nurses, which will require obtaining related instructional materials. Modifications in protocols for treatment will also be required. For example, healthcare providers should be trained in the use of appropriate pain-control measures since MVA usually requires different types and/or lower dosages of pain control than D&C. Incorporation of new procedures for achieving high-level disinfection or resterlization of the instruments will also be necessary.

# Patient-Management Issues

During this study, the process of data collection highlighted a number of issues associated with the way in which incomplete aborion patients were routinely managed in hospital settings. The results suggest that patient management is the primary factor that contributes to the different levels of resource utilization required for the two procedures, affecting the time patients spend in the hospital (cf. 23] as well as costs to the healthcare system. The findings from Ecuador show that technological change alone will not necessarily reduce the human and material resources required for the treatment of incomplete abortion. The maximum benefits of MVA are realized only when adoption of the technique is accompanied by changes in patient management, such as those suggested in this paper. Incremental benefits of MVA may be seen even when these changes are incorporated gradually.

Specifically, Lhie results from Ecuador show that inefficient patient-management protocols can negatively affect the time and cost data for MVA. In Ecuador, patients who were treated for incomplete abortion with MVA at two different hospitals (ECU2 and ECU5) had two very different experiences. At Hospital ECU2, patients had an average pre-evacuation wait of 2.39 hours; following the MVA procedure they remained in the hospital for an average of 10.58 hours for a total stay of almost 13 hours. Conversely at Hospital ECU5, patients waited an average of only 1.2 hours for treatment and remained in the hospital approximately 30 minutes folowing the procedure. This example suggests the importance of efficient management of the time women spend in the hospital but does not address the issue of quality of patient care which can be compromised at both ends of the time and cost continua.

Healthcare administrators should note that while many changes in patient management are not exclusive to MVA (i.e., improvements can be made in how both services are offered), many are facilitated by MVA. For example, both D&C and MVA procedures could theoretically be managed as outpatient services with similar resource expenditures. However, it is unlikely that D&C can be performed _more_ efficiently or at a _lower_ cost than MVA. D&C is a more institutionalized medical technique than MVA, and providers may be less inclined to move it from the operating-room setting where it has been traditionally practiced. MVA, on the other hand, was designed to be performed in an outpatient setting.

In this study, three interrelated management components were notable for their impact on patient flow. They were location of the evacuation procedure, the level of priority given to incomplete abortion patients and hospital discharge protocols. Following is a discussion of these factors along with suggestions about how the use of MVA combined with changes in hospital protocols and policies could improve the quality of abortion care as well as the utilization of resources.

_Location of the evacuation procedure._ In many hospitals, the operating room is a bottleneck for patient flow. This was especially true for D&C procedures in Kenya, where demands for operatingroom space and associated difficulties in scheduling resulted in long pre-evacuation waits (an average of 25.5 hours in Hospital KENI and 90.2 hours in Hospital KEN2). In Kenya, MVA was performed 18