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Joyce Phiri* is only one of many women admitted daily to Queen Elizabeth Central Hospital (QECH), in Malawi’s commercial capital Blantyre, for complications of unsafe abortions. Winasi Boma, a supervising nurse at QECH, says the gynaecology ward admits about 20 women each day. Roughly half of these, he says, are there for post-abortion care.
Like most of its neighbours in the region, abortion is illegal in Malawi (except to save the life of the mother). Phiri, a 21-year-old mother of two, sought to terminate her pregnancy only after a contraceptive implant failed. Clinicians at the health centre, operated by a major Malawian non-governmental organisation, apologised for the failure and offered, Joyce says, to “clean out” her uterus. She underwent “some sort of suction” (likely manual vacuum aspiration, according to Boma) and returned home. Two days later, severe pains wracked her lower abdomen. A visit to QECH revealed that products of conception still remained in her uterus.
Bonus Makanani, head of the Department of Obstetrics and Gynaecology at University of Malawi’s College of Medicine, says QECH commonly sees women who have sought abortions from health care workers — clinical officers, nurses, medical assistants, occasionally medical doctors. “A lot of them think they’ve got the theory, but I am not certain that they have the practical experience to undertake such procedures,” Makanani says. Such workers may begin the process and then send the woman to QECH once complications arise. Other women seek to induce an abortion by ingesting detergent powder, consuming drugs or herbal concoctions, or inserting sharp objects vaginally. Such methods can rupture the uterus or bowel and lead to infection, bleeding and in some cases infertility or death.
The World Health Organization estimates that 19 million unsafe abortions occur worldwide each year, killing 70,000 women. Most of these deaths occur in poor countries with restrictive abortion laws, such as Malawi. This country’s maternal mortality rate — which is estimated to be as high as 1,140 deaths per 100,000 live births — already ranks as one of the world’s worst. A recent study by the Ministry of Health, titled the Strategic Assessment, Magnitude and Consequences of Unsafe Abortion, found that abortion accounts for nearly a quarter of these deaths.
Another study, by Malawi’s Family Planning Research Centre, found that half of the women who suffer abortion-related complications are under the age of 25. At QECH, 54% of abortion-related deaths between 2001 and 2008 occurred among this age group.
“The ones who are having unsafe abortions are young women,” says Seodi White, National Coordinator of Women and Law in Southern Africa-Malawi. Moreover, White says, “unsafe abortion is related to poverty. Unsafe abortion has become a problem of the poor and the young.”
Indeed, neither Phiri nor her husband is formally employed. He sells cell phone airtime units and brings home a few dollars a day. She came to QECH because its services are free to patients.
“There’s no doubt that it’s the younger single women where we mostly see these problems,” Makanani says. “It’s certainly those that are less educated, less economically empowered, who are at a disadvantage. I’m sure they are the ones that would seek unsafe abortion because they don’t have the knowledge, and obviously they would also go to facilities that are less than ideal for undertaking such procedures.”
Makanani contrasted the women at QECH to those he sees in private practice. The latter, he says, are wealthier and more informed about sexual and reproductive health issues. Despite the law, Makanani says safe abortion services “are available within Malawi” — with adequate economic resources and the right personal connections.
Those accessing safe abortion services are also those with political power, notes Godfrey Kangaude, a lawyer specialising in sexual and reproductive rights. This, he says, helps account for political inertia on the issue. The Ministry of Health refused to comment for this story.
“On the public face, policy makers and politicians want to look good, want to look moral,” Kangaude says. “But privately they’re the very same who actually seek abortions. That’s why things don’t change. It’s because those who have the power and can talk publicly can access safe abortion.”
By providing post-abortion care at public hospitals, government implicitly acknowledges that illegal abortions take place in Malawi. Yet the topic remains deeply taboo. Even when women arrive at QECH with sticks in their uterus, they deny having induced an abortion. Beyond legal penalty (women are liable to seven years in prison and abortionists to 14), women fear social discrimination. Boma says they may face verbal abuse from hospital staff.
Advocates of legal reform must tread carefully. In a country where using contraception can brand women as promiscuous, mentioning abortion invites charges of moral degeneracy. Kangaude says some have accused him of imposing alien culture. He reminds them that Malawi’s penal code is a relic of British colonialism. Kangaude thinks abortion law will eventually change, but argues Malawi can also reduce the number of unsafe abortions by preventing unwanted pregnancies in the first place. The United Nations Children’s Fund (UNICEF) puts Malawi’s contraceptive prevalence at 41%. Kangaude would like to see this figure much higher.
But White says addressing family planning is not enough. Contraceptive use already occupies a huge part of the national discussion on sexual and reproductive health. Abortion must have a place in the debate as well. But without legal reform, White maintains, women will continue to suffer. Advocates point to South Africa, where legalisation of abortion cut abortion-related mortality by 91%. Though such liberal legislation — South Africa allows abortion on-demand — would likely face swift rejection in a nation as conservative and religious as Malawi, the country could begin by allowing abortion in a broader variety of cases: in instances of rape or incest, for example, or if the life of the foetus is in danger.
Stigma, White acknowledges, would persist, but this is no reason to shirk legal reform.
“The most important thing is, let’s put mechanisms in place to help those who are suffering, stigma or no stigma,” she says. “The stigma can continue, but let’s not use the stigma to stop women from accessing proper and effective health services.”
*Not her real name
Rebecca Jacobson is an American writer based in
Malawi. This article is part of the Gender Links Opinion and Commentary
Service.
