Silent killer: Unsafe and clandestine abortion crisis in Malawi

* Goes with it unplanned cost of an estimated US$314,000 annually to treat post-abortion health care

* Transition to safe and legal abortion would yield an estimated cost reduction of 20%-30%

* Yet review of the Termination of Pregnancy was completed and gazetted as a government Bill way back in 2017

Feature by Duncan Mlanjira

Abortion in one way is illegal but termination of pregnancy is legal — but it goes with it some restrictive conditions, which deny women and girls liberty to abort unplanned pregnancies and they resort to still go ahead through clandestine and unsafe abortion.

This has created a huge crisis in Malawi and from surveys done, each year, over 141,000 women and girls have abortions — almost all clandestine and the figure is likely to be higher because there are no records for those who successfully carried out the process.

The official figures are mostly obtained from government health facilities and from yet to be verified reports, there are many more women of affluent status, who have sought abortion services in private health facilities — again clandestinely.

When the women’s clandestine abortions goes awry, they rush to hospitals, especially the rural poor, who have to be treated for complications since the government allows for post-abortion health care.

This was enlightened by Centre for Solution Journalism (CSJ) during and interface meeting with senior media managers, to inspire the journalists on the need to amplify the abortion crisis in the country, yet a review of the Termination of Pregnancy was completed and gazetted as a government Bill way back in 2016 and is gathering dust after it was submitted to the Ministry of Health in 2017.

The media present at the interface were taken through several presentations by experts engaged by CSJ and from them, the situation at hand is indeed a crisis.

According to a survey by IPAS Malawi (‘Compilation of post-abortion cases in 2022’), women and girls who sought post-abortion treatment in the public heath facilities after induced abortions, accounted to  3,395 in Blantyre, 7,851 in Lilongwe and 569 in Rumphi in that year 2022 alone.

Also in 2022, data from government health facilities shows 36,225 suffered from serious complications of unsafe abortions and sought post abortion care.

Research conducted by the Guttmacher Institute and Malawi’s College of Medicine showed that in 2015 alone, over 141,000 induced abortions occurred in Malawi.

The annual national abortion rate was 38 induced abortions per 1,000 women aged 15-49 while the national abortion ratio was 23 abortions per 1,000 live births.

The abortion rate was the highest in the Northern Region with 61 induced abortions per 1,000 women aged 15-49; Southern Region had the next highest abortion rate — at 39 per 1,000 women; the Central Region was the lowest at 29 induced per 1,000 women aged 15-49 — (Sources incidence of induced abortion in Malawi — Polis CB, Mhango C, Philbin J, Chimwaza W, Chipeta E, Msusa A-2017)

Who is procuring abortion

According to the survey, ‘Incidence of induced abortion in Malawi’, about 81.4% women who induced abortion were married with mean age at 26 years old of which 65.4% were from rural areas.

An interview with four traditional leaders in Southern Region in ‘Findings of a Strategic Assessment of Unsafe Abortion in Malawi’ (2009) sums up a quote: “If you are poor, your voice is nothing — pregnancy is a death sentence for poor people in Malawi”.

The surveys also indicate that women of all education levels and from different religions procure abortions while in education, those not schooling and sought abortions were at 12.1%; at junior primary (1-5) at 25.1%; senior primary (6-8) at 29.2% while at secondary and higher at 33%.

Malawi touts herself as a God-fearing nation, yet the religion sector is also involved in unsafe abortions with Catholics at 23.3%; Protestants/Presbyterians at 28.7%; other Christians at 22.7%; Muslims at 10.3% —while non-believers its at 0.7%!

Women who had previous abortions and went on to have other induced abortions accounted for 22% while 22.6% had used contraception during the month they conceived.

Unplanned cost of health services

The trends of unsafe abortions have become a crisis in the country before they go with it unplanned cost of treating post-abortion complications, which is high because most such cases end up being admitted for a few days — contributing to the high cost of treatment, food, clinicians’ time and bed.

The cost, which according to Centre for Solutions Journalism, in partnership with its various stakeholders, is estimated to be at US$314,000 annually.

This is to treat post-abortion health care and a past study titled ‘Costs of post-abortion care in public sector health facilities in Malawi: A cross-sectional survey’ published in 2015; https://www.researchgate.net/publication/291010728_Costs_of_postabortion_care_in_public_sector_health_facilities_in_Malawi_A_cross-sectional_survey#pf5 — indicates that the median cost of treating one post abortion care (PAC) case in public facilities is US$40.

Part of the research indicates that the median cost per D&C case (US$63) was 29% higher than MVA treatment (US$49). Costs to treat severe non-surgical complications (US$63) were almost five times higher than those of a simple PAC case (US$13).

Severe surgical complications were especially costly to treat at US$128 — thus the cost for post abortion care treatment in public facilities in Malawi is an estimated $314,000 annually.

The survey indicated that transition to safe and legal abortion would yield an estimated cost reduction of 20%-30%.

Triggers and consequences

Why do the women and girls procure abortion? The surveys indicate that for the girls it was to stay in school as a result of defilement, rape and/or incest.

Older women that got pregnant was because extra marital affairs; too close to previous pregnancy; poverty; gender-based violence; men’s reluctance to accept responsibility of pregnancy and threat to life of the pregnant.

Malawi has the National Policy on Sexual Reproductive Health & Rights (2017-2022) but surveys observed that the law was restrictive as the chances of being in conflict with law instills fear in women to seek access to safe termination of pregnancy.

Thus, according the legal expert who was engaged by CSJ, Mateo Sisya, it increases clandestine and unsafe abortions resulting in increase in maternal mortality rate due to unsafe abortions.

Criminalisation of abortions compromises women’s rights to autonomy and bodily integrity, and this infringes upon their fundamental rights and perpetuates gender inequality.

Due to restrictive laws, women seeking abortions are often stigmatised and subject to societal judgement, leading to social isolation and emotional distress.

Restrictive laws against abortion also increase the dumping of new-born babies in some areas.

Causes of death from unsafe abortions

Medical expert at Blantyre District Health Office (DHO), Gloria Nkhula enlightened the journalists that women who seek abortions through traditional herbalists suffer from various complications such as rapture of wombs and heavy bleeding — thus they are rushed to hospitals for post-abortion treatment.

Due to their seriousness of their injuries, such women spend days and sometimes weeks in hospitals, some die before or when seeking post-abortion treatment.

She observed that if abortion in Malawi were legal, women seeking termination of unintended pregnancies would be spending just minutes or hours accessing the service in approved hospitals.

A survey by CSJ quotes Margaret Kawala of T/A Dzoole in Dowa, who had her womb removed due to unsafe abortion she had using a concoction from a herbalist.

She is on record of telling the media that after her third child, within 4 months, she discovered she was pregnant again and with her husband’s consent, they sought abortion at a nearby hospital but health workers there refused to treat her, justifying that it was against the law.

She went ahead and consulted a traditional herbalist who gave her a concoction but once home, she “felt like a grinder was cutting though her wombs” and started bleeding heavily and later collapsed.

When taken to a private hospital, the gravity of her case forced the clinician there to refer her to Kamuzu Central Hospital (KCH) where they found, after an expensive surgery, that her womb had been damaged and the only solution was to remove the uterus.

The sadder twist to the story: A year later her husband renegaded on their pact, and started engaging in infidelity wanting a woman to give him more children and when she allowed him to marry another woman, it was the beginning of more trouble — she was eventually dumped to look after three of her children.

Another case is of a 48-year old man from Kawawa Village in Lilongwe, Humphrey Zembeni, who was widowed to look after six children when his wife died due to complications from unsafe abortion.

He reported that his wife was taking contraceptives after their 6th child but got pregnant again. After she was convinced by someone else — with consent from the husband — the wife visited a herbalist at Nathenje for an abortion but started bleeding heavily thereafter.

She was taken to Bwaila Hospital, where they were referred to KCH but she died the following day due to heavy blood loss from a punctured uterus and other internal injuries. Health workers found cassava sticks rammed up into her birth canal thus rendered case hopeless at the hospital.

According to a report on the ‘Incidence of induced abortion in Malawi’; https://doi.org/10.1371/journal.pone.0173639, unsafe abortions account for up to 18% of maternal deaths, posing long-lasting complications such as infections, infertility and death.

“When a woman dies of cholera, the Ministry of Health is shaken, but when a woman dies from unsafe abortion or abortion complications, no one is shaken”— Emily Jackson, Brooke Ronald Johnson, Hailemichael Gerbreselassie, Godfrey D. Kangaude & Chisale Mhango 2011 (A strategic assessment of unsafe abortion in Malawi, Reproductive Health Matters).

Fact

As compiled by CSJ, abortion is wide spread and universal. Since the beginning of recorded history, women throughout the world have terminated unwanted pregnancies — the practice is well documented.

The first recorded evidence of an induced abortion was found in an Egyptian papyrus from 1550.

Fact: The criminal law against abortion does not work; it does not prevent abortion. Instead, it kills women, and places their health in danger by driving them to quacks or untrained persons.

Despite Malawi’s restrictive abortion law, over 141,000 women induce abortions every year, because when a woman decides that she does not want a pregnancy, she will do anything to terminate it — as attested to by Blantyre DHO’s Gloria Nkhula.

The World Health Organisation (WHO) identifies possible classifications for abortion as:

Safe abortion — provided by health professionals and with WHO-recommended methods (conducted by trained doctors in hospital, clinics and other health facilities;

Less safe abortion — performed by trained individuals but without using recommended methods, or with the use of methods that are safe but conducted without adequate information or support from trained individuals;

Unsafe — performed by individuals without training who use dangerous and invasive methods such as herbalists, witch doctors, traditional birth attendants and even pregnant women themselves.

Realities in Malawi

The surveys conclude that despite women knowing that unsafe abortion kills and knowing that it is against some religious teachings, women still procure unsafe abortions rather than keep unwanted pregnancies.

It has also been discovered that neither religious teachings nor restrictive abortion laws have persuaded women not to resort to terminating unwanted pregnancies.

The country has a restrictive law that is not achieving the intended purpose of protecting women’s lives, is the conclusion by CSJ, as the surveys have provided overwhelming evidence that where the prohibition of abortion has been replaced with a broad-based safe abortion law, women are no longer dying from complications of abortion.

For the Termination of Pregnancy Bill, if it will be enacted into law, it will be performed by certified health service providers where they are of the opinion, in good faith, that:

* The continued pregnancy will endanger the life of a pregnant woman;

* The termination of pregnancy is necessary to prevent injury to the physical or mental health of a pregnant woman;

* There is severe malformation of the foetus that will affect its viability or compatibility with life; or

* The pregnancy is a result of rape, incest or defilement — provided that the incident of rape, incest or defilement has been reported to the police and that the pregnancy has not exceeded 16 weeks from date of conception (Report of the Law Commission on the Review of the Law on Abortion in Malawi).

Coalition for the Prevention of Unsafe Abortion in Malawi (COPUA) charperson, Emma Kaliya — at Chitera Village in Chiradzulu during an interface meeting with local politicians on June 4, 2022, said: “The law on abortion did not fall from heaven — it dates back to the 1930s, and hence it needs review.

“Malawi should protect the rights of women, including allowing them to access safe abortions, so that they can live in good health.

Abortion is a challenging issue — we do not deny that — but we cannot allow women to die simply because is it a challenging issue. Religious leaders should try to resolve the dilemma by letting the State do its work to protect the health of women.”

Religions take on abortion

Roman Catholic Church

“Given this need, lest any obstacle arise between the request for reconciliation and God’s forgiveness, I henceforth grant to all priests, in virtue of their ministry, the faculty to absolve those who have committed the sin or procured abortion….there is no sin that God’s mercy cannot reach and wipe away when it finds a repentant heart seeking to be reconciled with the Father…May every priest, therefore, be a guide, support and comfort to penitents on this journey of special reconciliation” (Catholic News Agency, Pope extends jubilee mandate on abortion; https://www.catholicnewsagency.com/34956/pope-extends-jubilee-mandate-on-abortion-sspx-confession)

Catholics for Choice

“Everyone deserves equal access to the full range of reproductive healthcare services, including safe and legal abortion. The majority of Catholics believe that abortion should be legal.

“When navigating Catholic teachings on abortion, your conscience is the ultimate authority. Giving a woman a legal right to have control and agency over her body translates to other aspects of her life, namely her freedom to claim political, economic and social autonomy” (https://catholicforchoice.org/issues/abortion/)

Religious Leader Network for Choice

Rev. Fr. Martin Kalimbe

“The truth is that if we read the Bible, chapter by chapter, verse by verse, word by word, we will never find a verse that directly mentions or approves of abortion. The Bible’s silence on abortion is what has culminated into the different positions various churches have on the issue with some stating that abortion should not be provided on any ground, while others agree that it should only be provided to serve the pregnant women when her life is in danger.

“Other religious groups have regulations that allow their members to access abortion in case of rape, incest and foetal malformation. There are also churches which contend that the issue of access to abortion is a matter of individual conscience and it is not up to the State or the church to dictate reproductive decisions to individual citizens.

“All these different positions are there because the Bible does not mention the word abortion and does not offer guidance about it” (Quoted by Times Radio during Times Debate on September 28, 2021).

Sheikh Dr. Imuran Shareef Mahommed

“In Islam, abortion is forbidden. Although abortion is forbidden, there are some conditions under which it is permissible. Firstly, Islam allows women to terminate pregnancies before 120 days, when the life of the pregnant woman is at risk.

“Secondly, Muslim women can also access safe abortions due to foetal anomalies that are incompatible with life. Thirdly, women can also access safe abortion in case of rape, incest, defilement, and other sexual violence.

“Abortion is regarded under the said three conditions as a lesser evil because the most important thing is that the terminations should happen before 120 days.

“This is important because, in Islam, we believe that ensoulment takes place 120 days after conception. Ensoulment is when the foetus gains a soul” (he is a member of Religious Leaders Newtwork for Choice and quoted on Times Radio September 2021).

Centre for Solution Journalism

Brian Ligomeka, Director

“We are in the country where changing laws that benefit women is a huge problem as the patriarchal system and the champions of male chauvinism fight tooth and nail in the name of tradition, culture and religion.

“The enactment and setting up policies on Gender Equality Act, Marriage and Divorce legislation, Marriage Age and even Prevention of Domestic Violence Act faced serious challenges from the gurus of patriarchy.

“The sad part is that this type of resistance has fertile ground in poor countries like Malawi. In prosperous countries, laws that uplift lives of women are prioritised — we need to do the same so that rape and incest victims can access good services.

“The enactment of Termination of Pregnancy Bill into law, which the government prepared, will bring huge relief to victims of sexual assaults and help in reducing maternal deaths while improving safe motherhood.”