Abortion and Its Cost to Malawi

A self-conscious woman must, most likely, be in a tight spot when she decides to terminate pregnancy and part ways with a would-be baby before touching its nose.

Still, some women go ahead with the decision and part ways with would-be ‘babies’ before they are born. Others, however, die in the process— like a teenage girl from Zomba whose case of health complications was referred from Ngwelero Health Centre to Zomba Central Hospital last year.

Travelling from Ngwelero Health Centre, which is located 45-plus-kilometres away from Zomba Central Hospital, is no mean thing, according to Franstone Duwa, a clinical officer in the Department of Obstetrics and Gynaecology at Zomba Central Hospital.

One health worker in the Department of Obstetrics and Gynaecology at Zomba Central Hospital said on February 25 this year that the would-be mother did not make it, and died despite the health workers investing their best efforts in the task of saving “her dear life”.

“The woman who was referred to us from Ngwelero terminated her pregnancy unsafely [at home] around 9 o’clock in the morning, was rushed to Ngwelero Health Centre from where, after medical personnel observed some health complications, she was referred to our facility [Zomba Central Hospital]. She arrived around 3 o’clock in the afternoon. Unfortunately, there was no blood in the bank and she died,” said the health worker.



Costly affair

The extent of cases and costs associated with treating health complications arising from unsafe abortions at Zomba Central Hospital was, however, brought into the picture when Duwa cited statistics in the Department of Obstetrics and Gynaecology at Zomba Central Hospital.

“At the Gynae [Gynaecology] Clinic, we recorded 1, 150 admissions between July 2015 and December 2015, of which 544 – representing 47 percent— patients were admitted for post-abortion care,” said Duwa.

Out of the 1, 150 patients,21 were girls aged below 15 years [representing 3.8 percent], 109 were teenage girls aged between 15 and 19 years [representing 23.1 percent], 345 patients were married women aged between 20 and 34 years [representing 63.4 percent], and 69 patients were aged 35 years and above [representing 12.6 percent].

There was one case of death: That of the Ngwelero, self-conscious, woman who might have been in a tight spot to decide to terminate pregnancy and part ways with her would-be baby before touching its nose.

The situation is not very different at Queen Elizabeth Central Hospital in Blantyre where records indicate that, in the month of November 2015, 344 admissions were registered, out of which 93 patients needed post-abortion care services. Of these cases, 8 patients were below 19 years, 54 patients were aged between 20 and 30 years, 31 patients were aged between 30 years and above, among other findings.

In December, 255 admissions were made, of which 82 patients were treated for post-abortion care. Out of these patients, 18 were aged below 19 years, 53 were women aged between 20 and 30 years, 11 patients were above 30 years, among others.

In January this year, 301 admissions were recorded, of which 74 patients required post-abortion care services. Of these admission cases, 24 patients were aged below 19 years, 31 patients were aged between 20 and 30 years, and 30 patients were above 30 years.

There was one death.

“This is [the case of] a 20-year-old woman who was breeding heavily. A plan for MVA [Manual Vacuum Aspiration— a medical procedure that results in removal of retained body products of child conception] was made. While in the MVA room, the woman had hypertension, shortness of breath. Then, the mother went into cardiac arrest and we administered CPR for some time but, unfortunately, she died,” said one health worker at Qech on February 26.

The news from another reputable health facility, Mwanza District Hospital— which serves patients from Chikhwawa, Mwanza and neighbouring Mozambique— is, again, not pleasing to the ear. It is the same, old story of self-conscious women who, finding themselves in a tight spot, decide to terminate pregnancy and part ways with their would-be babies before touching their noses.

Records indicate that there are 30 to 40 unsafe abortions registered every month, and the affected women report to Mwanza District Hospital to access post-abortion care services.

Statistics indicate that, between January and December 2015, two patients were referred to Queen Elizabeth Central hospital due to complications related to the use of unsafe abortion tools.

Such tools, according to Dr Francis Kamwendo, Associate professor Obstetrics and Gynaecology at the College of Medicine, a constituent college of the University of Malawi, include alligator pepper, chalk and alum, bleach, Bahaman grass, cassava sticks, among others. These are weapons of death.

However, the 30 to 40 women who have been admitted to Mwanza District Hospital in the past two years must thank the private sector for timely intervention.

Mwanza District Health Officer, Raphael Lawrence Piringu, said the district used to struggle to get MVA kits before Vale Logistics bought the kits and donated them to the hospital. Other districts, like Neno, are not very lucky. In fact, Mwanza District Health Office donated 15 MVA sets to Neno, which did not have any, early this year and these are enough to serve Neno women and health workers for one year, according to Piringu.

“Generally, between 15 and 20 percent of cases registered in the female ward and maternity wing have to do with [the provision of] post-abortion care services. We sometimes register four to five post-abortion care cases or those related to miscarriage. In fact, most abortion cases are induced [not natural],” said Piringu, adding:

“In the case of those who induce abortion, we ensure that we quickly stop the breeding and, within 24 hours, take the patient to the theatre. Sometimes, we face the worst case scenario where we have to remove the uterus. In 2015, we surgically removed two uteruses and it is not a nice experience,” said Piringu.



Keeping pregnancy to term

Not that all women terminate pregnancy when circumstances surrounding conception justify such a course of action, though.

In Mwanza District, a 13-year-old girl decided to hold on to the foetus and successfully delivered at the hospital despite being a victim of rape.

And, in the last week of February this year, a 23-year-old rape victim chose to deliver when others would have embraced the option of terminating pregnancy.

These are cases of women who, finding themselves in a tight spot, decide to hold on to the pregnancy in order not to part ways with their would-be baby before touching its nose.



Dangerous terrain

Dr Chisale Mhango, one of the commissioners for the Special Law Commission that was established in 2013 and given the task of reviewing the country’s abortion laws, said unsafe abortion is one of the factors that contributed to Malawi’s failure to meet the Millennium Development Goal on reducing maternal mortality rate to 275 [deaths] per 100, 000 live births.

According to the 2010 Malawi Demographic Health Survey (MDHS), out of every 100, 000 babies delivered in the country’s health facilities, 574 have to die! This means— pending announcement of the latest MDHS findings— Malawi is on tenth position in terms of countries with the highest maternal mortality rates in Africa.

An analysis of World Health Organisation statistics revealed that Chad, with 1, 100 maternal mortality rates per 100, 000 live births, tops the list of countries with the highest Maternal Mortality Rates. Somalia is second, with 1, 000 cases per 100, 000 live birth, followed by Sierra Leone [890], Central African Republic [890], Burundi [800], Guinea Bissau [790], Liberia [770], Sudan [730], Cameroon [690], and Malawi on tenth position [574].

“Seventeen out of every 100 maternal mortality rate cases in the country are a result of unsafe abortion. In fact, complications of unsafe abortion are the forth commonest cause of maternal deaths in Malawi, after breeding, sepsis [infection] and hypertension. This is complicated by the fact that research findings indicate that the proportion of girls [aged between 15 and 19 years] having their first sexual encounter is increasing. In 2004, it was 48 percent and in 2010, it [the rate] was at 56 percent,” said Chisale.

Chisale, who once headed the Ministry of Health’s Reproductive Health Unit before joining the College of Medicine, added that the situation is compounded by the fact that only 59 out of 100 women use contraceptive methods in Malawi.



Legal path

Mhango observed that the current law on abortion only allows health officials to terminate pregnancy on medical grounds. Sections 149, 150 and 151 of the Penal Code address issues of procuring abortion, penalties applicable to those who play a role in procuring it and women caught in the act.

Punishments range from monetary fines to custodial sentences ranging from three years to 14 years imprisonment with hard labour.

The proposed law proposes that rape, incest, medical grounds such as severe malformation of the foetus and the need to safeguard the life of the mother, be embraced as justifiable grounds to terminate pregnancy.

Head of the Obstetrics and Gynaecology Department at Gogo Chatinkha Maternity in Blantyre, Dr Phylos Bonongwe, observed that Malawi is losing millions of kwacha by sticking to the “old laws on abortion”.

“Research findings indicate that, after shifting to safe abortion, over K300 million could become available to spend on other healthcare needs in public facilities in Malawi. Mind you, it was discovered at the time of analysing the costs associated with unsafe abortion that the country could save US$250, 000, which is more than K300 million now considering that the kwacha has lost its value against the United States Dollar,” said Chisale.

Mulanje Mission Hospital-based nurse and midwife, Keith Lipato, said Malawi’s abortion law is “gender insensitive”. Lipato observed that a “restrictive legal environment’ was to blame for high maternal mortality rates in Malawi.

“It [the law] is basically unfair because it does not put the man in the picture. It punishes only women and, yet, it takes two [people] to tangle. We are being unfair to women. What if a woman has been raped and does not want to take the pregnancy to term?” queried Lipato.

In 2008, gender activists opened a can of worms when they proposed that rape cases that take place in the marriage set up [dubbed ‘marital rape’] should be penalised. But, while observing that it would be a violation of women’s rights to deny them the right to terminate pregnancy in cases of rape, human rights lawyer Chrispin Sibande said the concept of marital rape applies only when couples are on separation, and that it would be difficult to enforce the law on marital rape when couples are in good books.