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The Incidence of Induced Abortion in Malawi

Authors:

Abstract

Abortion is legally restricted in Malawi, and no data are available on the incidence of the procedure. The Abortion Incidence Complications Methodology was used to estimate levels of induced abortion in Malawi in 2009. Data on provision of postabortion care were collected from 166 public, nongovernmental and private health facilities, and estimates of the likelihood that women who have abortions experience complications and seek care were obtained from 56 key informants. Data from these surveys and from the 2010 Malawi Demographic and Health Survey were used to calculate abortion rates and ratios, and rates of pregnancy and unintended pregnancy. Approximately 18,700 women in Malawi were treated in health facilities for complications of induced abortion in 2009. An estimated 67,300 induced abortions were performed, equivalent to a rate of 23 abortions per 1,000 women aged 15-44 and an abortion ratio of 12 per 100 live births. The abortion rate was higher in the North (35 per 1,000) than in the Central region or the South (20-23 per 1,000). The unintended pregnancy rate in 2010 was 139 per 1,000 women aged 15-44, and an estimated 52% of all pregnancies were unintended. Unsafe abortion is common in Malawi. Interventions are needed to help women and couples avoid unwanted pregnancy, reduce the need for unsafe abortion and decrease maternal mortality.
International Perspectives on Sexual and Reproductive Health88
Unsafe abortion is a public health concern for many de-
veloping countries. The World Health Organization has
estimated that 21.6 million unsafe abortions and 47,000
abortion-related deaths occurred globally in 2008.
1
The
vast majority (98%) of unsafe abortions take place in de-
veloping regions. The risk of death from unsafe abortion
is highest in Sub-Saharan Africa, where an estimated 520
deaths occur per 100,000 unsafe abortion procedures, com-
pared with about 30 per 100,000 in the developed world.
1
Unsafe abortion is one of the major factors contribut-
ing to high levels of maternal mortality (pregnancy-related
deaths).
2
Sub-Saharan Africa has the highest maternal
mortality ratio in the world—an estimated 640 deaths per
100,000 live births in 2008, of which 14% were due to
abortion complications.
1,3
According to the 2010 Malawi
Demographic and Health Survey (DHS), the average ma-
ternal mortality ratio during the seven-year period before
the survey was 675 deaths per 100,000 live births (range,
570–780).
4
Although a comparison of maternal mortal-
ity ratios for 2004 and 2010 (984 and 675, respectively)
shows a substantial decline, the rate of maternal deaths
remains very high in Malawi.
3,5
A study at a large facility
in Malawi indicated that 24% of maternal deaths in 1999
were attributable to postabortion complications.
6
Studies have shown that banning or severely restricting
abortion does not reduce abortion rates, but instead affects
the safety of the procedure. In regions where most women
live under restrictive abortion laws, the estimated abor-
tion incidence is higher than it is in regions comprising
countries with liberal abortion laws.
1,7
In countries with
restrictive laws, not only do some women die from unsafe
abortion, but many others suffer long-term health conse-
quences, including chronic pain and sterility.
8
In Malawi, abortion is legal only when performed to
save a pregnant woman’s life.
9
Despite this restrictive law,
a study by the Family Planning Association of Malawi re-
vealed that women in Malawi seek abortion for a variety
of reasons, including poverty, unplanned pregnancy, coer-
cion, shame and fear of being forced out of school.
10
In a
2004 study of Malawian adolescents, more than one-third
of 15–19-year-olds and about one-fifth of 12–14-year-olds
reported having one or more close friends who had tried
to end a pregnancy.
11
As only a few Malawian studies on
abortion and related morbidity and mortality have been
conducted in the past decade (all of them small-scale, hos-
pital-based studies), up-to-date national data on abortion
are greatly needed.
6,12
To fill this important gap, and to pro-
vide evidence that can inform policymakers about the mag-
nitude and health impact of unsafe abortion, we sought to
estimate the incidence of induced abortion in Malawi.
METHODS
This study builds on data collection approaches and
methodologies used in previous abortion incidence and
morbidity studies conducted in South Africa, Uganda,
Kenya and Ethiopia.
13–17
Specifically, we used the Abortion
CONTEXT: Abortion is legally restricted in Malawi, and no data are available on the incidence of the procedure.
METHODS: The Abortion Incidence Complications Methodology was used to estimate levels of induced abortion
in Malawi in 2009. Data on provision of postabortion care were collected from 166 public, nongovernmental and
private health facilities, and estimates of the likelihood that women who have abortions experience complica-
tions and seek care were obtained from 56 key informants. Data from these surveys and from the 2010 Malawi
Demographic and Health Survey were used to calculate abortion rates and ratios, and rates of pregnancy and
unintended pregnancy.
RESULTS: Approximately 18,700 women in Malawi were treated in health facilities for complications of induced
abortion in 2009. An estimated 67,300 induced abortions were performed, equivalent to a rate of 23 abortions per
1,000 women aged 15–44 and an abortion ratio of 12 per 100 live births. The abortion rate was higher in the North
(35 per 1,000) than in the Central region or the South (20–23 per 1,000). The unintended pregnancy rate in 2010
was 139 per 1,000 women aged 15–44, and an estimated 52% of all pregnancies were unintended.
CONCLUSIONS: Unsafe abortion is common in Malawi. Interventions are needed to help women and couples avoid
unwanted pregnancy, reduce the need for unsafe abortion and decrease maternal mortality.
International Perspectives on Sexual and Reproductive Health, 2013, 39(2):88–96, doi: 10.1363/3908813
Brooke A.
Levandowski is
senior research and
evaluation associate,
Ipas, Chapel Hill, NC,
USA. At the time this
study was conducted,
Chisale Mhango was
director, Reproductive
Health Services,
Ministry of Health,
Blantyre, Malawi.
Edgar Kuchingale is
lecturer, Department
of Obstetrics and
Gynecology, Malawi
College of Medicine,
Blantyre. Juliana
Lunguzi is a mid-
wifery advisor, United
Nations Population
Fund, Lilongwe,
Malawi. Hans
Katengeza is reproduc-
tive health officer,
Reproductive Health
Unit, Malawi Ministry
of Health, Lilongwe.
Hailemichael
Gebreselassie is senior
research advisor,
Ipas, Nairobi, Kenya.
Susheela Singh is vice
president for research,
Guttmacher Institute,
New York.
By Brooke A.
Levandowski,
Chisale Mhango,
Edgar Kuchingale,
Juliana Lunguzi,
Hans Katengeza,
Hailemichael
Gebreselassie and
Susheela Singh
The Incidence of Induced Abortion in Malawi
Volume 39, Number 2, June 2013 89
nated. Lists of remaining facilities were given to Ministry of
Health zonal health supervisors,
who indicated that 427
facilities on the list were likely to be providing postabor-
tion care. We then used a single-stage stratified sampling
approach to select a nationally representative sample of
these facilities. We included in the sample all 188 public
and NGO facilities that were thought to provide postabor-
tion care (including public referral and teaching hospitals,
district hospitals, public health centers, NGO hospitals
and NGO health centers) and both private hospitals. The
237 listed private clinics were stratified by the country’s
five zones; we used systematic random sampling to select
one-third (79) of these facilities. In total, 269 facilities were
selected for the study (Table 1).
The research team contacted all facilities by telephone
to obtain the name of (and contact information for) the
main provider of postabortion care and to invite him or
her to participate in the study. During these conversations,
the research team confirmed that 166 of the 269 facilities
were currently providing postabortion care. Of these 166
facilities, 93 were public (46 health centers, 43 secondary
facilities and four tertiary facilities), 65 were run by NGOs
(35 health centers and 30 secondary facilities) and eight
were private (six clinics and two tertiary facilities).
Data Sources
The Prospective Morbidity Survey, Health Facilities Survey
and Health Professionals Survey were pretested in July
2009; data collection ran from August to October 2009.
•Prospective Morbidity Survey. The main provider of post-
abortion care at each participating facility attended a two-
day training program on the data collection tool. Provid-
ers who worked at larger facilities trained other providers
of postabortion care at their facilities once they returned.
The Prospective Morbidity Survey was fielded for 30 days
at each facility. For every woman who presented for post-
Incidence Complications Methodology (AICM), which in-
corporates data from two component studies, the Health
Facilities Survey and the Health Professionals Survey. The
methodology was adapted to utilize additional data from
a third source, the Prospective Morbidity Survey, on the
number of women treated for abortion complications.
18,19
The details of these surveys, as applied in Malawi, are de-
scribed below.
This study received ethical approval from the Malawi
National Health Sciences Research Committee. Data for
the Prospective Morbidity Survey were collected as an ex-
tension of routine medical record keeping performed by
postabortion care providers. The data collection tool close-
ly resembled a patient medical chart, except that names
and other identifying information were not recorded.
Informed consent was obtained from participants in the
Health Facilities and Health Professionals Surveys.
Sampling Frame
To generate the list of facilities in the sample, we followed
a three-step process. First, we compiled a list of all health
facilities in Malawi; next, we identified the facilities on the
list that were potential providers of postabortion care; and
finally, we further reduced the list to public and nongov-
ernmental (NGO) facilities known to provide postabor-
tion care.
To create the initial list, the research team, in collabora-
tion with the Malawi Ministry of Health and the Medical
Council of Malawi, used the November 2008 edition of
the Malawi Government Gazette, which listed all licensed
public, NGO and private hospitals and clinics along with
their registration number, address, district, type (such as
government health facility or Christian Health Association
of Malawi facility) and director. This list was supplemented
by lists of facilities associated with Banja La Mtsogolo* and
the Ministry of Health’s Reproductive Health Unit to cre-
ate a national list of 893 facilities.
To restrict this list to facilities that potentially provided
postabortion care, we took several steps. First, facilities that
clearly did not provide maternal health care, such as the
Malawi Defense Force health facilities and certain types of
specialized clinics (e.g., mental health clinics), were elimi-
*Banja La Mtsogolo is a nongovernmental organization affiliated with
Marie Stopes International.
†Zonal health supervisors are Ministry of Health employees who are
assigned to one of Malawi’s five geopolitical zones; they have frequent
contact with the government and NGO health facilities in their zone.
These individuals were able to obtain valuable, up-to-date information
on the services provided at facilities in their zone.
TABLE 1. Measures related to sample selection, by facility type, Prospective Morbidity Survey and Health Facilities Survey,
Malawi, 2009
Facility type No. of
facilities
No. of
facilities in
sampling
frame*
% of
target
facilities
sampled
No. of
sampled
facilities
No. of sampled
facilities
providing
postabortion
care
Prospective Morbidity
Survey
Health Facilities Survey
No. of
participating
facilities
% of
facilities
participating
No. of
partici-
pating
facilities
% of
facilities
participating
Public hospital 56 50 100.0 50 47 47 100 47 100
Public health center 405 64 100.0 64 46 44 96 45 98
NGO hospital 41 33 100.0 33 30 27 90 29 97
NGO health center 152 41 100.0 41 35 35 100 34 97
Private hospital 2 2 100.0 2 2 2 100 2 100
Private clinic 237 237 33.3 79 6 6 100 5 83
All 893 427 na 269 166 161 97 162 98
*Facilities thought to be providing postabortion care. Notes: NGO=nongovernmental organization. na=not applicable.
The Incidence of Induced Abortion in Malawi
International Perspectives on Sexual and Reproductive Health
90
of provider; and the probability that women who experi-
ence complications obtain medical care at a health facility.
Participants provided estimates for each of four subgroups
(poor rural women, nonpoor rural women, poor urban
women and nonpoor urban women) to capture expected
social and demographic differences in women’s access to
abortion services and postabortion care.
•Additional data sources. To cross-check whether postabor-
tion cases were undercounted in the Prospective Morbid-
ity and Health Facilities Surveys, as well as to assess the
completeness of logbook records, Ministry of Health zonal
supervisors collected logbook data from each facility on
the number of procedures completed in the 30 days prior
to and during data collection for the Prospective Morbid-
ity Survey. This information was used to conduct a validity
check of the number of women who obtained postabor-
tion care. In addition, to estimate abortion incidence and to
provide contextual information on reproductive health in
Malawi, we used data from the following sources: the 2008
Malawi Housing and Population Census,
20
the 2006 Mul-
tiple Indicator Cluster Survey,
21
the 2004 and 2010 DHS,
4,5
and the 2004–2005 Integrated Household Survey.
22
Calculation of Abortion Incidence
In the AICM, the incidence of abortion is estimated by de-
termining the number of women who received postabor-
tion care at health facilities during a one-year period and
then adjusting this figure to include women who had abor-
tion complications but did not obtain care at a health facili-
ty and those who had an abortion but did not have compli-
cations (and thus did not need treatment). The number of
women who received postabortion care is determined us-
ing annual postabortion care caseloads from the Prospec-
tive Morbidity and Health Facilities Surveys. Because some
women who receive postabortion care have had spontane-
ous abortions (miscarriages), the next step is to subtract
the estimated number of women who had obtained treat-
ment for complications of spontaneous abortions from the
total number of women with abortion complications; the
result is the number of women treated for complications
of induced abortions. Next, a factor or multiplier is gener-
ated using information obtained from the Health Profes-
sionals Survey to account for the remaining women who
had an induced abortion; the multiplier can be interpreted
abortion care during the data collection period, the pro-
vider recorded information on the woman’s demographic
characteristics, her presenting clinical signs and symptoms
and the clinical care she received. Ninety-eight percent of
selected facilities participated in the survey.
•Health Facilities Survey. The Health Facilities Survey was
also fielded at each facility. After attending a weeklong
training course on the study and its data collection tool,
Ministry of Health zonal supervisors interviewed a key in-
formant at each facility who was knowledgeable about pro-
vision of postabortion care at the facility. The informant,
who was typically the facility’s director or main provider
of postabortion care, was asked to estimate the number
of women treated for postabortion complications as inpa-
tients and outpatients, both in the past month and in an
average month. The two reference periods were used to
take into account variation over time in the facility’s case-
load. The informant also provided information on a range
of other topics, including the types of reproductive health
services provided at the facility (such as manual vacuum
aspiration) and details about postabortion family planning
provision. Ninety-nine percent of sampled facilities partici-
pated in the study.
•Health Professionals Survey. The investigators consulted
with a range of experts in the field of reproductive health
in Malawi to identify potential key informants for the
Health Professionals Survey. This produced a list of 123
possible respondents—health professionals who had ex-
tensive knowledge of the conditions under which women
obtain abortions in Malawi. Study investigators attempted
to contact each prospective participant to assess his or her
availability and interest in being interviewed; 56 were suc-
cessfully interviewed. Most respondents were obstetrician-
gynecologists (32%), medical officers (27%) or clinical
officers (21%); on average, they had 16 years’ experience
in reproductive health. Sixty-one percent of participants
were currently working in one of Malawi’s two major cit-
ies (Lilongwe and Blantyre), although 52% had worked in
a rural area for at least six months in the past five years.
During the interviews, the experts provided three types of
estimates: the percentage distribution of women who ob-
tain abortions, according to the type of provider; the prob-
ability that women who have an abortion experience com-
plications that require medical care, according to the type
TABLE 2. Indicators of postabortion care provision, by type of facility, Malawi, 2009
Indicator Public
hospitals
Public
health
centers
NGO
hospitals
NGO
health
centers
Private
hospitals
Private
clinics
All
(95% CI)
No. of women receiving postabortion care
Calculated using PMS data 13,688 3,215 4,780 3,855
61 1,035
26,634 (22,596–30,674)
Calculated using two HFS estimates 16,433 2,541 4,907 4,950
132 1,594
30,557 (26,098–35,016)
Calculated using all of the above 15,779 2,787 4,736 4,858
108 1,229
29,497 (25,635–33,359)
No. of facilities providing postabortion care 47 46 30 35 2 6 166
Mean no. of women treated per facility* 336 61 158 139 54 205 187
*Among facilities that provide postabortion care. Notes: Estimates of number of abortion complications use weighted data. Notes: CI=confidence interval.
PMS=Prospective Morbidity Survey. HFS=Health Facilities Survey.
Volume 39, Number 2, June 2013 91
facility in a recent year (54% nationally; 51–61% across
regions). By applying these proportions to the number of
spontaneous abortions, we estimate that 10,800 women in
Malawi were treated in health facilities for complications of
spontaneous abortion in 2009. Subtracting this number
from the number of women treated for any abortion com-
plications (29,500) yields the number of women treated
for complications of induced abortion (18,700).
To calculate the multiplier that accounts for women who
did not need or receive treatment, we used estimates from
Health Professionals Survey participants of the proportion
of women in the four population subgroups (urban poor,
urban nonpoor, rural poor and rural nonpoor) who receive
postabortion care if they have an abortion. These four es-
timates were weighted according to the subgroups’ repre-
sentation among all women of reproductive age. Using data
from the 2004–2005 Integrated Household Survey
22
in
combination with 2008 census data on urban-rural popula-
tion composition, we estimate that in 2009, 45% of women
were rural poor, 7% were urban poor, 40% were rural non-
poor and 8% were urban nonpoor. The multiplier is the in-
verse of the weighted proportion of abortion recipients who
were treated in health care facilities; in Malawi, this propor-
tion was 28% and the multiplier was 3.6 (i.e., 1.0/0.28). We
applied this multiplier to the number of women treated for
complications of induced abortion to produce estimates of
the number of women who had abortions in 2009, both
for Malawi as a whole and for the country’s major regions.
Given that these are approximate measures of abortion in-
cidence, we also provide upper and lower estimates by ap-
plying two alternative multipliers (2.6 and 4.6) obtained by
reducing or increasing the value of the multiplier by 1.0.
Validity Check
We used data from facility logbooks provided and tracked
by the Ministry of Health as a validity check of the robust-
ness of the estimate of the annual postabortion care case-
load. No special efforts were made for this study to ensure
the completeness of the logbook data; the data were col-
lected as recorded. Logbook data were available from 124
to mean that for every woman who obtained postabortion
care, a certain number of others also had an induced abor-
tion but did not receive or require treatment for compli-
cations. The product of the multiplier and the number of
women treated for complications of induced abortion is an
estimate of the number of induced abortions.
As noted earlier, our estimate of the number of women
treated for abortion complications was derived from mul-
tiple data sources. Prospective Morbidity Survey caseloads
during the 30-day data collection period were multiplied
by 12.2 to provide the number of women receiving post-
abortion care in 2009. In addition, the two estimates of
postabortion care caseloads obtained from the Health Fa-
cilities Survey—cases in the past month and those in the
typical month—were each multiplied by 12 to produce an-
nualized numbers. The three data points were then aver-
aged to create a best composite estimate of the annual case-
load for each facility. After weighting the data to adjust for
nonparticipating facilities and for proportional sampling
of private facilities, we estimate that a total of 29,500 wom-
en received postabortion care in Malawi in 2009 (Table 2).
This estimate includes both women who had induced
abortions and those who had spontaneous abortions. Be-
cause of the stigma surrounding the reporting of induced
abortions and the difficulty of clinically differentiating
complications of spontaneous abortions from those of
induced abortions, survey respondents were not asked to
distinguish between the two types of abortion complica-
tion patients. Instead, the AICM uses an indirect approach
to estimate the number of women treated in facilities for
complications of each type of abortion.
In particular, the number of late spontaneous abortions
(those that occurred at 13–21 weeks’ gestation and thus
would have required women to obtain facility-based care*)
is estimated to be 3.41% of the number of live births, a pro-
portion determined from clinical studies of spontaneous
pregnancy loss.
19,23,24
We estimated the number of births
in Malawi in 2009 by applying age-specific fertility rates
from the 2010 DHS (for the three-year period preceding
the survey) to the number of women in the population in
2009,
yielding an estimate of 585,100 live births (Table
3). The number of late spontaneous abortions, therefore,
would have been about 19,950. However, not all women
who have late spontaneous abortions obtain care at a
health facility; as a proxy for the proportion who do, we
used the proportion of women who gave birth at a health
*Women who have early pregnancy loss (before 13 weeks gestation)
are not expected to need facility-based care, and losses at or beyond 22
weeks are classified as fetal deaths, not spontaneous abortions.
†To estimate the number of women of reproductive age by age and
province in 2009, we applied the annual growth rate of Malawi’s popula-
tion from 1998 to 2008 (2.8%) to 2008 census data; the resulting estimate
was 2,883,800 women aged 15–44.
TABLE 3. Measures used to calculate number of women hospitalized for complications of induced abortion, nationally and by
region, Malawi, 2009
Region No. of women
treated for abortion
complications*
No. of women
with live births
No. of women
with spontane-
ous abortions
% of women
who deliver
in facilities
No. of women treated
in facilities for complications
of spontaneous abortion
No. of women treated in
facilities for complications
of induced abortion
All 29,497 585,095 19,952 53.8 10,811 18,686
North 5,258 78,294 2,670 60.6 1,618 3,640
Central 12,138 248,788 8,484 50.8 4,310 7,828
South 12,101 258,014 8,798 55.5 4,883 7,218
*Includes complications of both spontaneous and induced abortions.
The Incidence of Induced Abortion in Malawi
International Perspectives on Sexual and Reproductive Health
92
Unintended Pregnancy
The total number of pregnancies in 2009 was calculated
by summing the estimates of the numbers of live births, in-
duced abortions and spontaneous abortions (early or late).
To estimate the number of pregnancies that end in spon-
taneous abortions, we used a model-based approach de-
rived from clinical studies of pregnancy loss by gestational
age;
23,24
according to this model, the estimated number of
pregnancy losses is equal to 20% of the number of live
births (whether planned or unplanned) plus 10% of the
number of induced abortions. The numbers of planned
and unplanned births were calculated by applying 2010
DHS data on the percentage of births that were wanted
and the percentage that were either mistimed or unwant-
ed* to the total number of live births. Unintended preg-
nancies are defined as those that ended in an unplanned
birth, an induced abortion or a spontaneous abortion (if
the pregnancy was not planned); similarly, intended preg-
nancies are those that ended in a planned birth or in a
spontaneous abortion (if the pregnancy was planned).
Other Analyses
Rates of abortion and hospitalization for complications of
unsafe induced abortion in 2009 were estimated per 1,000
women aged 15–44. We used age-specific fertility rates from
the 2010 DHS to calculate the abortion ratio, expressed as
the number of abortions per 100 live births. Pregnancy
rates and unintended pregnancy rates were calculated
based on the number of women aged 15–44 in 2009. Data
were analyzed using Stata version 11 and Excel 2007. Un-
weighted counts and weighted proportions are reported for
Malawi as a whole as well as for the Northern, Central and
Southern regions. Postabortion care caseload data from the
facilities were weighted to generate estimates for a nation-
ally representative sample of facilities providing such care.
RESULTS
Postabortion Services Caseload
From Prospective Morbidity Survey data, we calculated
that 26,600 women were treated for complications in
Malawi in 2009 (Table 2). We obtained a slightly higher
estimate of annual caseload (30,600) when we averaged
(75%) of the 166 facilities in the study. Zonal supervisors
extracted logbook data on the number of postabortion
care procedures that were recorded during the 30 days
prior to data collection and the number recorded during
the 30 days of data collection. The mean of these two num-
bers was used to represent the logbook monthly caseload,
which was annualized by multiplying by 12.2, yielding an
estimate of 32,700.
For the subset of facilities with logbook data, an r
2
test
was used to determine the correlations of the logbook
caseload with the Prospective Morbidity Survey caseload
and the Health Facilities Survey estimates. The r
2
test had a
value of 0.9 for the comparison between logbook data and
Prospective Morbidity Survey data, indicating high compa-
rability. The test had a value of 0.7 for the comparison of
logbook data with the mean of the two Health Facilities
Survey estimates, and values of 0.5 and 0.7 for the com-
parison with the average month’s and previous month’s
Health Facilities Study estimates, respectively, indicating
lower comparability.
To test the robustness of our estimate of the number of
women who obtained postabortion care at health facilities
in 2009, we created a composite variable that averaged the
four estimates (the Prospective Morbidity Survey caseload,
the two Health Facilities Survey estimates and the logbook
caseload). The resulting estimate was that 29,900 women
were treated for complications (95% confidence inter-
val, 24,300–35,500 women), which is almost the same
as the estimate of 29,500 calculated earlier by averaging
the three values obtained from the Prospective Morbidity
and Health Facilities Surveys. This similarity confirms that
those estimates were robust and strengthens our confi-
dence in the validity of the data from the Prospective Mor-
bidity and Health Facilities Surveys.
*The DHS data on wantedness (wanted at the time, mistimed or unwant-
ed) refers to births in the preceding three years.
TABLE 4. Number of induced abortions, abortion rate and abortion ratio among women aged 15–44, by multiplier, nationally and according to
region, Malawi, 2009
Region No. of women treated
for induced abortion
No. of induced abortions Abortion rate Abortion ratio
Multiplier Multiplier Multiplier
2.6 3.6 4.6 2.6 3.6 4.6 2.6 3.6 4.6
All 18,686 48,584 67,270 85,956 16.8 23.3 29.8 8.3 11.5 14.7
Northern
3,640 9,464 13,104 16,744 25.1 34.8 44.4 12.1 16.7 21.4
Central
7,828 20,353 28,181 36,009 16.8 23.3 29.8 8.2 11.3 14.5
Southern
7,218 18,767 25,985 33,203 14.5 20.0 25.6 7.3 10.1 12.9
Notes: Abortion rate is number of abortions per 1,000 women aged 15–44. Abortion ratio is number of abortions per 100 live births.
TABLE 5. Number of pregnancies, rates of pregnancies and unintended pregnancies,
and percentage of pregnancies that are unintended, nationally and by region, 2009
Region No. of
pregnancies
Pregnancy
rate
Unintended
pregnancy rate
% of pregnancies that
are unintended
All 776,112 269 139 51.7
North 108,367 288 128 44.6
Central 329,546 271 148 54.3
South 338,200 260 134 51.5
Note: Pregnancy rates are per 1,000 women aged 15–44.
Volume 39, Number 2, June 2013 93
mate abortion incidence in Sub-Saharan Africa have been
conducted in the past few years in Burkina Faso, Ethio-
pia and Rwanda, and less recently in Nigeria and Ugan-
da.
15,17,25–27
All of these studies have included not only
public-sector but also not-for-profit and private-sector facil-
ities, thereby providing more comprehensive and accurate
estimates of the number of women obtaining postabortion
care, and, in turn, of overall abortion incidence.
Abortions are likely to be highly unreported in studies
that measure abortion incidence using direct techniques
(such as interviewing women or providers), especially in
settings where abortion is legally restricted.
28
As a result,
indirect estimation techniques are accepted as the pre-
ferred approach for estimating abortion incidence in le-
gally restrictive settings. The AICM has been widely used
and found to yield robust estimates over time and across
countries.
This is the second study, after a prior analysis of Ethio-
pia,
15
to measure the number of women treated for post-
abortion care by combining two approaches: a Prospective
Morbidity Survey that collects patient-specific data for a
period of 2–4 weeks (30 days in the case of this study)
and a Health Facilities Survey (the approach used by AICM
studies), in which interviews with facility directors or other
knowledgeable informants are used to obtain aggregate es-
timates of the number of women treated in each facility
in the past month and in an average month. Use of these
two different approaches produces a more robust estimate
of this core input indicator for the estimation of abortion
incidence, thus increasing one’s confidence in the validity
of the study results.
Our validity check revealed that logbook data, where
available, more closely resembled Prospective Morbidity
Survey caseload data than they did estimates from the
Health Professionals Survey, indicating that logbooks
may be a good source of caseload information and could
be referred to when collecting information about women
who receive postabortion care in Malawi. Further studies
would allow researchers to explore the extent to which log-
book data can be considered a comprehensive data source
and could support caseload projections from provider es-
timates or other data collection tools used on a per-case
basis.
The limitations of the AICM have been described else-
where;
19
they include the challenge of obtaining a quan-
titative multiplier from qualitative interviews with health
professionals and the inability to verify a hospitalization
rate for late miscarriages. We focus here on the specific
challenges of applying the methodology in Malawi. Data
quality will always be a concern; however, we feel that by
using three sources of caseload information and the valid-
ity check, we were able to achieve and validate an annual
estimate of the number of women treated for postabortion
care that is more accurate than an estimate based on a
single source. Although Malawi is a small country, some
participants in the Health Professionals Survey may not
have been highly knowledgeable about current conditions
the two Health Facilities Survey estimates. The composite
variable that averaged all three data sources yielded an esti-
mate of 29,500 women treated for abortion complications.
On average, 187 women were treated in each of the 166
facilities offering postabortion care in 2009; almost half of
women who obtained such care did so at public hospitals,
which treated a mean of 336 women per facility.
Of the 29,500 women treated for abortion complications,
more than 12,100 received care in the Central region (41%)
and a similar number was treated in the South (Table 3).
As noted earlier, an estimated 10,800 of the 29,500 women
with complications were treated for spontaneous abortion;
thus, we estimate that 18,700 women were treated in health
facilities for complications of unsafe induced abortion.
For Malawi overall, the rate of treatment for complica-
tions for either type of abortion (induced or spontaneous)
was 10.2 per 1,000 women aged 15–44 (not shown). The
treatment rate was highest in the North (14.0) and lower
in the Central region (10.0) and the South (9.3). The hos-
pitalization rate for complications of unsafe induced abor-
tion was 6.5 per 1,000 women aged 15–44 for the country
as a whole; it was 9.7 in the North, 6.5 in the Central re-
gion and 5.6 in the South.
Induced Abortion
From the Health Professionals Survey, we estimated that
28% of women who had induced abortions in Malawi in
2009 were treated at a health facility; the corresponding
multiplier was 3.6 (range, 2.6–4.6). Applying the multipli-
er to the estimated number of women treated for complica-
tions (18,700) yields an estimate of 67,300 induced abor-
tions (range, 48,600–86,000) in Malawi in 2009 (Table 4).
This is equivalent to an annual induced abortion rate of 23
per 1,000 women aged 15–44 (range, 17–30 per 1,000).
The estimated induced abortion ratio is 12 per 100 live
births (range, 8–15 per 100). Regional differences in the
rate and ratio were similar across measures; the North had
the highest abortion rate (35 per 1,000 women) and ratio
(17 per 100 live births).
Unintended Pregnancy
The overall pregnancy rate in Malawi in 2009 was 269
pregnancies per 1,000 women aged 15–44 (Table 5). This
rate was slightly higher in the North (288) than in the Cen-
tral region (271) and the South (260). The national un-
intended pregnancy rate was 139 per 1,000 women aged
15–44; the rate was slightly higher in the Central region
(148) and lower in the North (128). Overall, 52% of preg-
nancies in Malawi were unintended; again, the propor-
tion was slightly higher than average in the Central region
(54%) and somewhat lower than average in the North
(45%).
DISCUSSION
This study is the first to estimate the incidence of abor-
tion and unintended pregnancy in Malawi, nationally and
regionally. Comparable studies that used the AICM to esti-
The Incidence of Induced Abortion in Malawi
International Perspectives on Sexual and Reproductive Health
94
1990 and 2015.
29
Global recommendations include taking
three major steps to improve maternal and reproductive
health for women: increasing access to family planning;
improving access to quality care during pregnancy and
childbirth; and increasing access to safe abortion services
(to the extent allowed by the law), including provision of
postabortion care for women with complications of in-
duced and spontaneous abortions.
30
Sexually active Malawian women, regardless of age or
marital status, need greater access to family planning ser-
vices and contraceptive choices. In 2010, 46% of married
women reported currently using contraceptives, but an
additional 26% had an unmet need for family planning.
4
Although the use of modern methods by married women
rose from 28% in 2004 to 42% in 2010, our study found a
high unintended pregnancy rate of 139 per 1,000 women
aged 15–44.
4,5
These figures illustrate that women need
better access to contraceptive services (including informa-
tion about and access to a range of methods) to increase
the level of use and to reduce the incidence of contracep-
tive failure resulting from inconsistent and incorrect use.
Young women are especially in need of such services, as
15% of unmarried women aged 15–24 are sexually active,
4
and half of all women seeking postabortion care in Malawi
are aged 15–24 years.
31
As part of an initiative that was started in 2003, the Re-
productive Health Unit of the Malawi Ministry of Health
has been increasing, through provider training and facil-
ity upgrades, the number of public facilities that provide
postabortion care. Continuation of such efforts is needed
to ensure that trained providers and equipped facilities are
paired and distributed in such a way as to provide high
quality coverage for postabortion care throughout the
country. In addition, trained providers need constant ac-
cess to the tools that are critical for reducing maternal mor-
tality: short- and long-term contraceptive methods for the
prevention of unwanted pregnancy, misoprostol for treat-
ment of postpartum hemorrhage, and manual vacuum as-
piration and misoprostol for the treatment of incomplete
abortion.
Unsafe abortion can lead to maternal mortality, and Ma-
lawi has one of the highest maternal mortality rates in the
world; 18% of maternal deaths in the country are attribut-
able to unsafe abortion.
1
The findings of this study warrant
careful consideration as the government and civil society
organizations in Malawi continue efforts to achieve the
Millennium Development Goals and improve the health
of women and their families. At a minimum, needed mea-
sures include continued improvements in access to con-
traceptive services, with a special focus on information
and services for young people both in and out of school,
as well as training in abortion-related care for health care
providers in the public and private sectors. Reforming the
abortion law to allow explicitly for more indications for le-
gal induced abortion, and making these services available,
would reduce the number of women who have complica-
tions of unsafe induced abortion. The health of women
in rural areas, as three-fifths of them were working in ur-
ban areas. Future studies should identify and interview
more key informants with recent rural experience. Finally,
this study does not provide national estimates of the num-
ber of women treated at all facilities, but rather of women
treated at facilities that were believed to be providers of
postabortion care. If some facilities that were not known to
provide postabortion care services were actually providing
these services, our findings may underestimate the num-
ber of women treated for postabortion complications.
We estimated the abortion rate in Malawi in 2009 to be
23 per 1,000 women aged 15–44. The World Health Orga-
nization estimated the incidence rate for Africa as 28 and
for the Eastern Africa subregion (which includes Malawi)
as 36, indicating that our estimate is plausible and that
Malawi may have a somewhat lower rate than is typical of
Eastern Africa.
1
Studies that used a comparable methodol-
ogy have found similar abortion incidence rates in other
African countries, including Burkina Faso (18 per 1,000),
Ethiopia (23), Rwanda (25), Nigeria (25) and Uganda
(56).
15,17,25–27
The multipliers in these studies fall within
a relatively narrow range (3.5–7.3) and are comparable to
the value in our study (3.6), lending further support to our
findings.
Interestingly, the abortion rate in Malawi was highest
in the Northern region. DHS data suggest that married
women in this region have greater access to family plan-
ning than do women elsewhere in Malawi; in 2010, only
24% of women in the North had an unmet need for fam-
ily planning, compared with 27% and 26% in the Central
and Southern regions, respectively.
4
However, use of tradi-
tional methods, which have higher failure rates than mod-
ern methods, is higher in the North (about 8% of married
women) than in the other two regions (where about 3% of
married women use these methods), perhaps accounting
for part of the difference.
4
Other DHS data from 2010 provide cultural and socio-
economic context surrounding these numbers. The pro-
portion of women in the Central region who had had no
schooling was four times that of women in the North, and
at the national level, women with no education had had
their first birth six years earlier than had women with more
than a secondary education (at age 18 vs. age 24). Two
in five women in the Central region had no exposure to
newspapers, television or radio, compared with three out
of 10 women in the North. Seventy percent of women in
the North had been exposed to media-based family plan-
ning messages in the past few months, compared with only
58% of women in the Central region. Therefore, compared
with their counterparts in the North, women in the Central
region are less educated—both in general and in terms of
family planning—and have less exposure to informational
resources, including those that provide family planning
messages.
4
According to the United Nation’s Millennium Develop-
ment Goals monitor, Malawi is “off track” for achieving
goal 5—a 75% reduction in maternal mortality between
Volume 39, Number 2, June 2013 95
20. Malawi National Statistical Office, 2008 Population and Housing
Census Results, Lilongwe, Malawi: National Statistical Office, 2008.
21. Malawi National Statistical Office and United Nations Children’s
Fund (UNICEF), Malawi Multiple Indicator Cluster Survey 2006: Final
Report, Lilongwe, Malawi: Malawi National Statistical Office and
UNICEF, 2008.
22. National Statistical Office, Malawi Second Integrated Household
Survey, 2004–2005, Zomba, Malawi: National Statistical Office, 2005.
23. Bongaarts J and Potter RG, Fertility, Biology and Behavior: An
Analysis of the Proximate Determinants, New York: Academic Press,
1983.
24. Harlap S, Shiono PH and Ramcharan S, A life table of spontane-
ous abortions and the effects of age, parity and other variables, in:
Hook EB and Potter I, eds., Human Embryonic and Fetal Death, New
York: Academic Press, 1980, pp. 145–158.
25. Sedgh G et al., Estimating abortion incidence in Burkina Faso us-
ing two methodologies, Studies in Family Planning, 2011, 42(3):147–
154.
26. Basinga P et al., Abortion incidence and postabortion care in
Rwanda, Studies in Family Planning, 2012, 43(1):11–20.
27. Henshaw S et al., The incidence of induced abortion in Nigeria,
International Family Planning Perspectives, 1998, 24(4):156–164.
28. Rossier C, Estimating induced abortion rates: a review, Studies in
Family Planning, 2003, 34(2):87–102.
29. United Nations, MDG monitor: Malawi, 2010, <http://www.mdg-
monitor.org/country_progress.cfm?c=MWI&cd=454>, accessed July
18, 2010.
30. Women Deliver, Focus on 5: women’s health and the MDGs, 2010,
<http://www.womendeliver.org/knowledge-center/publications/
focus-on-5>, accessed July 15, 2010.
31. Levandowski BA, Reproductive health characteristics of young
Malawian women seeking post-abortion care, African Journal of
Reproductive Health, 2012, 16(2):253–261.
RESUMEN
Contexto: El aborto está legalmente restringido en Malaui y
no hay datos disponibles sobre la incidencia del procedimiento.
Métodos: Se aplicó la Metodología sobre complicaciones rela-
cionadas con la incidencia del aborto para estimar los niveles
de aborto inducido en Malaui en 2009. Los datos relacionados
con la provisión de la atención postaborto fueron recolectados
de 166 instituciones de salud públicas, no gubernamentales
y privadas. Asimismo, 56 informantes clave proporcionaron
estimaciones sobre la probabilidad de que las mujeres que tie-
nen abortos experimenten complicaciones y busquen atención
médica. Se usaron los datos de estas encuestas y de la Encues-
ta Demográfica y de Salud de Malaui de 2010 para calcular
tasas y razones de aborto, así como tasas de embarazo y de
embarazo no planeado.
Resultados: Se estima que en 2009 unas 18.700 mujeres en
Malaui recibieron tratamiento en instituciones de salud por
complicaciones relacionadas con el aborto inducido. Un núme-
ro estimado de 67.300 abortos inducidos fueron practicados,
lo que equivale a una tasa de 23 abortos por 1.000 mujeres en
edades de 15–44 años y una razón de aborto de 12 por 100
nacidos vivos. La tasa de aborto fue más alta en la región Norte
(35 por 1.000) que en las regiones Central o Sur (20–23 por
1.000). La tasa anual de embarazo no planeado en 2010 fue de
139 por 1.000 mujeres en edades de 15–44 años, y se estima
que un 52% del total de los embarazos no fueron planeados.
and their families in Malawi deserves the highest priority.
Because of a restrictive abortion law, almost 70,000 wom-
en in Malawi every year are risking their health and their
lives by having a clandestine abortion.
REFERENCES
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3. WHO et al., Trends in Maternal Mortality: 1990 to 2008, Geneva:
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6. Lema VM et al., Maternal mortality at the Queen Elizabeth Central
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in Kenya, BJOG, 2005, 112(9):1229–1235.
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18. Fetters T, Prospective approach to measuring abortion-related
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The Incidence of Induced Abortion in Malawi
International Perspectives on Sexual and Reproductive Health
96
d’avortements pratiqués est estimé à 67.300, soit un taux de
23 avortements pour mille femmes âgées de 15 à 44 ans et un
ratio de 12 avortements pour cent naissances vivantes. Le taux
d’avortement est supérieur dans la région du nord (35 pour
mille), par rapport à celle du centre ou du sud (20–23 pour
mille). Le taux annuel de grossesse non planifiée a été calculé
en 2010 à 139 pour mille femmes âgées de 15 à 44 ans et les
grossesses non planifiées sont estimées à 52% de l’ensemble
des grossesses.
Conclusions: L’avortement non médicalisé est fréquent au
Malawi. Des interventions sont nécessaires pour aider les
femmes et les couples à éviter les grossesses non désirées, -
duire le recours à l’avortement non médicalisé et faire baisser
la mortalité maternelle.
Acknowledgments
This research was funded primarily by the Consortium for
Research on Unsafe Abortion in Africa and its principal donor, the
UK Department for International Development. Additional fund-
ing was provided by UNFPA Malawi.
Author contact: levandowskib@ipas.org
Conclusión: El aborto inseguro es común en Malaui. Se ne-
cesitan intervenciones para ayudar a las mujeres y parejas a
evitar el embarazo no planeado, reducir la necesidad del abor-
to inseguro y disminuir la mortalidad materna.
RÉSUMÉ
Contexte: L’avortement est limité par la loi au Malawi et au-
cune donnée n’est disponible sur l’incidence de la procédure.
Méthodes: La méthode AICM (Abortion Incidence Compli-
cations Methodology) a été utilisée pour estimer les niveaux
de l’avortement provoqué au Malawi en 2009. Les données de
prestation de soins après avortement ont été collectées auprès
de 166 établissements de santé publics, non gouvernementaux
et privés et les estimations de la probabilité de complications
et de demande de soins parmi les femmes ayant subi un avor-
tement ont été obtenues de 56 témoins privilégiés. Les données
obtenues de ces enquêtes et de l’Enquête démographique et de
santé 2010 du Malawi ont servi à calculer les taux d’avorte-
ment, de grossesse et de grossesse non planifiée.
Résultats: Selon les estimations, 18.700 femmes ont été trai-
tées dans les établissements de santé du Malawi pour com-
plications d’un avortement provoqué en 2009. Le nombre
... Evidence from these studies converge that the interaction between unmet/met needs for contraception is complex. This study extends the frontiers of evidence on the relationship between contraception needs and occurrence of pregnancy termination in SSA, where a high proportion of pregnancies terminated are unsafe [2,18]. ...
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... The AICM uses estimates of post-abortion care caseloads in health facilities, in combination with a multiplier that accounts for the proportion of abortions that will not necessitate facility-based medical care, to create an induced abortion incidence estimate (Singh, Prada, and Juarez 2010). This method has been successfully implemented in over 25 countries with varying degrees of restrictive abortion climates, including 11 in sub-Saharan Africa Basinga et al. 2012;Chae et al. 2017;Henshaw et al. 1998;Keogh et al. 2015;Levandowski et al. 2013;Mohamed et al. 2015;Moore et al. 2016;Polis et al. 2017;Prada et al. 2016;Sedgh et al. 2011;Singh et al. 2005;Sully et al. 2018). The recent rise in the use of medication abortion, which can potentially be accessed from drug stores or the informal sector and has lower rates of complications that require care, means that abortions often do not require any interaction with the medical system. ...
... In a 2010 study, it was found that unsafe abortion was the second leading cause of pregnancy related mortality in Malawi, accounting for nearly one in five of all maternal deaths. Based on the AICM methodology, Levandowski et al. (2013) 95%CI: 22,674) seek PAC at health facilities in Malawi annually. Of the 2,546 women in the study, 27% presented with severe or moderate morbidity. ...
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... This paper uses the Abortion Incidence Complications Method (AICM) [13] to estimate the incidence of induced abortion in Zimbabwe. The AICM has been widely applied in over 25 countries worldwide, including 10 in sub-Saharan Africa [14][15][16][17][18][19][20][21][22][23][24][25][26][27]. The methodology indirectly estimates the incidence of abortion by obtaining a national estimate of the number of PAC cases treated in facilities, and then estimating what proportion of all abortions in the country would result in women receiving PAC. ...
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Background Zimbabwe has the highest contraceptive prevalence rate in sub-Saharan Africa, but also one of the highest maternal mortality ratios in the world. Little is known, however, about the incidence of abortion and post-abortion care (PAC) in Zimbabwe. Access to legal abortion is rare, and limited to circumstances of rape, incest, fetal impairment, or to save the woman’s life. Objectives This paper estimates a) the national provision of PAC, b) the first-ever national incidence of induced abortion in Zimbabwe, and c) the proportion of pregnancies that are unintended. Methods We use the Abortion Incidence Complications Method (AICM), which indirectly estimates the incidence of induced abortion by obtaining a national estimate of PAC cases, and then estimates what proportion of all induced abortions in the country would result in women receiving PAC. Three national surveys were conducted in 2016: a census of health facilities with PAC capacity (n = 227), a prospective survey of women seeking abortion-related care in a nationally-representative sample of those facilities (n = 127 facilities), and a purposive sample of experts knowledgeable about abortion in Zimbabwe (n = 118). The estimate of induced abortion, along with census and Demographic Health Survey data was used to estimate unintended pregnancy. Results There were an estimated 25,245 PAC patients treated in Zimbabwe in 2016, but there were critical gaps in their care, including stock-outs of essential PAC medicines at half of facilities. Approximately 66,847 induced abortions (uncertainty interval (UI): 54,000–86,171) occurred in Zimbabwe in 2016, which translates to a national rate of 17.8 (UI: 14.4–22.9) abortions per 1,000 women 15–49. Overall, 40% of pregnancies were unintended in 2016, and one-quarter of all unintended pregnancies ended in abortion. Conclusion Zimbabwe has one of the lowest abortion rates in sub-Saharan Africa, likely due to high rates of contraceptive use. There are gaps in the health care system affecting the provision of quality PAC, potentially due to the prolonged economic crisis. These findings can inform and improve policies and programs addressing unsafe abortion and PAC in Zimbabwe.
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Introduction The maternal mortality ratio is decreasing globally, although it remains high in Malawi. Unsafe abortion is a major cause and treatment of complications after abortion is a big burden on the health system. Even though manual vacuum aspiration (MVA) is the recommended surgical treatment of incomplete abortions in the first trimester, many hospitals in Malawi continue to use sharp curettage. It is known to have more complications and is more expensive in the long run. The purpose of this study was to determine the effectiveness of a structured MVA training programme in the treatment of incomplete abortions in Malawi. Methods A quasi-experimental before-and-after study design was employed in an MVA training programme for health personnel at three hospitals in Southern Malawi. A total of 53 health personnel at the Queen Elizabeth Central Hospital and the district hospitals of Chikwawa and Chiradzulu (intervention hospitals) were trained in the use of MVA. Kamuzu Central Hospital in Lilongwe and the Thyolo District Hospital served as control institutions. Medical files for all women treated for an incomplete abortion at the study hospitals were reviewed before and after the intervention. Information on demographic and obstetric data and the type of treatment was collected. Results There was a significant increase in the use of MVA from 7.8% (95% CI 5.8 to 10.3) to 29.1% (95% CI 25.9 to 32.5) 1 year after the intervention. In comparison, we found a mere 3% increase in the control hospitals. Conclusions By providing a refresher training programme to health personnel who treat women with incomplete abortions, it was possible to increase the use of MVA as recommended in the Malawi national guidelines.
... Unsafe abortion continues to be a major public health challenge in Malawi. The first nationwide cross-sectional survey on the magnitude of unsafe abortion found that in 2009 an estimated 67 300 abortions occurred 1 and 18 700 women were treated in health facilities for abortion-related complications. 2 Of these women, 15 000 needed uterine evacuation procedures requiring the government to spend an estimated US$314 000 in total. 3 up to 18% of the maternal mortality ratio in Malawi. ...
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Despite adopting a progressive legal and policy framework informed by internationally recognized human rights norms and values, Malawi has not complied with the obligation to explain its abortion law in accordance with legal and human rights standards. In 1930, the colonial government adopted a Penal Code derived from English criminal law, containing provisions regulating access to abortion, but has not undertaken measures to explain when abortion is lawful. What constitutes legal abortion has never been clarified for health providers and potential clients. Consequently, eligible girls and women fail to access safe and legal abortion. The Malawi Law Commission, following its review of the colonial abortion law, has proposed liberal changes which, if implemented, would expand access to safe abortion. However, the immediate step the government ought to take is to clarify the current abortion law, and not to wait for a new law expected to materialize in the indeterminate future. This article is protected by copyright. All rights reserved.
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