Training providers. Postabortion MVA training requires a high level of technical assistance from experienced trainers, especially in the start-up phase. Later, on-going training and supervision help providers maintain skills and assure quality of care (186). Training usually involves a brief, intensive course on the basic steps of MVA, infection prevention, and family planning. For example, recent pilot projects in Egypt and Nepal tested models for introducing MVA, using 6-day, competency-based training programs for physicians. The Population Council provided training at two Egyptian hospitals, and the Johns Hopkins University Program for International Education in Reproductive Health (JHPIEGO) provided training at a maternity hospital in Nepal. Training focused on learning by doing, beginning with practice on anatomic models. After training, providers performed MVA under the close medical supervision of an experienced clinician during the first few months (103, 177). Currently, training programs in postabortion MVA have started in over 20 countries in Africa, Asia, and Latin America (186).

Site selection. Choosing the right site is important when first introducing MVA training. Key personnel at the chosen site must have a commitment to postabortion care and provide strong leadership in adopting new treatment protocols. Also, adequate training requires a high volume of abortion complication cases. Thus hospitals that already treat abortion complications are a logical choice for introducing MVA; staff can be trained to switch from using sharp curettage to MVA. In the Nepal pilot project, for example, the national maternity hospital was selected as the initial training site because 1,400 women a year seek treatment there for postabortion complications, and the hospital trains many medical personnel (177).

Treatment area. Hospitals may need to redesign their treatment areas and plan patient flow to avoid unnecessary delays and overnight stays. For example, performing MVA in a separate treatment room frees the operating room for other procedures (127). Also, because women need to be quickly and easily transferred from the admitting area to the MVA treatment area, its location in the hospital is critical. In Kenyatta National Hospital, for example, MVA was introduced in a procedure room directly opposite the admitting room (134). In Nepal the postabortion care unit was set up in a room adjacent to the admitting room (177).

Patient management. Because abortion complications range from simple to life-threatening, a triage, or screening system helps to manage the flow of patients so that each receives appropriate, prompt care. In the Nepal pilot project, for example, a flow diagram helped providers determine the severity of each woman's condition, using information from a brief reproductive history and a physical exam (177).

Equipment and supplies. While MVA requires little specialized equipment and few drugs, providers need to develop a system for continued resupply of MVA kits and other consumable items such as cotton, gauze, disinfectants, and soap; pharmaceuticals such as antibiotics, local anesthesia, pain medications; and intravenous fluids (293). Introducing MVA also requires coordinating with other hospital departments such as those in admitting, pharmacy, medical records, clinical laboratory, equipment and supply, and with surgical, obstetrical, and gynecological departments, so that each understands its role in the new treatment practices (177).