Unsafe Abortion in Malawi

7/27/2019 Unsafe Abortion in Malawi

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Dr. Caroline Tatua


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Introduction-

What would you do and why?A 14 year old girl comes to you and says she has an

unplanned and unwanted pregnancy (6 weeks) andshe wants you to terminate because she needs to stayin school.

A 27 year old woman comes to you and says she ispregnant as a result of being raped and she wants to

terminate on those grounds.A 40 year old woman is pregnant but has a heart

condition that threatens her life if she carries thepregnancy to term, and wants to terminate.


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The regulatory framework

LEGAL FRAMEWORK

Sets the boundaries

POLICY FRAMEWORK

Provides direction within the boundaries


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Law governing access to and provision of

abortion careCONSTITUTION

Bill of Rights eg Right to life, dignity, equality, freedom of conscienceLEGISLATION (SUBSIDIARY LEGISLATION, RULES OR REGULATIONS)

Sections 149 151 read with Section 243 of the Penal Code

Sections 10 12 Medical Practitioners and Dentists Act

Medical Council of Malawi - Code of Ethics and Professional Conduct

COURT DECISIONS

COMMON LAW Eg Rex vs Bourne

INTERNATIONAL HUMAN RIGHTS LAW

Treaties eg. Protocol to the African Charter on the Rights of Women inAfrica

Decisions by judicial bodiesOTHER

Religious law eg. Canon Law (Catholic Church)

Customary law

Ethics


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Offences Against the Person Act of

England of1861, section 58This is the origin of Malawi abortion law word

for word:Any person who, with intent to procure

miscarriage of a woman, whether she is or isnot with child, unlawfully administers to her orcauses her to take any poison or other noxiousthing , or uses any force of any kind, or uses any

other means whatever, is guilty of a felony andis liable to imprisonment for fourteen years.


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The boundariesTHE PENAL CODE

Any person who , with intent to procure a miscarriage of a womanwhether she is or is without a child.shall be guilty of a felonyand shall be liable for imprisonment for 14 years (Section 149)

Any woman who being with child, unlawfully terminates herpregnancy is guilty of a felony and will be liable to 7 yearsimprisonment (Section 150)

Any person who unlawfully provides to means to terminate pregnancyto the woman will be liable to 3 years imprisonment (Section 151)

A person will not be criminally liable if he/she in order to preserve thewomans life, does harm to the foetus (Section 243)


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The Boundaries:Code of Ethics and Professional Conduct (MedicalCouncil of Malawi).

The Laws of Malawi prohibit the termination ofpregnancy on demand. Practitioners found guilty ofprocuring or attempting to procure abortions ormiscarriages are liable to severe penalties under the

Penal Code (Cap: 7:01). In all cases of illegaltermination of pregnancies, the penalty shall besuspension or erasure from a register (Section 5.1)


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Policy on abortion care: some

important documents

Malawi Growth and Development Strategy 20062011

2007 Road Map for Accelerating the Reduction ofMaternal and Neonatal Mortality and Morbidity inMalawi

Reproductive Health Strategy

National Sexual and Reproductive Health and RightsPolicy 2009 (SRHR Policy)


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Policy highlights Government will provide Post Abortion Care (various RH

documents) National SRHR Policy- Section 3.2 Maternal andNeonatal Health.

Serviceproviders in the public and private sectors shall provideor refer for safe abortion to the full extent of the laws of Malawiall women deemed to require or requesting the termination oftheir pregnancies (Article 3.2.2.11 of National SRHR policy)

All women who have complications of abortion shall have accessto quality post abortion services, including post abortioncounselling and family planning to avoid repeat abortions.(Article 3.2.2.9 of SRHR Policy)


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Policy Highlights: Manual Vacuum Aspiration shall be the main method

for managing incomplete abortion where gestationalage permits(Art.3.2.2.10 of SRHR Policy)


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Abortion care to the full extent of

the law in MalawiTermination done in good faith with reasonable care topreserve the life of the pregnant woman

Does this include:

Girl who is too young to carry pregnancy (10 yearsold)?

Girl who threatens to commit suicide if she does nothave termination?

Woman who is sickly because her immune system iscompromised?

A woman who gets pregnant at 54?


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Interpretation for implementers Law and policy on abortion in Malawi may not

offer clear guidance on what health professionalsshould do under a diversity of circumstances(compare with Ethiopia, Zambia and SouthAfrica Law on abortion handouts)

There is need for standards and guidelines whichinterpret the law and policies:

To make things clear and protect healthprofessionals from being accused of over-steppingboundaries

To ensure quality of care


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Effects of restricting safe abortion on

maternal mortality: The case of Romania

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Deathsper100,0

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Maternal mortality rate Abortion related Obstetrical risk

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From reality to the ideal Law and policy out of touch with reality women and

girls continue seeking abortion for reasons other thanstated by law.

Due to fear of prosecution and stigma, abortions areusually clandestine.

Clandestine abortions are more likely to be unsafe

even if carried out by a skilled provider.Women and girls should have access to safe abortion

when they need, not when the government thinks it isright Need for legal and policy reform


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Abortion data:Research: 3 studies

Magnitude study

Strategic assessment

Cost study

Health systems improvement in 38 hospitals

in Central West ZoneSupport for policy change (COPUA)


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Magnitude study summary

findings: Over 100,000 induced abortions annually in Malawi.

Over 30,000 women treated annually for induced abortioncomplications in health facilities 31,021,( MoH Malawi, 2009)(9

8 of 10 women in study were married

Half were under the age of 25.

Half had attended at least primary school

2 of 3 women were from rural areas


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Strategic assessment: Process

WHO human rights tool to review laws, policies andregulations on abortion was adapted for Malawi.

2-week field assessment by 24 stakeholders: Governmental bodies; human rights groups; NGOs

Inputs from 485 people in 10 health districts

In-depth interviews and focus group discussions; visitsto health facilities were some of the approaches used.


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Strategic assessment: Findings Nearly everyone knew or had heard about:

Someone who had induced an abortion

Women who had complications from unsafe abortion Methods used to induce abortion

Where to seek abortion services

Why women and girls choose to induce abortion

That abortion is prohibited but not exactly what the lawsays


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Strategic assessment: Findings

(cont.) Most respondents felt:

Poor girls and women have unsafe abortions becausethey cant pay for a safe one elsewhere

The strict law does not prevent abortion and is notenforced

Despite personal opposition, it is necessary forgovernment to increase indications for legal abortion

Young women have particular challenges (lack of skillsin SHR issues; lack of services; poor provider attitudes)


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Strategic assessment: Findings

(cont.)PAC and Family Planning Service Findings:

Commodity stockouts (MVA kits, FP methods)

Contraception uptake is low Insufficient staffing Long queues, delays in offering services

Myths about FP methods

Poor knowledge and use of EC


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Public HealthFacility Costs

of Treatment of

AbortionComplications

in Malawi


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The costs of unsafe abortionObjectives if the study:

To determine how much money public health facilities

spend on resources directly related to providing of post-abortion care (PAC) services

Medications Clinical supplies Staff time

To determine how much money could be saved and usedfor other health care needs if we reduce morbidity fromunsafe abortion


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Eliminating unsafe abortionAfter shifting to safe abortion, $435,000 per yearcould

become available to spend on other health care needsin public facilities in Malawi

Shifting to safe abortion with WHO-recommendedmethods will decrease unsafe abortion complicationrates

This is better for women, families, and the healthsystem


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Dissemination of cost data Policy makers- will help to change policy which will

reduce cost on management of unsafe abortion

DHMT Promote health workers to scale up the costeffective technologies

Community

-they will have knowledge to demand the

services-Early good health seeking behaviors


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What do the studies bring out?

o Unsafe abortion is common and a well known SRHproblem

o Current laws are ineffective in preventing abortions andlead to abortion complications

oViews are often conservative and influenced by religion

o Nevertheless, preference for abortion to be moreaccessible to improve safety


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Conclusions from studies (cont.)Needs:

oIncrease access to contraceptive services

oTraining in abortion-related care forhealth care providers in both the publicand private sectors

oReform abortion policies/law to allow formore indications for induced abortion


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WHO Statement on Abortion Laws

Whether abortion is legally restrictedor available on request, a womans

likelyhood of having an unwantedpregnancy is about the same.

The legal status of abortion has no

effect on a womans need for abortion.Legal restrictions and other barriersforce women to seek abortion fromunskilled providers, or self-induce it


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Abortion Rates Are Similar

Regardless of the LawRegion Rate

Africa 29

Asia 29Europe 28

North America 21

World 29


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What can health providers do? Facilitate bridging the gap between experience and

policy so that law and policy responds to lived realitiesof women and girls

Provide services to the fullest extent of the law(Comprehensive Abortion Care); clarify boundaries,call for standards and guidelines on provision ofabortion care

For those who can - Advocate for policy and legalreform

Documents

Unsafe Abortion in Malawi