Malawi could end the horror of unsafe abortion, but religion and parliament stand in the way.
Restrictive laws are not deterring women and girls from seeking abortions. Instead, they are pushing them towards clandestine procedures, which often cause complications and even death. Meanwhile, emergency healthcare for tens of thousands of survivors also drains public resources. It is easy to see why Malawi’s Ministry of Health would like to see safe abortion provided where necessary. But religious groups and parliament remain obstacles.
On a cold morning in 2021, Chrissy*, a 24-year-old domestic worker in Blantyre City, writhed in unbearable pain, which she insisted were severe menstrual cramps. Her agony intensified even after she took home remedies and over-the-counter painkillers. As Chrissy’s pain and bleeding became uncontrollable, her employers rushed her to the hospital. There, clinicians discovered that she had clandestinely terminated a pregnancy, leaving behind remnants that were causing severe complications. Despite medical evidence of an unsafe abortion, Chrissy adamantly maintained her claim that she had merely “missed her periods”.
This case is a poignant reminder of the urgent need for comprehensive reproductive health education, increased access to contraception, and safe abortion services in Malawi. Perhaps above all in this conservative country, there needs to be less of the abortion stigma that forces young women like Chrissy to risk their lives and feel they must hide their trauma. While Malawi’s government seems to be moving towards ending this nightmare, religious groups and parliament still stand in the way.
Scared and in denial
As it is, unsafe abortion tragedies continue to overwhelm post-abortion care (PAC) providers within Malawi’s healthcare system.
Several healthcare workers told the Platform for Investigative Journalism Malawi (PIJ) that they have provided PAC to girls as young as 13, and have witnessed preventable deaths because patients delay seeking medical care. They are concerned that, due to limited access to sexual and reproductive health information and services, many girls and young women – like Chrissy – don’t know how to avoid pregnancy. Confused, scared, and in denial after falling pregnant in a situation where they feel they cannot talk to or ask advice from anyone, they eventually attempt to terminate pregnancies that are three to four months old.
“A majority of the women and girls who come for PAC have had unsafe abortions, but they usually refuse [to disclose details] if asked… Some are married, but most are schoolgirls who either come with friends or alone,” says a PAC provider who asked to remain anonymous.
Most patients arrive in a life-threatening state
According to the caregiver, most patients arrive in a life-threatening state. “Some come with decomposed placenta issues… We assist them as an emergency,” he notes. A decomposed placenta in the uterus can cause serious infection, which in turn can be deadly.
The methods used in clandestine abortions are in themselves often dangerous. The PIJ was told about women and girls who drink washing powder or herbal concoctions, or who insert cassava sticks and hangers (among other sharp materials) into their bodies to terminate pregnancies.
A PAC provider at a rural health centre reports handling about six post-abortion cases each month. “They usually present with heavy bleeding and tend to hide the cause. We just manage them and refer patients with complications to the district hospital,” she says.
Recently, this skilled healthcare worker assisted a 40-year-old woman who had been bleeding for weeks due to an unsafe abortion. “We conducted manual vacuum aspiration to clean her womb, but we still referred her to the district hospital because she lost a lot of blood,” she explained. The provider says she frequently receives requests for safe abortions, but health workers’ hands are tied by the country’s abortion laws, which only permit abortion to save a woman’s life. “I once got three of such demands in six months,” she states. “There are likely more cases that go undocumented in health facilities.”
Logbooks
The practice of documenting the cases does, however, seem to be gaining ground. Logbooks in health facilities show tens of thousands of PAC cases nationwide from 2020, with a steady increase to 58,000 in 2022. Hawa Shabir, a programmes officer for the NGO Go Fund a Girl Child, attributes the increase to publicity around the issue and the increased likelihood of reporting on such cases. “The increase doesn’t mean that women and girls are deliberately having unsafe abortions to access PAC. Unsafe abortion has always been a reality, but it’s only in recent years that we are openly discussing it,” observes the Mangochi-based youth rights activist.
Disinfectant and pain-relief are in short supply
The 58,000 recently noted cases may only be the tip of the iceberg, most of which remains buried under stigma, secrecy, and undocumented deaths. Research conducted by the US Guttmacher Institute and the Malawi College of Medicine (CoM) in 2017, for example, concluded that more than 141,000 pregnancies were clandestinely terminated in Malawi in 2015 alone.
Sadly, improved documentation does not equal improved care. Malawi’s hospitals and clinics are generally not well equipped to save the lives of girls and women brought in bleeding. PIJ was told that PAC equipment, which needs to be sterile to prevent dangerous infections, is sometimes left unsterilised due to frequent shortages of disinfectant in health centres. PAC providers stated that, in the absence of disinfectant, staff are often forced to wash their equipment with soap instead. “This creates a fertile ground for infections since the uterus is very sensitive,” one said. Additionally, the procedures are often extremely painful due to stockouts of pain-relief medication. (See also this earlier ZAM article on mismanagement and corruption in health structures in Malawi).
It is difficult to find estimates of the numbers of girls and women who die yearly after unsafe abortions. A commonly used figure, including by the Health Ministry, is that 18% of all maternal deaths are attributable to this cause. With maternal deaths per year hovering around 1,100-1,200, this would indicate between 70 and 150 abortion-related deaths in Malawi per year.
Colonial legacy
Malawi’s abortion laws are a legacy from British colonial rule. Although the country gained independence in 1964, it still upholds several colonial-era laws, including sections 149-151 of the Penal Code, which prohibit attempts to procure an abortion except when the woman’s life is in danger. Specifically, Section 149 states that anyone who attempts to cause a miscarriage through “administering poison, using force, or any other means” shall be “guilty of a felony and liable to imprisonment for up to fourteen years.” Section 243 allows surgical operations only if they are necessary to save the life of the mother. Section 150 of the Penal Code stipulates that anyone who unlawfully procures, administers, or aids in an abortion is “liable to seven years” in prison. Section 151 imposes a three-year jail sentence on “anyone who supplies commodities” for illicit abortion.
Pressure delays the new bill
Malawi’s government has long planned to change these laws. In 2012, then-President Joyce Banda appointed a Special Law Commission to review the old laws, following a request from the Ministry of Health aimed at reducing pregnancy-related deaths. The commission, comprising doctors, lawyers, faith leaders, and chiefs, evaluated local evidence and policies in conjunction with international treaties, and visited several African countries for guidance. After nationwide consultations and a thorough analysis of the situation, the commission in 2015 recommended expanding the grounds for legally permissible abortion. If passed, the proposed Termination of Pregnancy Bill would grant women the right to seek an abortion (1) if the pregnancy results from rape, defilement, or incest; (2) to preserve their physical and mental health; and (3) if the foetus is severely malformed.
MAPUTO PROTOCOL
In May 2005, Malawi ratified the Maputo Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa, which guarantees comprehensive sexual and reproductive health rights, including safe abortion. Article 14 of the African Union protocol, signed in Mozambique’s capital, guarantees the right to seek safe abortion under circumstances such as rape or incest, or where the foetus is non-viable, or where continuation of the pregnancy endangers the woman’s mental or physical health. As a state party to these continental standards, Malawi is obligated to permit abortion on the grounds listed; however, colonial-era laws, conservative pressure, and administrative barriers continue to impede women’s access to safe abortion services.
“Difficult and costly”
The Ministry of Justice and Constitutional Affairs recommended in March 2016 that the proposed abortion law be debated in parliament. But it would still take until 2021 before Chiradzulu East MP Mathews Ngwale volunteered to table the bill for debate – and even then, parliamentarians rejected his proposal. The government, under pressure from religious groups, has not tabled the new law for discussion again.
But the issue has not gone away, neither in terms of suffering nor – an important consideration for the government – in terms of financial cost. Echoing a 2015 study, estimating that access to safe abortion could reduce post-abortion care costs by 20–30 per cent, Ministry of Health spokesperson Adrian Chikumbe said in response to PIJ questions that “delays in seeking medical services (post-abortion)” make the treatment of complications “difficult and costly.”
Chikumbe, while counting how many patients seek PAC in Malawi weekly in health centres and district hospitals, added that “most clients who have complications from abortions are poor and reside in rural areas,” and that the scourge also places a burden on the economy. “They miss out on economic activities when they are sick or admitted until recovery.”
Whereas, according to MoH procedures pricing, post-unsafe abortion care could run into over US$1,000 per patient, a safe abortion in early stages of pregnancy could be done for a quarter of that amount, and would result in much less death, states Chris Kandionamaso, a health system adviser for the Malawi branch of IPAS, an international NGO that seeks to increase access to safe abortions and contraception. Kandionamaso adds that Malawi’s restrictive abortion laws also contradict the 2013 Gender Equality Act, which guarantees every woman and girl access to comprehensive sexual and reproductive health services, and that these laws violate their human rights.
“Forced pregnancy is an issue of violence”
“There is unequal access to healthcare, which hinders women’s ability to make decisions about their own bodies, going against the principles of gender equality,” he says. The IPAS official further observed that forcing women to carry unwanted pregnancies to term is an issue of violence against women, especially in cases of forced pregnancies. “This can have severe physical, emotional, and psychological consequences for women, undermining their ability to live free from violence and coercion – a fundamental aspect of gender equality.”
CLAUSES FOR THE CONSERVATIVES
Malawi’s proposed new Termination of Pregnancy Bill is designed to appease conservative and religious groups as much as possible. It allows health workers to refuse to perform abortions, except in cases where the woman’s life is in danger. It mandates counselling before and after abortion services, including family planning guidance. It further grants parents and legal guardians the authority to approve or reject the procedure for minors, unless the service provider determines that the proceeding is in the child’s best interest.
Responding to conservative concerns in the country, Hawa Shabir of Go Fund a Girl Child explains that “advocating for more grounds to be added to the current pregnancy termination options doesn’t mean health facilities will terminate every unwanted pregnancy.” But more flexibility is required, because “if a girl or woman has been raped, their psychological well-being is compromised due to trauma. And if a pregnancy results from incest, the biological makeup of the child is compromised.”
Josephine Chinele is a multi-award-winning investigative journalist who has worked for newspapers, radio, and television platforms in Malawi, Tanzania, and South Africa, and as a fellow for the Los Angeles Times in the USA amid other international journalism fellowships. She is passionate about sexual reproductive health and rights issues, having reported on the topics for over 15 years.
This article is republished in edited form with permission from the Platform for Investigative Journalism Malawi. See the original here.
