___It's a very complicated issue here___: Factors contributing to the limited and declining use of Manual Vacuum Aspiration for postabortion care in Malawi A Qualitative Study of Health Workers Opinions

Malawi has one of the highest maternal mortality ratios in the world. Unsafe abortions contribute significantly to Malawi's maternal mortality and morbidity, where abortion is illegal except to save the woman's life. Postabortion care (PAC) aims to reduce the adverse consequences of unsafe abortions through emergency care, treatment of incomplete abortion, counseling and contraception. Manual vacuum aspiration (MVA) is recommended for treatment of incomplete abortion by WHO and national policies in Malawi. However, MVA usage in Malawi is low and decreasing, with sharp curettage being used in preference, but little is known about the reasons for this. Using Greenhalgh et al.'s (2004) framework of determinants of diffusion, dissemination and implementation of innovations in healthcare settings, this qualitative study aimed to investigate factors contributing to the limited and declining use of MVA in Malawi, adding to a limited research base about what influences rejection of recommended PAC innovations. The primary data collection method involved semi-structured interviews with health workers who provide PAC in a central hospital and a district hospital in Malawi. Findings and emergent themes were considered in four areas that may be influencing the limited and declining use of MVA: the outer context, the health workers, the organisation and the innovation. Abortion stigma and high rates of unsafe abortions and women presenting for PAC were highlighted as important contextual issues. Health workers described varying attitudes towards PAC. Staff shortages, social interactions, power dynamics and expected job roles create challenges for both PAC provision and MVA use. A lack of a sustainable equipment supplies was considered a major barrier to MVA usage; leadership, training, supervision and feedback and monitoring were also highlighted as important organisational factors. Finally, whilst benefits of MVA were acknowledged, health workers tended to prioritise personal risks and benefits to using MVA. The findings highlighted that these factors interconnect to influence the limited and declining use of MVA. Effective and sustainable PAC will require the consideration of all these factors as well as the wider context and a health systems approach.msc_srhunpub1863_ethesesunpu