Our study showed an increase in the use of MVA and maintenance of MA rates since the establishment of a surveillance network of good practices for safe abortion (MUSA Network) in a university hospital. Being admitted in 2020 and having a lower gestational age were factors associated with increased use of MVA. A higher level of education was the only factor associated with a greater use of MA.
The choice of the uterine evacuation method influences the incidence of both short- and long-term adverse events. Efforts to replace uterine curettage with alternative methods are recommended in the WHO manuals . Adverse events from curettage can occur immediately, such as in cases of uterine perforation. One study evaluated 706 women who underwent laparoscopic sterilization shortly after the first trimester uterine curettage. Among them, the surgical team suspected that some uterine perforation could have occurred in 0.28% of the cases; however, the rate of perforation verified during laparoscopy was 1.98%, which was seven times higher than that expected . Complications of curettage can also be diagnosed. In a study that evaluated women who underwent hysteroscopy after 12 months of spontaneous abortion (86% performed curettage), the prevalence of synechiae was 19.1% . In addition to changes in the menstrual cycle, such as amenorrhea, it was estimated that 7–40% of women with uterine synechiae were infertile [22, 23].
Currently, MVA is considered the technique of choice for surgical uterine evacuation in pregnancies of up to 12 to 14 weeks. It is a quick procedure that can be performed in outpatient clinics using less complex anesthetic procedures [8, 13]. It has been emphasized that the replacement of uterine curettage by MVA reduces the mortality rate from 1.23–0.07% . A systematic review that analyzed complications related to MVA showed that less than 5% of women experienced hemorrhage without blood transfusion, less than 0.1% presented with uterine perforation or bleeding requiring blood transfusion, less than 0.5% were hospitalized, and only 3% had repeated aspirations, with no maternal deaths reported . These results show that the use of MVA instead of curettage should play a major role in the strategy of improving care during abortions and should be encouraged in all health facilities .
The WHO suggests that whenever possible, the uterine curettage procedure with a rigid instrument should be replaced by MVA ; however, curettage is still widely used in Brazilian hospitals . According to a national mixed methods study in Brazil, only 45% of women used MVA in legal abortion services . In Honduras, an initiative undertaken to increase the use of MVA at the expense of curettage has not achieved the desired success. 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 . 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 . 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]. In the present study, we found a significant trend toward an increase in the use of MVA after the installation of a surveillance network in which one of the initiatives is to hold regular team meetings, which highlights the role of initiatives that promote changes in clinical practices for patient benefit.
Among the alternatives to surgical procedures, MA is considered an effective procedure, with success rates between 75% and 90% [32, 33, 34]. In the present study, MA was performed in 11.54% of cases, and there was no increase in use even after the establishment of a surveillance network for good practice. For comparison and contextualization purposes, in the United States, uterine evacuation performed exclusively with medications was used in approximately 40% of all abortions in 2018, with most patients being up to 9 weeks pregnant . In Brazil, misoprostol is used for uterine emptying in hospitalized patients . In comparison to surgical procedures, MA takes longer to complete , leading to a longer hospital stay; thus, it may not be the first choice for women or doctors. Higher levels of education in women in abortion situations may increase the possibility of uterine evacuation using medication. Follow-up after MA is based on self-recognition of signs and symptoms [3, 15]; thus, it is possible that health professionals believe it is more secure to recommend it to women who may have a greater capacity for recognizing alarm signs. In our study, approximately 20% of women had a higher educational level, with a 2.3 times greater chance of receiving MA. These results are similar to those of Bolnga et al., who also reported a higher frequency of MA among women with a higher educational level .
This study had some limitations. First, it was a cross-sectional study; thus, a cause-effect relationship could not be established. Furthermore, it was not possible to differentiate provoked abortion from spontaneous abortion, except in cases of legal induction. Regarding MA, it was not possible to consider the influence of different doses of misoprostol used during the analyzed period. In addition, women had data analyzed only during the hospitalization period and were not followed up after discharge. However, we believe that the obtained results are valid. Recently, a Brazilian study showed that among Brazilian medical residents in Gynecology and Obstetrics, knowledge of MA is limited . Inadequate training of physicians caring for patients experiencing abortion can be an obstacle to the use of safe techniques for uterine evacuation. Our study highlighted that a surveillance network of good clinical practices can play an important role in medical education and help improve the quality of care provided to women.