Quantitative Results
Demographic data
A total of 400 participants from the three sites were enrolled: 200 participants from Bwaila hospital in Lilongwe, and 100 participants from each of the district hospitals of Mchinji and Salima. The main demographic characteristics of the participants are shown in table 1. The largest group of the study participants 127 (31.8%) were in the age group of 20-24 years; 176 (44%) participants had secondary education, followed by 168 (42%) who had primary education; 304 (76%) were married; 332 (83%) had their first abortion and 263 (65.8%) had a planned pregnancy.
Table 1: Demographic characteristics of participants treated with misoprostol for incomplete abortion in Malawi 2020.
Characteristics of women
|
Frequency (%)
|
Age in years
|
|
15-19
|
64 (16)
|
20-24
|
127 (31.8)
|
25-29
|
92 (23)
|
30-34
|
74 (18.5)
|
35 and above
|
43 (10.8)
|
Total
|
400 (100)
|
Completed education
|
|
Did not attend school
|
34 (8.5)
|
Primary
|
168 (42)
|
Secondary
|
176 (44)
|
Tertiary
|
22 (5.5)
|
Total
|
400 (100)
|
Marital Status
|
Single
|
81 (20.3)
|
Married
|
304 (76)
|
Divorced
|
7 (1.8)
|
Widowed
|
8 (2)
|
Total
|
400 (100)
|
Number of abortions (previous and current)
|
1
|
332 (83)
|
2
|
59 (14.8)
|
3
|
9 (2.3)
|
Total
|
400 (100)
|
Planned pregnancy
|
Yes
|
263 (65.8)
|
No
|
137 (34.3)
|
Total
|
400 (100)
|
The majority of women 233 (58.3%) reported no problems with the treatment. However, 167 (41.8%) participants reported having experienced some side effects of misoprostol, such as: lower abdominal pain 76 (33.8%); diarrhoea 35 (15.6%); nausea 28 (12.4%); heavy bleeding 26 (11.6%); mild fever 19 (8.4%); high fever 17 (7.6%), and other problems 24 (10.7%).
As shown in Table 2, most participants 380 (95.2%) reported having received support from the health care workers and 384 (96.2%) said the support offered was helpful. In total, 249 (62.3%) of the participants were offered family planning services. Furthermore, 376 (94%) of the participants expressed satisfaction with the support they received from health care workers. Similarly, 374 (93.5%) participants were satisfied with misoprostol as treatment for incomplete abortions. In addition, a majority of participants, 359 (89.8%) reported to have been given clear instructions on the treatment.
Table 2: Support offered to women with incomplete abortions in 3 public hospitals in Malawi, 2020.
Area
|
Response
|
Frequency
|
Percentage
|
Support offered by the health care workers
|
Yes
|
380
|
95.2
|
No
|
19
|
4.8
|
Total
|
399
|
100
|
Type of support offered
|
Medication
|
384
|
96
|
|
Counselling
|
190
|
47.6
|
|
Ultrasound scanning
|
53
|
13.3
|
|
Total
|
627
|
156.9
|
Rating of the support offered
|
Very helpful
|
119
|
29.8
|
Helpful
|
265
|
66.4
|
Not helpful
|
15
|
3.8
|
Total
|
399
|
100
|
Level of satisfaction with care received
|
Extremely satisfied
|
112
|
28.0
|
Satisfied
|
264
|
66.0
|
Dissatisfied
|
13
|
3.3
|
Extremely dissatisfied
|
11
|
2.8
|
Total
|
400
|
100
|
Offered a family planning service
|
Yes
|
249
|
62.3
|
No
|
151
|
37.8
|
Total
|
400
|
100
|
Time when family planning service was offered
|
Immediately
|
138
|
55
|
|
One week after treatment
|
103
|
41
|
|
Later than a week after treatment
|
10
|
4
|
|
Total
|
251
|
100
|
Most participants, 361 (90.3%), indicated that medical management was better for them than surgical management. In addition, when questioned about their opinions and feelings on the treatment received, more participants regarded medical treatment as the most reliable, and that it should be routinely used. Furthermore, 25.5% of the participants considered the drug to have many benefits for the woman’s health as shown in Table 3. The majority of participants 364 (91%) indicated that they would recommend medical treatment for incomplete abortion to friends.
Table 3: Opinions of women after medical treatment of incomplete abortion in public hospitals in Malawi, 2020.
Opinion
|
Frequency (%)
|
Medical treatment is the most reliable treatment and should be used routinely.
|
176 (44.0)
|
Medical treatment has many benefits on the mother’s health.
|
102 (25.5)
|
I am undecided about my views on medical treatment.
|
69 (17.3)
|
Medical treatment has undesirable side effects that suggest the need of caution in its use.
|
46 (11.5)
|
Medical treatment is dangerous and should not be used.
|
7 (1.8)
|
Total
|
400 (100)
|
Qualitative Results
Three major themes emerged from the data: ‘experienced effects of misoprostol’, ‘support offered to women by health care workers’, and ‘perceptions of women after taking misoprostol’. The themes and subthemes are presented in Table 4.
Table 4: Themes and sub-themes on perceptions and experiences of women who were treated with misoprostol, 2020.
Theme
|
Sub-themes
|
Experienced effects of misoprostol
|
Experiences after taking misoprostol
Perceived benefits of misoprostol
|
Support offered to women by health care workers
|
Medication
Advice on family planning
Advice on possible drug effects and follow-up
|
Perceptions of women after taking misoprostol
|
Feelings of satisfaction with treatment
Opinion on the use of misoprostol
|
Experienced effects of misoprostol
The participants experienced medical treatment of abortion in different ways. They described signs and symptoms of bleeding, pain, and expulsion of the products of conception. They acknowledged the positive effects of the drug as well as treatment failure, and adverse effects.
Experiences after taking misoprostol
After taking the treatment, women experienced different effects of the drug. Most of the women reported experiencing effects such as abdominal pain and backache after taking the drug. In addition, the majority of women experienced mild to moderate bleeding and some women reported passage of products of conception some hours after taking the drug.
“After I placed the drugs under my tongue it took some hours then I started experiencing backache. I was feeling like labour [pains], when labour was established it took some time then later I started bleeding” [responder 2].
“I was passing blood only but when I checked on the pad, the pad had some clots this happened after I took the drugs and also the time I went to the toilet I heard that I dropped two things but I didn’t had a clue of those things” [responder 4].
Drug side effects are common; almost every drug has some undesirable effects. A few women experienced some side effects of misoprostol, some experienced shivering, headache, fever, feeling cold, diarrhoea, vomiting and heart palpitations.
“I felt cold, Shivering, headache, Fever…. I took the drugs around 2 in the afternoon, I started feeling cold, having fever, shivering, then at 3 am I had diarrhoea then I started bleeding then it was already morning of the other day” [responder 1].
Drug failure was reported by some women who took the treatment. Despite the majority reporting benefits of misoprostol, some women indicated that though misoprostol was their preferred treatment, their problems were still not resolved after treatment. Some were still experiencing abdominal pains, others were still bleeding, and others reported having foul-smelling discharges.
“The help was adequate but am still having the problem, it’s not resolved yet… after taking the drugs I was passing out foul discharges and was still experiencing abdominal pains then I came back here. …, I have finished the drugs last week but am still having the same experience with no improvement” [responder 1].
It was revealed that the drug was not always available at the hospital pharmacy and patients were asked to buy the drug from local pharmacies, where the drugs could be of substandard quality. The women indicated that the lack of drugs in hospitals and procurement of counterfeit drugs was a possible reason for failed treatment.
“There were no drugs here I had to buy somewhere so I think I was not given the right drugs because I stopped bleeding but now has started again” [responder 9].
Perceived benefits of misoprostol
Women in this study highlighted a number of benefits of medical treatment. The majority indicated that the treatment received at the hospital was helpful and adequate. They indicated that misoprostol addressed their needs as their wombs were evacuated without problems. More benefits of medical management such as pain relief and prevention of infection were reported by a number of women. Many women report a lot of pain when going through an abortion. In this study, it was reported that the abortion was not as painful because they experienced relief from abdominal pain after taking the treatment.
“The treatment that I was given was perfect because they issued drugs which helped to clean up my womb and the other drugs which helped me that, my womb should not be infected …The drugs helped me in such way that I didn’t feel any pain at all” [responder 4].
People have treatment preferences when ill. When asked about their preferred treatment, most women reported that given a choice, they would prefer to be treated using misoprostol over surgical management. Even those that had no previous abortion preferred misoprostol. The most cited reason was fear of pain associated with a surgical procedure.
“I feel like they should continue to use this method of drugs I have heard that other methods are so painful… The best is the drug because when it start working in the body all things come out at once” [responder 7].
Even though the majority of women preferred misoprostol, one woman indicated that she preferred surgical procedures regardless of the pain that comes along with the procedure.
“Better surgical procedure though it is painful” [responder 16].
Perceptions of women after taking misoprostol
Feelings of satisfaction were noticeable as some women reported that they did not bleed a lot after receiving the drug and that there was an improvement in their condition.
“I was satisfied with the help I received” [responder 3].
“My views are; these drugs are very effective the way I was and now there is an improvement and the bleeding has stopped” [responder 20].
Sentiments of dissatisfaction were also uttered by participants. Some women indicated that though they received the medication, nothing had changed; they were still facing problems and hence were not satisfied with the use of misoprostol. The treatment failure was reported by a few participants who reported back to the clinic for review after noticing that their problem was not resolved after taking the medication.
“I… finished the drugs last week but am still having the same experience with no improvement. … I feel like I didn’t get the right treatment because I am still having abdominal problems, I would have loved if the remains of conception were expelled” [responder 1].
When asked if they would recommend the treatment to their friends with a similar condition, some women indicated that they would advise friends to choose the drug (misoprostol) as they felt that the drug is effective and easy to use.
“… if I can find a person with the same problem I can advise her to go to the hospital so that she can receive the same treatment that I got and also my body is very light now”. …“These drugs should not stop being given so that those people who have the problem similar to mine should be helped as well” [responder 11].
Support offered by health care workers
Medication
Patients receive different forms of support from the health care workers when they visit the hospital. When asked about the support received from health care workers, most women reported that they received drugs such as misoprostol, antibiotics such as doxycycline and metronidazole or amoxicillin, and analgesics such as paracetamol or ibuprofen. The women were also advised on when, how, and for how long they should take the drugs. Some were advised to take misoprostol at the hospital. Some were advised to go home before they took misoprostol, as they could start bleeding before reaching their homes because no sanitary pads were provided at the hospital.
“When I came here I was given drugs which I placed under the tongue and they also gave me flagyl [metronidazole] and DCN [doxycycline] and did scanning, … I was told that the drugs which I was placing under the tongue, should be placed after an hour that’s all” [responder 1].
“I was told to take those drugs which I was given all of them according to instructions and that if I will not take the drugs my womb can get infected the medical personnel will remove it and another drug was Panado” [responder 15].
Advice on family planning
In addition to medication, the women reported that they received advice on family planning in particular, pregnancy spacing and modern family planning methods. They were advised to wait for six months before they became pregnant again. A few women cited that they never received advice on family planning:
“They didn’t tell me anything” [responder 18].
“They said I should get family planning method otherwise I will get pregnant again and there are several methods orals, Injections, Norplant” [responder 17].
Advice on possible drug effects and follow-up
Advice on possible side effects of the drug and when to return for follow-up visit at the clinic was also given. The women indicated that the health care workers supported them with information on what to anticipate after taking misoprostol. They were informed that they could experience side effects like shivering, mild fever, diarrhoea, nausea, and vomiting. Furthermore, they were advised to report back to the clinic immediately if they experience problems or after one week if they do not experience any problems.
“Was told that I would expect nausea/ vomiting, diarrhoea, dizziness but nothing happened to me” [responder 8].
“I was told that I should be admitted but after I pleaded with them they gave me drugs that I should take when I get home and was told I should come back after a week for review” [responder 9].