Safe and unsafe medical technologies are used in everyday abortion care
Technologies considered to be safe and those that are considered risky were both used in abortion care practice. Most cases of induced abortion were conducted in for-profit private health acilities, using D&C technology, which is discouraged in the national policy guidelines. Although induced abortions were solely reported in the private health facilities, health workers from public health facilities transferred patients with induced abortion care needs to their own privately-owned facilities, where they delivered the service. MVA was largely used in public and non-profit making health facilities as shown- below (Fig. 1).
Classification does not make a technology safe
MVA, mainly used in public and not-for-profit facilities, was regarded as effective for inducing abortion in pregnancies under 12 weeks, and in completing abortion with retained products. MVA was considered inexpensive for both the health facility and atients, since nodrugs are used and a patient does not need hospitalization. However, many health workers considered it to be time-consuming, tedious and inefficient. Most reported that it took from 30 min to an hour, depending on whether tissue was retained in the uterus. Without adequate time and patience, the abortion would remain incomplete, with the risk of septicemia. Further, in for-profit facilities, MVA was perceived as ineffective, lacking the ability to aspirate particularly when gestational age was over 12 weeks:
“For us, we go for Continuous Medical Education (CMEs) and they want us to use MVA for abortion. But MVA cannot work well if the pregnancy is over three months. We do not use this system because it cannot aspirate the contents from the terus.”(Suzan, nurse - private health facility). Some patients returned to the health facility with complications as a result:
“You may think everything has been sucked out but three to four days later, you find the patient coming back with lower abdominal pain and with labor-like contractions, saying that: ‘I am bleeding things which are clots’. If there are no retained products, the patient would not have labor-like contractions.” (Walter, medical officer - private health facility).
Concern relating to the sterilization of MVA equipment was reported. Sterilizing MVA required experience and adherence to a systematic process of standard high-level decontamination, letting the instrument stay in a highly concentrated disinfectant for at least 20 minutes, and then washing it in sterilized or boiling water. However, few health workers could conduct adequate high-level decontamination to ensure that the MVA was safe to use on the next woman. They did not use timers when disinfecting and, at times, MVAs were left for too long in boiling water or in disinfectants such as jik (Consequently, the plastic technology lost its effectiveness. “Last week when we went for an outreach in a public facility, I saw a health worker trying to heat [the MVA] and then it was shrinking.” (Sarah, regional quality assurance officer). Further, sterilization was contingent on the availability of disinfectants, but supplies were irregular and well below facility supply based on activities in public health facilities:
“Here, we are expected to use at least 5 litres of jik every day because we have to decontaminate everything; because you find we are having fluids and blood all the time. But we are given only 2 litres. Sometimes you get 5 litres in a week.” (Loy, medical worker, district hospital).
MVA involves multiple components which need to be disassembled and reassembled during disinfection. However, not all interviewees could assemble the MVA to create the vacuum needed for aspiration. At regional quality assurance trainings, very few participants could assemble, use and disassemble the MVA to the satisfaction of the quality assurance officers, despite the fact that this was follow-up training on skills which, in theory, health workers already possessed.
Abortifacients
There are three pharmacological drugs commonly used in abortion care: Misoprostol, Mifepristone and Divabo. Although Misoprostol is licensed in Uganda to manage post-partum hemorrhage, it is also used in other conditions like treating ulcers and for inducing abortion. Misoprostol was most commonly reported as ideal for removing retained products of conception, especially after MVA. Health workers across different health facilities and participants in the regional training meetings all supported its use. Misoprostol and Divabo were delivered through not-for-profit facilities to enable women to procure abortions. Once abortion was induced using abortifacients, a woman then sought post abortion care at a public health facility. This practice was negatively sanctioned by some health workers:
“We got Misoprostol for managing PPH [post-partum hemorrhage] which is the biggest cause of maternal mortality here, and if we used it that way then it would be Ok. Unfortunately, people are using it for abortion” (District Health Official).
While considered to be very effective, Divabo was available only in non-profit health facilities; government facilities were not supplied with Divabo because of the government policy on abortion, while profit-making facilities were sidelined because the drug was not available to them. Besides supply challenges, Misoprostol was associated with incomplete abortion after induction due to errors in dosage, due to inadequate knowledge about the correct dosage among health workers, and women who self-administered the drug. Complications from the unsuccessful use of Misoprostol led to the need for other technologies.
Dilation and Curettage (D&C)
D&C is a surgical procedure involving the use of a set of instruments to remove the products of conception from the uterus, and is widely used in abortion care in private health facilities despite its discouragements. Health workers use D&C to open the cervix and then a curette to scrape the walls of the uterus and scoop out the products of conception. In non-profit health facilities, health workers had phased out this technology and did not use it for abortion care. In private health facilities nurses and midwives used D&C, and in public health facilities, it was used in emergency cases and only by medical doctors.
Choice and application of medical technologies shaped by fear and monetary incentives
In everyday practices of abortion care, both technologies classified as safe and those considered risky and discouraged by PAC guidelines were used. This study revealed that health workers in private health facilities considered D&C to be effective because it could be used regardless of gestational age, in contrast to MVA which should only be used on first trimester pregnancies. D&C was also considered speedy and effective. Induced abortion services were delivered largely for monetary gain and time-saving technologies mattered because of the need to reduce the risk of apprehension as the practice is restricted. One respondent added:
“The reasons for doing this [delivering induced abortion] on side of health workers is money, not that I am helping her just to abort. But in helping her, you hope to get something [money]. Those who come, we do not call them, no. They also come when they have their burdens, which they would like you to help them offload. So, even you who is helping her to offload the burden, you also expect something in return. In a way, I am earning a living” (Dan, male nurse-Private health facility).
“There is a lot of money in these cases more than other maternal health conditions; we would not handle these cases if it were not for money. They bring money and we handle the cases.” (Jacob, medical officer-private health facility).
Providing induced abortion care was considered worth undertaking because of financial benefits, notwithstanding the risk of arrest and loss of their practicing license, if apprehended. To navigate the restrictive and surveilling system in public health facilities, some health workers transferred patients with induced abortion care needs to their own private health facilities, where they delivered the service. After the procedure, treatment of patients depended on their financial ability. Poor patients were given painkillers and told to buy antibiotics from pharmacies once they had money. Many women, particularly young girls who presented for care, had no money.
D&C was considered time-saving technology, that minimized risk of apprehension during practice, and allowed health workers to operate on many patients in a short time. To many health workers, MVA took much time, and it was difficult to disinfect the equipment. MVAs were available in some profit-making health facilities but not used. MVAs were mainly used by health workers in non-profit health facility as these were monitored and regulated by non-state actors who promoted quality sexual and reproductive health services in the region.
Misoprostol and Divabo were used in non-profit health facilities but rarely by profit-making health facilities, as these made practice simpler and so, health workers with pecuniary interests found it difficult to convince patients to pay the finances they desired. Divabo was available in non-profit health facilities, but not in public and private health facilities. Thus, the choice and application of medical technologies was shaped by the ease with which health workers navigated the restrictive moral and policy context. Health workers acknowledged that risks occurred in the use of D&C in abortion care practice, and outcomes depended largely on the technical competency of the health worker. Perforations were reported even when an abortion was performed by a highly skilled doctor:
“We normally have these [perforation] cases. They are very many. Even now we have a case on our ward, and it was done by a doctor whom, we know was trained …when they did an ultrasound, they realized she had perforations.” (Jacob, medical officer-private health facility).
Participants in in-depth interviews indicated that induced abortion was conducted in fear of apprehension, triggering panic during operations. Moreover, this also inhibited consultations with other doctors. Many health workers had knowledge gaps about the anatomy of the uterus and lacked access to diagnostic technologies such as ultrasound scanners, and applied D&C without guidance, risking perforating the uterus, as the depth of the uterus was difficult to determine. Moreover, due to moral sensitivity and fear of stigmatisation, many patients delayed to report to a health centre for post-abortion care, returning only later with sepsis and necrosis, when their uterus then had to be removed to prevent loss of life. Often delayed cases were very young women who feared reporting, could not easily get permission from their parents, and lacked the resources for medical attention:
“There was a 16-year-old girl who got pregnant but went and had an abortion from wherever she went and she kept quiet, not knowing that the person who did it was maybe not skilled in it and they perforated the uterus. I think she stayed in the village for around a week. By the time she came here, she was discharging pus down there [vagina]. The uterus was perforated. She came with signs of intestinal obstruction, because, I think, in the process of conducting it [abortion], the thing (curette) passed through the uterus and someone pulled the guts. And by the time we intervened, she was already toxic. They resuscitated her, and they did an operation on Monday, but she passed away yesterday. Part of the gut was cut off. It was terrible!” (Faith, midwife-district hospital).
Ultrasound scanning technology a necessary component of medical technology in abortion care
Gestation and ultrasound gestation age is key to understanding the choice of technology for abortion. Determining the gestational age -conventionally estimated as the number of completed days after the onset of the last normal menstrual period - is important as the medical technologies accessible at primary care level are designed to induce and complete an abortion of a fetus under 12 weeks. Although MVA, D&C, and abortifacients are allowed only for use on fetuses under 12 weeks, often determining gestational age is difficult and most health workers rely on patients’ reports. Ultrasound technology allows for greater certainty of gestational age, but only two of the four health facilities had ultrasound technology on site; and health workers from one of these had access only once a week, on the day allocated for maternal healthcare. Health workers relied on information provided by patients to establish gestation age, and when this was inaccurate, the outcomes of the MVA were compromised. As one health provider noted, it was tricky to solicit reliable information from women seeking abortion care.
“Remember they are young people; they would not like to disclose that they are getting such conditions from this [abortion] problem. History taking becomes very tricky, they will never disclose. And if someone is not very good at doing physical examination, they may miss it [the complication resulting incomplete abortion]” (Kizza (pseudonym), medical worker- district hospital).
Without access to ultrasound, health workers relied on physical examination. Ultrasound was used for emergency abortion care rather than prior to abortion to determine method of termination. Moreover, patients were referred for ultrasound as an out-of-pocket expense to detect retained products of conception and uterine perforation, conditions associated with the prior use of MVA and D&C respectively. Ultrasound was not a technology for which health workers received training in quality assurance and training meetings; nor was there training on the interpretation of ultrasound images despite recognition of its value in diagnosing retained products of conception or confirming completion. Although ultrasound may not be needed for outcome assessment when treating incomplete abortion, clinical examination is inadequate without ultrasonography to evaluate tissue retention in patients with post-abortion bleeding.
Riskiness is an emergent outcome of care practice not necessarily objective condition of a specific technology
Drawing from observations and field data, riskiness in abortion care emerges out of conditions of fear of the restrictive law and policy which criminalizes aiding procurement of induced abortion, while motivated of pecuniary interests in care practice. Criminalization shapes abortion care outcomes in multiple ways in Uganda. First, health workers choose specific technologies which minimize the risk of exposure of practices that conflict with national abortion law. In health facilities where abortions were induced, health workers relied mostly on D&C technology because it was regarded as time-saving and effective. But criminalization increased the fear and tension in operations, thus affecting the efficiency and increasing the risk of an incomplete abortion or uterine perforation. Due to fear, health workers operated by stealth, limiting the possibilities of consultation when complications emerged. This deprived patients of the opportunity to benefit from wider specialist consultation, and increased the risks of severe morbidity, emergency surgery (such as hysterectomy), and death. Emergency case handling practices were designed to enable a health worker to escape the law, with the patient’s health and life apparently secondary. Practices such as abandoning patients, whisking them to, and leaving them at the gates of hospitals, and leaving bodies at morgues, reflect how patients are handled when abortion care is criminalized.
Criminalization compromises the ability of district health teams to monitor, supervise and regulate the use of medical technologies and practice of abortion and post-abortion care. Women and health workers act in collusion against state law and healthcare policy. Consequently, neither party reports the district health team, except when a woman’s health condition deteriorates dramatically; and quality of care is not regulated since there is no evidence of the practice. In the private health sector where induced abortion was most common, facility norms relating to terms of payment shaped the choice of technologies, again with limited regulation, supervision and monitoring. In contrast, in the social franchise clinics and public health facilities where the practice was supervised, there were positive outcomes. Therefore, while a restrictive legal regime increases the financial value of abortion care for individual health workers involved in its delivery, it deepens women’s vulnerability to poor health outcomes.
Motives and pecuniary interests
Financial motives shift attention from patient care outcomes to health worker interests. In applying medical technologies for induced abortion and managing complications from abortion, health workers have a range of motives and interests, including monetary. Contrary to the idea that medical technologies are favoured because of their efficiency, health workers from private health facilities preferred to use technologies with the greatest financial benefit. In this regard, despite the risk of uterine perforation, D&C was preferred. Health workers in private health facilities were paid according to the number of patients attended to per day. In addition, a patient’s care package was determined based on ability to pay. Health workers employed in public health facilities transferred patients to their private clinics for financial reasons while also protecting patient privacy and avoiding apprehension for criminal practice. Meanwhile, spontaneous miscarriages within private and public health facilities were treated as health conditions attracting fewer financial returns.
Financial motivations create opposing forces in abortion care practice as the duty to provide care was considered secondary to the material benefits to health workers providing abortion care. Many health workers saw service delivery as an instrument to meet financial goals, and accordingly women’s bodies were objectified as a means for financial benefits. Equally, medical technologies were interpreted in terms of their value for financial gain. According to Susan, a midwife in a private health facility, “there is no health condition which is more financially rewarding than abortion.” This assertion vividly illustrates that material conditions dominate the delivery of abortion care service. Financial incentives as a means of quality-of-care improvement have been institutionalized in maternal health care, through results-based financing and the introduction of voucher schemes [14]. In private healthcare facilities, institutionalization occurred through remuneration, based on the number of patients served in a day. Within the broader social and economic environment, health workers’ identities were evaluated according to their ability to meet personal, familial and collective responsibilities, less so their loyalty to medical professional ethics and values. These internalized conditions were invoked in abortion care, and the restrictive environment offered health workers an opportunity to exploit women in need of care.
Overall, medical technologies for abortion and abortion care are inscribed with restrictions on gestational age, local moralities and legislation. While some health workers adhere to the restrictions, others transgress them as they transgress the law on abortion. This increases risks and can lead to poor outcomes. Medical technologies and health worker actions are both interpreted according to the social and legal context in which they are used. This explains health workers’ emphasis on financial gains from abortion; because abortion is criminalized, health workers offset the risks of terminating and providing care for complications by direct financial gain. Classifying medical technologies as ‘safe’ and others as ‘risky’ and inappropriate to use in primary care settings does not make them risk-free. Not all practices involving ‘risky’ technologies, such as D&C, actually result in poor abortion care outcomes, and in Eastern and Southern Africa, D&C remains the preferred method of post-abortion care in hospitals. Elsewhere in Africa, other studies show that even technologies considered to be safe technologies can result in risk and injury such as perforations of the uterus [11,12]. Most importantly, medical technologies are used in combination depending on the nature of abortion care issues. Where MVA and Misoprostol fail to aspirate and evacuate all products from the uterus, resulting in incomplete abortion, D&C may be needed. Although the integration of midwives and nurses in abortion care delivery, in many contexts, leads to better abortion care outcomes, their practices are not immune to unsafe and risky conditions, particularly in legally restrictive environments.