has identified various advantages of MVA
over D&C, Greenhalgh et al. (2004) point out that perceived advan-
tages are most important for the uptake of innovations, which are
not fixed and open to negotiation and adjustment.
All participants noted MVA is the first-line treatment for first-
trimester incomplete abortions and curettage should be used for
higher gestations. Some staff members felt for this reason, curettage
will continue to be used more often than MVA, as they perceived
second-trimester abortions to be more common. However, a clinical
officer suggested that some practitioners struggle to determine preg-
nancy gestations and when in doubt, opt for curettage.
Numerous advantages of MVA over curettage were expressed;
most commonly that it is associated with fewer complications.
We can do MVA patient with minimal complications, minimal.
And MVA we cannot perforate unless you are careless. (P.1,
nurse, QECH)
Other advantages cited were that it is cheaper, simpler and quicker
to perform, requires less staff and allows for rapid discharge of pa-
tients resulting in fewer in-patients. Staff noting these advantages
were those mainly responsible for patient care post-procedure:
nurses in QECH and clinical officers in Chiradzulu; these cadres will
feel this benefit more directly to their personal workload.
Yet, many health workers noted that curettage is used more com-
monly in their hospital than MVA. Participants often referred to
other staff preferring curettage; only one participant stated he per-
sonally preferred curettage, as from his experience MVA seems to
have a higher risk of incomplete procedures; a concern that some
other participants shared. Participants suggested junior staff might
prefer curettage as they are more familiar with it and are worried
310 Health Policy and Planning, 2017, Vol. 32, No. 3
about making mistakes or performing incomplete procedures and
disappointing their seniors.
so people are trying to impress and as a result they tend to do
something that they are comfortable with rather than the thing
that they are supposed to do. (P.6, intern, QECH)
Paradoxically, MVA’s perceived simplicity entails a risk; if compli-
cations do occur, they may be attributed more easily to a lack of
competence or being ‘careless’.
It appears, then, that health workers’ attitudes towards using
MVA are affected by perceived personal benefits or risks of MVA,
whether reducing inpatients and workload, becoming personally re-
sponsible for an incomplete procedure or complication or incurring
colleagues’ negative views of one’s professional capacity.
Discussion
Our findings demonstrate how multiple ‘hardware’ and ‘software’
issues interact and reinforce each other to influence MVA use.
Greenhalgh et al. (2004) stress that few studies consider this inter-
connectedness. The wider context of PAC and abortion influences
many factors contributing to low MVA usage. PAC has been pro-
moted as the least contentious service for reducing unsafe abortions’
adverse consequences (Barot 2014), but it cannot be separated from
the socio-cultural, religious and legal status of abortion. Negative at-
titudes surrounding abortion may lead to delays; women who delay
seeking care are at increased risk of more severe complications such
as sepsis, resulting in being more likely to require further procedures
in theatre rather than MVA as an outpatient. Negative attitudes
may also result in providers’ negative attitudes towards providing
PAC, low prioritization of services and low motivation to improve
services. The idea that large numbers of women choosing to induce
abortions are increasing already heavy workloads may further re-
duce prioritization and motivation to improve PAC. Practical diffi-
culties, such as unreliable equipment supplies, make MVA a more
difficult option than curettage; when motivation and prioritization
are low, staff will likely opt for the easier option, which may not be
what is best for the patient.
Staff shortages, relationships, expected job roles and power dy-
namics appear very important in this context and impact on many
elements. Although social interactions are being increasingly
recognized as important for innovation use (Cain and Mittman
2002), Greenhalgh et al. (2004) note there is a dearth of research
investigating this. The findings of this study support McPake and
Koblinsky’s (2009) and Gilson’s (2012) assertion that health systems
are social in nature; people and their views, behaviours and inter-
actions shape how policies recommending innovations are imple-
mented. Staff relationships impact on training and supervision and
power dynamics may affect staff attitudes towards MVA and their
willingness to use it. Despite widespread acknowledgement of MVA
policies and its benefits, the personal risks and benefits of using
MVA appeared more important. Greenhalgh et al. (2004) emphasize
that it is important that those with more power, such as purchasers,
senior clinicians and managers, see the benefits of creating an ena-
bling environment for staff to use it. Graff and Amoyaw (2009)
found that a lack of prioritizaiton of PAC in Ghana led to purchas-
ing equipment for other services rather than MVA when funds were
limited. Moreover, purchasers may not appreciate MVA’s advan-
tages as equipment is more expensive and does not last as long as
curettage equipment (Zaidi et al. 2014), although it is still more
cost-effective as it can be performed as an outpatient procedure.
Our findings highlight the value of using Greenhalgh et al.’s
(2004) framework as opposed to more individualistic behavioural
theories; rejection of MVA is clearly not only a choice based merely
on individual knowledge and attitudes but also influenced by staff
relationships and broader contextual and organizational issues.
Furthermore, this study adds to the existing literature on diffusion
of innovations. First, this study examines issues from health work-
ers’ viewpoints, which are key as providers’ perceptions inform and
shape practice (Blaauw et al. 2006;Aniteye and Mayhew 2013).
Furthermore, Greenhalgh et al.’s (2004) framework is based largely
on studies conducted in high-income settings. We demonstrate its
applicability to LMIC but here certain factors such as limited mater-
ial and human resources will carry more weight. This study high-
lighted the strong importance that power dynamics can play in
diffusion of innovations. The importance of staff roles and power
dynamics between staff cadres appeared to come through in another
study of MVA usage in another LMIC, with some doctors feeling
midwives always require supervision when performing MVA, des-
pite policies and training to allow for tasking-shifting of MVA to
midwives (Paul et al. 2014). It is therefore possible that whilst power
differentials will affect the provision of care everywhere
(Greenhalgh et al. 2004), they may affect diffusion of innovations
more in LMIC settings but this requires more research.
Furthermore, the study emphasizes the difficulty and complexities of
sustaining the adoption of an innovation, which Greenhalgh et al.
(2004) highlight has been a neglected research area. Rogers (2003)
theorizes that once adoption of an innovation reaches almost 100%,
it will be self-sustaining, as it becomes ‘a normal and taken-for-
granted way of working’ (McEvoy et al. 2014, p. 3). This process is
termed routinization (Greenhalgh et al. 2004), institutionalization
(Billings et al. 2007) or embedding (May et al. 2007). However,
MVA use became briefly widespread in Malawi but then decreased
as facilities struggled to maintain skills and supplies. Routinization
may be less applicable to LMIC health systems, which may be sus-
ceptible to externally driven changes such as finance or supply chain
difficulties. Hence, it is equally, if not only more important, particu-
larly in LMIC, to consider both how to achieve widespread adoption
of innovations but also how to sustain use.
Limitations and future research
This study adds to a limited research base about what influences re-
jection of recommended PAC innovations. However, there are limi-
tations. Some findings may partially be a by-product of the
interview context; e.g. participants may have over-emphasized the
importance of resource issues in the hope the interviewer could help
the situation. Furthermore, as this is a small-scale study involving
only two hospitals, transferability to other situations may be limited.
Greenhalgh et al. (2004), however, note that generally insights re-
garding diffusion of innovations cannot be readily transferred to
other contexts due to the importance of the ‘fit’ between the innov-
ation and the local system or context. Whilst the study provides
some general insights into factors that contribute to rejection of rec-
ommended innovations, it is recognized that MVA and PAC may be
a special case and involves moral sensitivities that other innovations
and policies would not. Thus, we need to be careful with assuming
insights could apply to other health innovations.
A particular limitation in the context of PAC in Malawi is that
no urban or rural health centres were included. As they are often the
first contact for women seeking PAC, yet generally suffer from even
worse resource shortages, further research involving health centres
would be beneficial. Longitudinal ethnographic research could also
Health Policy and Planning, 2017, Vol. 32, No. 3 311
provide further insights and may be particularly useful for under-
standing how best to sustain innovation use in different situations,
as how innovations work out in different contexts is never predict-
able (McPake and Koblinsky 2009).
Implications and recommendations
In spite of the aforementioned limitations, we can make some tenta-
tive recommendations. Recognizing the danger of claims to context-
free knowledge and one-size-fit-all solutions (Sheikh et al. 2014),
these may only be relevant to Malawi and similar LMIC.
Participants emphasized reliable, sustainable equipment supplies
and practical, regular training are necessary to increase MVA use.
Simpson (2005) argues that local ownership of programmes with a
bottom-up approach, i.e. health workers creating strategies them-
selves, improves sustainability. It is also important that practitioners
are involved in equipment purchasing decisions, as they understand
the cost-effectiveness and importance of MVA. On-the-job training
promotes adoption of innovations (Cain and Mittman 2002), but
the current system for doctors in Malawi appears inadequate, and
nurses may not receive on-the-job training at all. Training desig-
nated staff members in teaching others to provide on-the-job train-
ing and supervision may help (RamaRao et al. 2011). However,
since trained nurses currently rarely perform MVA, it is possible
training more nurses may not improve matters.
There is a growing recognition that for successful, sustainable
health programmes whole health systems need to be strengthened,
including all six WHO building blocks (service delivery, human re-
sources, information, medicines and technologies, financing, govern-
ance) (Simpson 2005;Billings et al. 2007;Gilson 2012). This
research has indicated that effective and sustainable PAC policy
likely requires a broader people-centred health systems approach.
Evidence from Hunduras shows that providing MVA equipment
and training alone is unlikely to increase use; Chincilla et al. (2014)
suggest other system factors and human resource issues needed to be
addressed. These include shortages of health workers; a significant
problem in Malawi, particularly in rural areas (WHO 2014), which
have worse and higher rates of abortion complications (Kalilani-
Phiri et al. 2015). However, training and staff shortages are not the
only human resource issues, addressing staff relationships and
power dynamics that negatively impact on PAC and MVA usage is
equally important. Regular team meetings can improve communica-
tion between cadres, team-working and performance (Firth-Colins
2001;Borril and West 2003). A doctor remarked that in QECH
daily team meetings used to occur but stopped due to staff shortages.
Recommencing these may be beneficial but only if different cadres
feel respected and safe to participate (Firth-Colins 2001). Team
meetings may also encourage support and recognition of junior staff
members, which might improve motivation and job satisfaction
(McAuliffe et al. 2009) but only if managers have sufficient training
and awareness about supporting junior staff. Finally, it is important
to consider negative attitudes towards, and low prioritization of,
PAC. Strengthening regular training for all staff may improve staff
attitudes towards women requiring PAC (Shah et al. 2014). Building
on the satisfaction that some staff described from helping vulnerable
women and saving lives, and their recognition of the complexity of
the lives of many women with induced abortions may decrease
judgements, improve care and increase MVA use through increasing
motivation to adopt the innovation that is considered best practice,
even if it is not always the easiest option. However, attempting to
alter attitudes and behaviours, and indeed to improve MVA use and
PAC provision more generally, in a context where abortion is illegal,
highly stigmatized and compounded by multiple gender and power
dynamics will remain ‘complicated’.
Acknowledgement
Prof. Jon Øyvind Odland, Dr. Ursula Kafulafula, Dr. Gladys Gadama and
Dr. Frank Taulo for their help and support with data collection.
Funding
This work was supported by Queen Margaret University’s student develop-
ment fund and the Institute of International Health and Development.
Ethical approval: Ethical approval was granted from both Queen Margaret
University (QMU) and the Malawi College of Medicine Research and Ethics
Committee.
Conflict of interest statement. None declared.
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... Malawi, staff shortages resulted in one or two nurses covering up to 70 patients, the discontinuation of manual vacuum aspiration, and limited on-the-job training [82]. A large and increasing proportion of unsafe abortion admissions can stretch human resources even further, leading health care staff to likely prioritize the easier option over the patient's best interests [82]. ...
... Malawi, staff shortages resulted in one or two nurses covering up to 70 patients, the discontinuation of manual vacuum aspiration, and limited on-the-job training [82]. A large and increasing proportion of unsafe abortion admissions can stretch human resources even further, leading health care staff to likely prioritize the easier option over the patient's best interests [82]. ...
... Shortages of physical resources, such as manual vacuum aspiration instruments, led health care providers in Malawi to automatically resort to dilation and curettage even though dilation and curettage is more expensive, is slower and more difficult to perform, requires more staff, and results in more in-patients [82]. Medication stock-outs due to poor supply chain management resulted in women in Nepal being denied legal abortions [77]. ...
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... The main obstacles cited for an increase in the use of MVA were the lack of training, lack of adequate methods to control pain, and the reluctance of some physicians to abandon the use of traditional curettage [28]. A qualitative study of MVA utilization in Malawi showed that the lack of training and limited human resources are not the only factors preventing the increase in MVA use [29]. The authors report that addressing staff relationships and power dynamics that negatively impact MVA usage is equally important and that performing regular team meetings can improve communication between cadres and promote teamwork and performance [30,31]. ...
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Background Reducing the burden of unsafe abortion rests considerably on women’s ability to access appropriate and timely treatment or services. A critical component of that care relies on a functional supply chain to ensure availability of abortion drugs and supplies within the health system. Disruptions in the supply of medical abortion drugs delay provision of abortion services and can increase the risks to a woman’s health. We examine the ways in which supply chain management (SCM) affects women’s ability to access safe and timely abortion to meet their reproductive health needs and highlight the gap in evaluation research on which SCM interventions best improve access to safe abortion care. SCM comprises a critical component of efficient and sustainable abortion service provision and is a requisite for expansion of services. Furthermore, governments are responsible for safeguarding links in the abortion supply chain, from registration to distribution of abortion drugs and supplies. Strategic public–private partnerships and use of innovative local or community-based distribution mechanisms can strengthen supply chain systems. Finally, alternatives to the pull-based models of distribution could alleviate bottlenecks in the final steps of abortion supply chains. Programs aimed at increasing access to safe and comprehensive abortion care must include SCM as a foundational component of service provision. Without access to a sustainable and affordable supply of abortion drugs and equipment, any attempt at providing abortion services will be critically limited. More implementation research is needed to identify the most effective interventions for improving SCM.
... If institutionalized abortion care is immune to risk, how do we explain the poor health outcomes which some researchers report (Bechem et al., 2016;Ganatra et al., 2017)? Why would there be a decline in the use of medical technologies which are classified 'safe', and a shift towards those known to be 'risky' (Cook et al., 2017;Odland et al., 2014)? ...
... Their solutions then can be organized and made accessible to the majority so they can have the tools needed to succeed [26,42]. Success in confronting adversity depends in part on a combination of individual-, political-, health-and social-systems that positively or negatively impact an individual's or organization's ability to implement change [43]. Roger's Theory of Innovations provides a framework from which to analyze these complex factors and explain how positive deviant midwives have succeeded. ...
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Background: Despite a recognized need for midwives to provide post abortion care, there exist barriers preventing them from integrating lifesaving skills such as manual vacuum aspiration (MVA) into practice. This collaborative research with the Professional Association of Congolese Midwives (SCOSAF), sought to understand how certain midwives in the Democratic Republic of Congo (DRC) have overcome barriers to successfully integrate MVA for post abortion care. Specifically, in order to provide locally-driven solutions to the problem of inadequate post abortion care in the DRC, this study aimed to identify examples of positive deviance, or midwives who had successfully integrated MVA in complex working environments following an in-service training facilitated by their midwifery association, SCOSAF. Methods: Creswell’s mixed method comparative case study design was used to identify positive deviant midwives who had practiced MVA one or more times post training and to explore their strategies and enabling factors. Other midwives who had not practiced MVA post training permitted for a comparison group and further interpretations. Sources of data included a sequential survey and semi-structured interviews. Results: All 102 midwives invited to be surveyed were recruited and 34% reported practicing MVA post training (positive deviant midwives). No statistical significance was found between the two groups’ demographics and practice facility type. Overall, both groups had positive attitudes regarding midwifery-led MVA and legalization of abortion. Positive deviant midwives demonstrated and described more confidence and competence to practice and teach MVA. They were more likely to identify as teachers and overcome interprofessional barriers by teaching MVA to physicians, medical students and other midwives and position themselves as experts during post abortion emergencies. Conclusion: Results provided important insight to midwives’ integration of post abortion care in Kinshasa. Strategies used by positive deviant midwives in emergencies allowed them to navigate challenging contexts in order to practice MVA, while simultaneously increasing the credibility of their profession and the dissemination of evidenced-based MVA practice. Programs designed to work with and promote positive deviant midwives as knowledge brokers could be tested for their overall impact on the diffusion of midwifery-led MVA to improve access to safe, respectful reproductive care.
... Their solutions then can be organized and made accessible to the majority so they can have the tools needed to succeed [26,42]. Success in confronting adversity depends in part on a combination of individual-, political-, health-and social-systems that positively or negatively impact an individual's or organization's ability to implement change [43]. Roger's Theory of Innovations provides a framework from which to analyze these complex factors and explain how positive deviant midwives have succeeded. ...
Article
Full-text available
Background Despite a recognized need for midwives to provide post abortion care, there exist barriers preventing them from integrating lifesaving skills such as manual vacuum aspiration (MVA) into practice. This collaborative research with the Professional Association of Congolese Midwives (SCOSAF), sought to understand how certain midwives in the Democratic Republic of Congo (DRC) have overcome barriers to successfully integrate MVA for post abortion care. Specifically, in order to provide locally-driven solutions to the problem of inadequate post abortion care in the DRC, this study aimed to identify examples of positive deviance, or midwives who had successfully integrated MVA in complex working environments following an in-service training facilitated by their midwifery association, SCOSAF. Methods Creswell’s mixed method comparative case study design was used to identify positive deviant midwives who had practiced MVA one or more times post training and to explore their strategies and enabling factors. Other midwives who had not practiced MVA post training permitted for a comparison gro cup and further interpretations. Sources of data included a sequential survey and semi-structured interviews. Results All 102 midwives invited to be surveyed were recruited and 34% reported practicing MVA post training (positive deviant midwives). No statistical significance was found between the two groups’ demographics and practice facility type. Overall, both groups had positive attitudes regarding midwifery-led MVA and legalization of abortion. Positive deviant midwives demonstrated and described more confidence and competence to practice and teach MVA. They were more likely to identify as teachers and overcome interprofessional barriers by teaching MVA to physicians, medical students and other midwives and position themselves as experts during post abortion emergencies. Conclusion Results provided important insight to midwives’ integration of post abortion care in Kinshasa. Strategies used by positive deviant midwives in emergencies allowed them to navigate challenging contexts in order to practice MVA, while simultaneously increasing the credibility of their profession and the dissemination of evidenced-based MVA practice. Programs designed to work with and promote positive deviant midwives as knowledge brokers could be tested for their overall impact on the diffusion of midwifery-led MVA to improve access to safe, respectful reproductive care.
... Their solutions then can be organized and made accessible to the majority so they can have the tools needed to succeed [26,42]. Success in confronting adversity depends in part on a combination of individual-, political-, health-and social-systems that positively or negatively impact an individual's or organization's ability to implement change [43]. Roger's Theory of Innovations provides a framework from which to analyze these complex factors and explain how positive deviant midwives have succeeded. ...
Preprint
Full-text available
Background: Despite a recognized need for midwives to provide post abortion care, there exist barriers preventing them from integrating lifesaving skills such as manual vacuum aspiration (MVA) into practice. This collaborative research with the Professional Association of Congolese Midwives (SCOSAF), sought to understand how certain midwives in the Democratic Republic of Congo (DRC) have overcome barriers to successfully integrate MVA for post abortion care. Specifically, in order to provide locally-driven solutions to the problem of inadequate post abortion care in the DRC, this study aimed to identify examples of positive deviance, or midwives who had successfully integrated MVA in complex working environments following an in-service training facilitated by their midwifery association, SCOSAF. Methods: Creswell’s mixed method comparative case study design was used to identify positive deviant midwives who had practiced MVA one or more times post training and to explore their strategies and enabling factors. Other midwives who had not practiced MVA post training permitted for a comparison group and further interpretations. Sources of data included a sequential survey and semi-structured interviews. Results: All 102 midwives invited to be surveyed were recruited and 34% reported practicing MVA post training (positive deviant midwives). No statistical significance was found between the two groups’ demographics and practice facility type. Overall, both groups had positive attitudes regarding midwifery-led MVA and legalization of abortion. Positive deviant midwives demonstrated and described more confidence and competence to practice and teach MVA. They were more likely to identify as teachers and overcome interprofessional barriers by teaching MVA to physicians, medical students and other midwives and position themselves as experts during post abortion emergencies. Conclusion: Results provided important insight to midwives’ integration of post abortion care in Kinshasa. Strategies used by positive deviant midwives in emergencies allowed them to navigate challenging contexts in order to practice MVA, while simultaneously increasing the credibility of their profession and the dissemination of evidenced-based MVA practice. Programs designed to work with and promote positive deviant midwives as knowledge brokers could be tested for their overall impact on the diffusion of midwifery-led MVA to improve access to safe, respectful reproductive care.
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Introduction Complications due to unsafe abortions are an important cause of morbidity and mortality in many sub-Saharan African countries. We aimed to characterise abortion-related complication severity, describe their management, and to report women’s experience of abortion care in Africa. Methods A cross-sectional study was implemented in 210 health facilities across 11 sub-Saharan African countries. Data were collected on women’s characteristics, clinical information and women’s experience of abortion care (using the audio computer-assisted self-interviewing (ACASI) system). Severity of abortion complications were organised in five hierarchical mutually exclusive categories based on indicators present at assessment. Descriptive bivariate analysis was performed for women’s characteristics, management of complications and reported experiences of abortion care by severity. Generalised linear estimation models were used to assess the association between women’s characteristics and severity of complications. Results There were 13 657 women who had an abortion-related complication: 323 (2.4%) women were classified with severe maternal outcomes, 957 (7.0%) had potentially life-threatening complications, 7953 (58.2%) had moderate complications and 4424 (32.4%) women had mild complications. Women who were single, multiparous, presenting ≥13 weeks of gestational age and where expulsion of products of conception occurred prior to arrival to facility were more likely to experience severe complications. For management, the commonly used mechanical methods of uterine evacuation were manual vacuum aspiration (76.9%), followed by dilation and curettage (D&C) (20.1%). Most frequently used uterotonics were oxytocin (50∙9%) and misoprostol (22.7%). Via ACASI, 602 (19.5%) women reported having an induced abortion. Of those, misoprostol was the most commonly reported method (54.3%). Conclusion There is a critical need to increase access to and quality of evidence-based safe abortion, postabortion care and to improve understanding around women’s experiences of abortion care.
Article
Objective: The goal of this scoping review was to summarize the literature on facilitators and barriers to surgical practice change. This information can inform research to implement best practices and evaluate new surgical innovations. Background: In an era of accelerated innovations, surgeons face the difficult decision to either acknowledge and implement or forgo new advances. Although changing surgical practice to align with evidence is an imperative of health systems, evidence-based guidelines have not translated into consistent change. The literature on practice change is limited and has largely focused on synthesizing information on methods and trials to evaluate innovative surgical interventions. No reviews to date have grounded their analysis within an implementation science framework. Methods: A systematic review of the literature on surgical practice change was performed. Abstracts and full-text articles were reviewed for relevance using inclusion and exclusion criteria and data were extracted from each article. Cited facilitators and barriers were then mapped across domains within the implementation science Theoretical Domains Framework and expanded to the Capability, Opportunity, Motivation, and Behavior model. Results: Components of the Capability, Opportunity, Motivation, and Behavior model were represented across the Theoretical Domains Framework domains and acted as both facilitators and barriers to practice change depending on the circumstances. Domains that most affected surgical practice change, in order, were: opportunity (environmental context and resources and social influences), capability (knowledge and skills), and motivation (beliefs about consequences and reinforcement). Conclusions: Practice change is predicated on a conducive environment with adequate resources, but once that is established, the surgeon's individual characteristics, including skills, motivation, and reinforcement determine the likelihood of successful change. Deficiencies in the literature underscore the need for further study of resource interventions and the role of surgical team dynamics in the adoption of innovation. A better understanding of these areas is needed to optimize our ability to disseminate and implement best practices in surgery.
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Background: This collaborative research with the Professional Association of Congolese midwives (SCOSAF) in the province of Kinshasa, Democratic Republic of Congo sought to understand how midwives have integrated manual vacuum aspiration (MVA) for post abortion care. Methods: A positive deviant approach to Creswell’s mixed method comparative case study design was used to identify midwives who have integrated MVA post training and to explore enabling factors. Case group comparisons of positive and non-positive deviant midwives provided further interpretations. Results: All 102 midwives invited to be surveyed were recruited. They included 34% who reported practicing MVA post training. No statistical significance was found between the two groups’ demographics and facility type. Overall, groups had positive attitudes regarding midwifery, MVA, and legalization of abortion. Positive deviant midwives demonstrated and described more confidence and competence to practice and teach MVA. They were more likely to identify as teachers and overcome interprofessional barriers by teaching MVA to physicians, medical students and other midwives and position themselves as experts during post abortion emergencies. Conclusion: Results provided important insight to midwives’ integration of post abortion care in Kinshasa. Strategies used by positive deviant midwives in emergencies allowed them to navigate challenging contexts in order to practice MVA, while simultaneously increasing the credibility of their profession and the dissemination of evidenced-based MVA practice. Programs designed to work with and promote positive deviant midwives as knowledge brokers could be tested for its overall impact on the diffusion of midwifery led MVA to improve access to safe respectful reproductive care.
Article
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The migration of doctors and nurses from low- to high-income countries has left many countries relying on mid-level cadres as the mainstay of their health delivery system, Malawi being an example. Although an extremely important resource, little attention has been paid to the management and further development of these cadres. In this paper we use the concept of organisational justice – fairness of treatment, procedures and communication on the part of managers – to explore through a questionnaire how mid-level cadres in jobs traditionally done by higher-level cadres self-assessed their level of job satisfaction. All mid-level health workers present on the day of data collection in 34 health facilities in three health districts of Malawi, one district each from the three geographical regions, were invited to participate; 126 agreed. Perceptions of justice correlated strongly with level of job satisfaction, and in particular perceptions of how well they were treated by their managers and the extent to which they were informed about decisions and changes. Pay was not the only important element in job satisfaction; promotion opportunities and satisfaction with current work assignments were also significant. These findings highlight the important role that managers can play in the motivation, career development and performance of mid-level health workers. Résumé La migration de médecins et d'infirmières de pays pauvres vers des pays à revenu élevé oblige beaucoup de pays, dont le Malawi, à s'appuyer sur des cadres moyens comme pivot de leur système de santé. Bien qu'il s'agisse d'une ressource extrêmement importante, la gestion et le développement ultérieur de ces cadres n'ont guère reçu d'attention. Dans cet article, nous utilisons le concept de justice organisationnelle – traitement, procédures et communications équitables de la part des superviseurs – pour étudier au moyen d'un questionnaire comment les cadres moyens occupant des emplois traditionnellement dévolus aux cadres supérieurs évaluent leur satisfaction professionnelle. Tous les soignants de niveau intermédiaire présents le jour du recueil des données dans 34 établissements de santé du Malawi, sélectionnés dans un district pour chacune des trois régions géographiques, ont été invités à participer; 126 ont accepté. La manière de concevoir la justice était fortement corrélée avec le niveau de satisfaction professionnelle, en particulier dans quelle mesure les cadres moyens estimaient être bien traités par leur superviseur et être informés des décisions et des changements. Le salaire n'était pas le seul élément déterminant: les possibilités d'avancement et la satisfaction quant aux tâches professionnelles actuelles avaient aussi une influence. Ces conclusions soulignent le rôle important que les superviseurs peuvent jouer dans la motivation, les perspectives de carrière et les performances des soignants de niveau intermédiaire. Resumen Debido a la emigración de médicos y enfermeras de países de bajos ingresos a países de altos ingresos, muchos países, como Malaui, tienen que depender de los prestadores de servicios de nivel intermedio como el pilar del sistema de salud. Aunque son un recurso sumamente importante, no se ha prestado mucha atención al manejo y desarrollo de este grupo de profesionales. En este artículo se utiliza el concepto de justicia organizacional – en el trato, los procedimientos y la comunicación por parte de los administradores – para explorar mediante un cuestionario cómo los profesionales de nivel intermedio en trabajos realizados tradicionalmente por profesionales de nivel superior autoevaluaron su nivel de satisfacción laboral. Se invitó a participar a todos los trabajadores de salud de nivel intermedio presentes el día de la recolección de datos en 34 establecimientos de salud, en tres distritos de salud de Malaui, uno de cada región geográfica; 126 accedieron. Las percepciones de justicia estaban muy correlacionadas con el nivel de satisfacción laboral, en particular las percepciones de cuán bien eran tratados por sus supervisores y hasta qué grado se les informaba sobre las decisiones y los cambios. La paga no era el único elemento importante en la satisfacción laboral; las oportunidades de ascenso y la satisfacción con las asignaciones laborales también eran significativas. Estos hallazgos resaltan el importante papel que pueden desempeñar los administradores en la motivación, el desarrollo profesional y el desempeño de los trabajadores de salud de nivel intermedio.
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Health systems could obtain substantial cost savings by providing safe abortion care rather than providing expensive treatment for complications of unsafely performed abortions. This study estimates current health system costs of treating unsafe abortion complications and compares these findings with newly-projected costs for providing safe abortion in Malawi. We conducted in-depth surveys of medications, supplies, and time spent by clinical personnel dedicated to postabortion care (PAC) for three treatment categories (simple, severe non-surgical, and severe surgical complications) and three uterine evacuation (UE) procedure types (manual vacuum aspiration (MVA), dilation and curettage (D&C) and misoprostol-alone) at 15 purposively-selected public health facilities. Per-case treatment costs were calculated and applied to national, annual PAC caseload data. The median cost per D&C case ($63) was 29 % higher than MVA treatment ($49). Costs to treat severe non-surgical complications ($63) were almost five times higher than those of a simple PAC case ($13). Severe surgical complications were especially costly to treat at $128. PAC treatment in public facilities cost an estimated $314,000 annually. Transition to safe, legal abortion would yield an estimated cost reduction of 20 %-30 %. The method of UE and severity of complications have a large impact on overall costs. With a liberalized abortion law and implementation of induced abortion services with WHO-recommended UE methods, current PAC costs to the health system could markedly decrease.
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Objective: To assess the severity of abortion complications in Malawi and to determine associated risk factors. Methods: Between July 20 and September 13, 2009, a cross-sectional survey was conducted at 166 facilities providing postabortion care services. Data were collected for all women with an incomplete, inevitable, missed, complete, or septic abortion. Weighted percentages were calculated to obtain national estimates. Results: In total, 2067 women met the inclusion criteria. Estimates suggest that 80.9% of women who presented for postabortion care in Malawi in 2009 were married and 64.8% were from rural areas. One-quarter (27.4%) presented with severe or moderate morbidity. Sepsis (13.7%), retained products of conception (12.7%), and fever (12.3%) were the most common complications. The case fatality rate was 387 deaths per 100 000 postabortion care procedures. Women with severe or moderate complications were significantly more likely to be from rural areas than from urban areas; to have reported interfering with their pregnancy; and to be separated, divorced, or widowed than to be single. Conclusion: In 2009, many women seeking postabortion care in Malawi presented with complications. Advocacy is needed to influence policies that will allow expanded access to safe abortion services for women of all ages and in all areas.
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In Burkina Faso, abortion is legally restricted and socially stigmatised, but also frequent. Unsafe abortions represent a significant public health challenge, contributing to the country's very high maternal mortality ratio. Inspired by an internationally disseminated public health framing of unsafe abortion, the country's main policy response has been to provide post-abortion care (PAC) to avert deaths from abortion complications. Drawing on ethnographic research, this article describes how Burkina Faso's PAC policy emerged at the interface of political and moral negotiations between public health professionals, national bureaucrats and international agencies and NGOs. Burkinabè decision-makers and doctors, who are often hostile to induced abortion, have been convinced that PAC is 'life-saving care' which should be delivered for ethical medical reasons. Moreover, by supporting PAC they not only demonstrate compliance with international standards but also, importantly, do not have to contend with any change in abortion legislation, which they oppose. Rights-based international NGOs, in turn, tactically focus on PAC as a 'first step' towards their broader institutional objective to secure safe abortion and abortion rights. Such negotiations between national and international actors result in widespread support for PAC but stifled debate about further legalisation of abortion.
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Objectives To investigate the use of manual vacuum aspiration in postabortion care in Malawi between 2008–2012. Methods A retrospective cross-sectional study was done at the referral hospital Queen Elisabeth Central Hospital, and the two district hospitals of Chiradzulu and Mangochi. The data were collected simultaneously at the three sites from Feb-March 2013. All records available for women admitted to the gynaecological ward from 2008-2012 were reviewed. Women who had undergone surgical uterine evacuation after incomplete abortion were included and the use of manual vacuum aspiration versus sharp curettage was analysed. Results Altogether, 5121 women were included. One third (34.2%) of first trimester abortions were treated with manual vacuum aspiration, while all others were treated with sharp curettage. There were significant differences between the hospitals and between years. Overall there was an increase in the use of manual vacuum aspiration from 2008 (19.7%) to 2009 (31.0%), with a rapid decline after 2010 (28.5%) ending at only 4.9% in 2012. Conversely there was an increase in use of sharp curettage in all hospitals from 2010 to 2012. Conclusion Use of manual vacuum aspiration as part of the postabortion care in Malawi is rather low, and decreased from 2010 to 2012, while the use of sharp curettage became more frequent. This is in contrast with current international guidelines.
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Health policy and systems research (HPSR) is a transdisciplinary field of global importance, with its own emerging standards for creating, evaluating, and utilizing knowledge, and distinguished by a particular orientation towards influencing policy and wider action to strengthen health systems. In this commentary, we argue that the ability of the HPSR field to influence real world change hinges on its becoming more people-centred. We see people-centredness as recognizing the field of enquiry as one of social construction, requiring those conducting HPSR to locate their own position in the system, and conduct and publish research in a manner that foregrounds human agency attributes and values, and is acutely attentive to policy context. Change occurs at many layers of a health system, shaped by social, political, and economic forces, and brought about by different groups of people who make up the system, including service users and communities. The seeds of transformative practice in HPSR lie in amplifying the breadth and depth of dialogue across health system actors in the conduct of research - recognizing that these actors are all generators, sources, and users of knowledge about the system. While building such a dialogic practice, those conducting HPSR must strive to protect the autonomy and integrity of their ideas and actions, and also clearly explain their own positions and the value-basis of their work. We conclude with a set of questions that health policy and systems researchers may wish to consider in making their practice more people-centred, and hence more oriented toward real-world change.
Article
As part of efforts to achieve Millennium Development Goal 5 – to reduce maternal mortality by 75% and achieve universal access to reproductive health by 2015 – the Malawi Ministry of Health conducted a strategic assessment of unsafe abortion in Malawi. This paper describes the findings of the assessment, including a human rights-based review of Malawi's laws, policies and international agreements relating to sexual and reproductive health and data from 485 in-depth interviews about sexual and reproductive health, maternal mortality and unsafe abortion, conducted with Malawians from all parts of the country and social strata. Consensus recommendations to address the issue of unsafe abortion were developed by a broad base of local and international stakeholders during a national dissemination meeting. Malawi's restrictive abortion law, inaccessibility of safe abortion services, particularly for poor and young women, and lack of adequate family planning, youth-friendly and post-abortion care services were the most important barriers. The consensus reached was that to make abortion safe in Malawi, there were four areas for urgent action – abortion law reform; sexuality education and family planning; adolescent sexual and reproductive health services; and post-abortion care services.
Article
Using qualitative data on post abortion care services at the Komfo Anokye Teaching Hospital in Kumasi, Ghana, the paper explored evidence of social stigma as a factor in post abortion care. Results from 6 focus group discussions, 10 narratives and observations identified three areas of stigma. The Patients (perspective and experience), the Providers (the medical environment and setting) and the Community (family, relations and peers). Evidence from the focus group discussions, narratives and observations suggested social stigma as a significant factor in the process of pre-marital sex, abortion and post abortion care. At the individual level there was fear, shame and embarrassment. The medical setting was judgmental, indifferent and/or showed disdain while there was moral consensus, the morality of abortion by family, peers and community. In recognition of the dangers inherent in unsafe abortion outside the medical setting and in view of the fact that death from complications of unsafe abortion is preventable, these findings have implications for intervention and policy. The paper recommended collective effort to addressing all three areas of stigma and post abortion care. Sustained education, sensitization and dissemination using all available channels including traditional teachings and practices to reduce stigma and provide safer alternatives were suggested.
Article
Background. Despite the proven efficacy of manual vacuum aspiration (MVA) for incomplete miscarriages its use is low in Swaziland, including Raleigh Fitkin Memorial (RFM) Hospital, Manzini. Uncertainty about the cost implications of introducing MVA to replace dilatation and curettage (D&C) is probably the major obstacle to change. Objectives. To evaluate the cost-effectiveness of introducing MVA as an evacuation method for first-trimester incomplete miscarriages, as well as assess the implications of the introduction of MVA for the entire post-miscarriage care budget at RFM Hospital. Methods. The methods comprised cost-effectiveness and budget-impact analyses from a healthcare perspective based on a theoretical cohort. Clinical outcomes data for procedures were obtained from the relevant literature. Costs were collated from prospective suppliers and then compared for the two treatment modalities. Future numbers of annual evacuations were extrapolated from previous annual figures. First-trimester miscarriages were in turn extrapolated from proportions found in previous studies. Total budgets were calculated under the current scenario, and for scenarios where MVA was introduced. Results. With initial capital costs of ZAR11 093.00, introduction of MVA for first-trimester incomplete abortions would cut postmiscarriage care costs by 34.7%. MVA would cost ZAR819.86 per procedure, while D&C costs ZAR1 255.40 per procedure. An estimated 26 MVA procedures done instead of D&Cs would compensate for the initial capital investment. Introduction of MVA into the postmiscarriage care programme would save the hospital about ZAR516 115.30 annually, with clinical outcomes at least similar to D&C. Conclusions. MVA should be considered as the first option in first-trimester post-miscarriage care.