Introduction

Estimates suggest that 208 million women worldwide become pregnant every year and approximately 25% of all pregnancies end in abortion [1]. One in two abortions, mostly in developing countries, is unsafe, leading to approximately 47000 yearly maternal deaths due to complications [1–3]. In Brazil, despite the National Abortion Survey showing a drop in abortion hospitalization rates [4], 200 women die annually from unsafe abortions. Furthermore, 20% of women up to the age of 40 have had an illegal abortion, half of whom were subsequently hospitalized for abortion-related complications [5–7]. Restrictive laws only permitting pregnancy termination in cases of sexual violence, risk of maternal death, or fetal anencephaly limit the provision of safe abortion, allowing avoidable morbidity and mortality to persist [7,8].

Improving women’s access to postabortion care methods is recommended by the World Health Organization (WHO) guidelines for reducing unsafe abortion [1,9,10]. The management of uterine evacuation is essential in comprehensive abortion care and reduces abortion-related complications. Further, it minimizes the costs associated with treating unsafe abortion complications [1,9,11,12]. Therefore, efforts to replace uterine dilatation and curettage (D&C), which is associated with a higher risk of uterine perforation and intrauterine synechiae, with alternative methods are recommended [10,13]. Medical abortion (MA) using pharmacological drugs such as mifepristone or misoprostol is safe and effective, is associated with fewer complications, avoids surgery-related risks, and is feasible in low-resource settings [9,14]. Additionally, the recommended surgical uterine evacuation technique is manual vacuum aspiration (MVA), which is safer, faster, less painful, and associated with fewer complications than D&C [15].

The method of uterine evacuation highlights the quality of a healthcare facility’s abortion care [16–18]. Respectful services and women-centered counseling provide positive experiences and reduce adverse abortion-related outcomes. In the decision-making process, women choose MA four times more frequently than other methods. For those who prefer surgical methods, MVA leads to fewer side effects and greater satisfaction than sharp curettage [15]. Monitoring these indicators for safe abortions enables assessment of disparities in the quality of care provided to these women.

Ensuring a standard in abortion healthcare services may identify which evidence-based practices should be prioritized for data collection [10]. Surveillance systems can improve the quality of care and help countries monitor and evaluate programs aimed at preventing unplanned pregnancies as well as maternal morbidity and mortality. Moreover, abortion surveillance programs can track changes in clinical practice patterns and provide the data necessary to inform health policies [10,16,18]. In a previous study, we demonstrated how the use of a surveillance system increased contraceptive use before discharge in women hospitalized for abortion complications [19].

In Brazil, even with a decrease in abortions, almost 70% of all pregnancies are unplanned [4,20]. Restrictive laws increase the burden of unsafe abortions, which remain an important health issue [21]. The method of uterine evacuation impacts abortion safety provision, and monitoring clinical practices over time is necessary to improve postabortion care and foster improved public policies [1,10,19]. Therefore, this study aimed to evaluate the frequency of MVA and MA use in a hospital in Brazil and identify factors associated with the method of uterine evacuation after the implementation of a surveillance network.

Methods

Results

During the study period, 474 women with a mean age of 30.01 (± 7.48) years and median age of 30 (12–48) years were enrolled. The mean gestational age was 11.03 (± 3.56) weeks, and 30.38% of the women had not previously been pregnant. Most women did not use contraception (75.5%), and 69.85% of the pregnancies were unplanned. Of the 474 cases, 67 (14.1%) were legal abortions, and 66 of the 67 (98.5%) pregnancies resulted from sexual violence. Details of the patients’ clinical and sociodemographic characteristics are presented in Table 1.

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Table 1. Clinical and sociodemographic characteristics (n = 474).

https://doi.org/10.1371/journal.pone.0296009.t001

During the evaluation period, 433 (91.35%) women underwent uterine evacuation. The most common method was D&C, which was performed in 341 patients (78.75%). MVA was performed in 41 (9.46%) women, and MA using misoprostol was administered to 50 women (11.54%). At least one complication was observed in 24 of the 474 (5.06%) women, all of whom underwent D&C. Over the course of the surveillance period, we observed a significant increase in the use of MVA (Cochran–Armitage test: Z = 9.85; p < 0.001); however, no difference in the use of MA was observed (Z = 1.35; p = 0.178) (Fig 1).

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Fig 1. Methods of uterine evacuation between July 2017 and November 2020 by trimestral period.

Captions: MVA- manual vacuum aspiration; MA- medical abortion Cochran-Armitage test: MVA: Z = 9.85, P <0.001; MA: Z = 1.35; P = 0.178.

https://doi.org/10.1371/journal.pone.0296009.g001

Considering the factors associated with MVA, the procedure was performed more frequently in women with a lower education level (p = 0.04), those admitted in 2020 (p < 0.01), and those with no previous pregnancies (p < 0.01), lower BMI (p < 0.01), lower gestational age (p = 0.03), shorter symptom duration (p = 0.02), and higher hemoglobin levels (p = 0.04). In the multiple logistic regression analysis, admission in 2020 (odds ratio [OR] 64.22; 95% confidence interval [CI] 3.79–1086.69) and lower gestational age (OR 0.837; 95% CI 0.724–0.967) were independently associated with MVA. Regarding MA, women with a higher education level underwent this procedure more frequently (p = 0.03). Furthermore, the regression analysis revealed that a higher education level was the only factor independently associated with MA (OR 2.66; 95% CI 1.30–5.46) (Table 2).

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Table 2. Factors associated with uterine evacuation method (n = 381)^a.

https://doi.org/10.1371/journal.pone.0296009.t002

Discussion

The present study describes the uterine evacuation methods performed at a university hospital with an established surveillance network that encourages safe abortion practices (the CLAP MUSA-Network). During the observation period, MVA use increased, while the rate of MA remained unchanged. Women admitted in 2020 and those with a lower gestational age had an increased likelihood of undergoing MVA. In contrast, a higher level of education was associated with MA use.

In surgical abortion, replacing D&C with MVA is the key to preventing unsafe abortions [1,16]. Nevertheless, D&C is the second most frequently performed obstetric procedure in Brazilian public health facilities after vaginal delivery [20]. According to a national mixed methods study, only 45% of women who used legal abortion services underwent MVA [24]. Furthermore, several initiatives to replace D&C have not achieved positive results, differing from our findings. No overall improvement in MVA frequency was observed in Honduras and Malawi’s postabortion care, mostly because of the reluctance of healthcare providers to abandon D&C [25,26]. The present analysis shows a significant trend toward increased MVA use following implementation of the MUSA Network. Although the rate of MVA use was relatively low (9.46%) for most of the evaluation period, we observed a considerable increase in the final 6 months of the study, with the rate exceeding 60% in the last 3 months of 2020. The CLAP MUSA-Network promoted regular scientific meetings with other sentinel centers, reinforcing the importance of safe abortions and improving medical staff training. Nevertheless, we observed a relatively long period before the routine use of MVA was established in the hospital. We believe that this is because the hospital administrative team should also have been made aware of the use of safer uterine evacuation techniques. The meetings promoted by the CLAP MUSA Network were essential for raising awareness among the health unit’s management team to ensure the acquisition of hospital supplies necessary to routinely perform MVA on a permanent basis. This finding supports the idea that monitoring clinical care promotes and improves comprehensive abortion care [23,27]. Similar to our study, institutions in Bangladesh have also used monitoring to evaluate the progress achieved in replacing D&C with MVA and MA [28]. Additionally, the routine Abortion Surveillance program in the United States reports on the use of different methods to analyze the safety of abortion practices and has fostered a reduction in unplanned pregnancies [27].

MA is considered an effective alternative to surgical procedures, with a success rate of 75–90% [28,29]. In the present study, MA was performed in 11.54% of the patients, and no increase in its use was observed during the study period. In the United States, approximately 40% of all abortions in 2018 were performed exclusively using medication [27]. In Brazil, mifepristone is not available, and misoprostol is only used for uterine emptying in hospitalized patients [8]. Compared to surgical procedures, MA takes longer to complete and requires a longer hospital stay; thus, it may not be the first choice for women or medical professionals [1,12].

Follow-up after MA is based on the self-recognition of signs and symptoms [6]. Healthcare professionals might believe it is safer to recommend MA to women who may more readily recognize warning signs, preemptively seek medical services, and have a better understanding of the choices available [30]. In our study, approximately 20% of the women had a higher education level and a 2.3-times greater chance of receiving MA. Although we did not evaluate the decision-making process regarding the abortion method, other studies have reported similar results. Even when the procedures were performed by the same organization and professional, women who chose MA had a higher level of education [31,32].

This study has some limitations. First, the cross-sectional nature of the study means that a cause-and-effect relationship could not be established. Second, differentiating between provoked and spontaneous abortions was not possible, except in cases of legal induction. Regarding MA, the use of misoprostol in Brazil is restricted to the hospital setting, which prevents dispensation for home use. It was not possible to consider the influence of the misoprostol dosage used during the study period. Finally, the patients were only analyzed during hospitalization and were not followed up after discharge. Although the uterine evacuation methods are discussed with patients, the final decision lies with the responsible doctor. Nevertheless, we believe that our results are valid. The implementation of the CLAP MUSA-Network for the surveillance and implementation of good clinical practices has ensured the monitoring of clinical decisions inside institutions and promoted healthcare providers’ ongoing education, leading to a reduction in the use of D&C. The provision of safe abortion methods is central to the WHO and FIGO goal for equitable access to abortion care and improved women’s reproductive health [10,16].

Being part of a network that encourages the use of evidence-based clinical practices provides an opportunity for healthcare facilities to set priorities, evaluate outcomes, and implement policy changes to improve safe abortion access. Continuous monitoring of therapeutic indicators and medical education can help reduce abortion-related morbidities and mortality, and address the healthcare needs and rights of women.