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The proposed legislation on termination of pregnancy does not protect women or children in Malawi and is not fit for the intended purpose: Christian Medical and Dental Fellowship position

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MMJ VOL 29 (1): March 2017
Malawi Medical Journal 29 (1): March 2017
Special Section on Malawi Termination of Pregnancy Bill
http://dx.doi.org/10.4314/mmj.v29i1.18
CMDF position 70
This legislation represents a signicant move towards
liberalisation of abortion in Malawi. Those supporting the
legislation have founded their arguments mainly on the
premise that it will protect women and reduce maternal
mortality. We join with them to express our concern with the
high number of maternal deaths in the country and rmly
assert our commitment and role to ensure that no woman
dies from pregnancy-related complications. Aside from the
maternal mortality arguments, many of those supporting
this legislation take a “pro-choice” position, insisting that the
rights of a woman who is pregnant supersede any rights of her
unborn child, sidelining both male (parental) responsibility
and the responsibility of society to take charge of the wider
societal issues raised by “unwanted” pregnancies.
We assert that the bill does not mitigate the problem of
maternal mortality. Detailed study of the proposed clauses
in this bill leads us to conclude that more lives could be lost
if the bill was passed into law. We argue that:
the emphasis on maternal mortality reduction has
been misleading
Malawi has inadequate regulatory frameworks to
verify police reports and ensure that consent is
informed
Malawi has insufcient capacity in expertise to
ensure the accurate diagnosis of non-survivable
congenital abnormality
the proposed legislation provides inadequate
protection against abortion on demand, in the
wording of clause 3-1-b, which cites the prevention
of “injury to the physical or mental health of a
pregnant woman” as grounds for termination of a
pregnancy
the prevailing culture of tolerance towards gender
based and intimate partner violence leaves women
and girls with little choice in areas of reproductive
health
e emphasis on maternal mortality reduction
has been misleading
The recent decline in maternal mortality in Malawi has occurred
despite having the current “restrictive” law.1 Authors agree
that maternal mortality is largely preventable—the consensus
Commentary
e proposed legislation on termination of pregnancy
does not protect women or children in Malawi and
is not t for the intended purpose: Christian Medical
and Dental Fellowshipi position
outside the abortion debate points towards inadequate health
systems and poor access to family planning being the most
signicant contributors to maternal mortality.2 The World
Health Organization (WHO) estimates that roughly 13% of
maternal deaths may be accounted for by unsafe abortions,
but the validity of studies contributing to this estimate
have been questioned.3 Liberalisation of the abortion laws
is not the most effective way to reduce maternal mortality.
At Nkhoma Hospital in rural Lilongwe, maternal mortality
rates fell from 1518/100,000 to 109/100,000 between 2008
and 2015 by improving obstetric care within the connes
of the current restrictive abortion law. (Nkhoma HMIS
data, 2008 to 2015). An in-depth review of 58 maternal
deaths at the same hospital, from 2007 to 2011, showed
that only 3 maternal deaths (5.2%) were related to abortion
complications.4 Most patients experienced a delay in seeking
care (n = 37; 63.8%), a transport delay (n = 43; 74.1%), or
a delay in receiving adequate care (n = 34; 58.6%). These
common and important factors need to be addressed as a
matter of priority if a country wants to improve maternal
outcomes.
Similarly, a study in Mexico found that differences in maternal
deaths between states with restrictive and permissive
abortion laws were not explained by abortion legislation,
but by other factors, such as literacy rates among women,
maternal healthcare, access to clean water, proper sanitation
facilities, fertility rates, and the level of violence against
women. Loosening abortion restrictions did not produce a
drop in maternal mortality rates.5) The study suggests that
developing countries do not need to relax abortion laws to
reduce maternal mortality rates.
Malawi has inadequate regulatory frameworks
to verify that police reports are accurate and
ensure that consent is informed
The suggested rape clause is open to abuse since it is still
possible, in certain cases, to acquire police reports for a fee.
Consent processes remain poorly developed (a situation
affecting a variety of procedures in the medical eld), with
very little required from health workers to ensure that women
and girls fully understand the implications of undergoing
an abortion. “Counselling”, in Malawi, is a term that is
Beatrice Mwagomba1,2,3, M. Jane Bates2,3,7, Reynier G. Ter Haar2,4, Martha Masamba2,5,
Sekeleghe Kayuni2,6,7, Isaac Chirwa2,8
1. Ministry of Health, Lilongwe, Malawi
2. Christian Medical and Dental Fellowship, Malawi
3. College of Medicine, University of Malawi, Blantyre, Malawi
4. Nkhoma Hospital, Nkhoma, Malawi
5. Stellenbosch University, Stellenbosch, South Africa
6. MASM Medi Clinics Limited, Malawi
7. Liverpool School of Tropical Medicine, Liverpool, United Kingdom
8. Asamala Health Services, Lilongwe, Malawi
Correspondence: Dr Jane Bates (mjanebates@gmail.com)
MMJ VOL 29 (1): March 2017
CMDF position 71
http://dx.doi.org/10.4314/mmj.v29i1.18
Malawi Medical Journal 29 (1): March 2017
Special Section on Malawi Termination of Pregnancy Bill
understood to mean “giving advice” rather than listening to
and supporting a person through issues they face, and many
health workers in Malawi are not skilled in patient-centred
counselling. This brings about the risk that vulnerable women
and girls will be advised to a certain course of action without
fully understanding either what is happening to them, or the
potential physical and psychosocial consequences (including
the risks of bleeding and infection).
Malawi has insucient expertise to ensure the
necessary capacity for the accurate diagnosis of
non-survivable congenital abnormality
The legislation proposes that any certied health provider
may perform an abortion in the situation of a congenital
malformation that affects foetal viability or compatibility
with life. This clause refers to very few conditions, which
would be detected by the use of ultrasound scanning.
Initially, the proposed legislation had required subjective
evidence (in the “opinion” of the health worker, and “in
good faith”); this has been changed to require ultrasound
scanning. Malawi has limited health structures, resources, and
stafng in most rural areas, where almost 75% of Malawians
are located. Most facilities are run by only a single nurse, who
is overstretched and supported by unskilled staff. There is
every possibility that abortion would be recommended for
a variety of conditions (for example, hydrocephalus, spina
bida, and Downs syndrome), which are survivable and
amenable to medical intervention.
CMDF recommends that this clause should be removed.
ere is inadequate protection against abortion
on demand in the wording of clause 3-1-b
This clause, which cites prevention of “injury to the physical
or mental health of a pregnant woman” as grounds for
termination of a pregnancy, is not supported by current
data from the scientic literature. While there is an increase
in mental illness resulting from carrying an unwanted
pregnancy, this risk is the same whether the woman has an
abortion or goes on to give birth.6 Additionally, having an
abortion does not reduce the risk of mental illness.
While we recognise that the wording in the proposed bill is
not as liberal as the South African Choice on Termination of
Pregnancy Act 1996,6 the inclusion of this clause (3-1-b) is of
grave concern to us, as it has led other countries to effectively
practice abortion on demand, which the Malawi Special Law
Commission on the Review of the Law on Abortion have
specically stated they want to avoid. A United Kingdom
government report states that 98% of the 2 million abortions
performed in the UK, from 2005 to 2015, took place under
a clause with similar wording to that in clause 3-1-b of the
proposed Malawi Termination of Pregnancy Bill.7 The Special
Law Commission states that the mother should be at risk of
being a “physical or mental wreck” according to assessment
by a psychiatrist. Neither of these statements is appropriate
or realistic. There are no medical or psychiatric criteria to
dene the terms “physical or mental wreck” included in the
Special Law Commission wording. Nationally, psychiatric
services are grossly insufcient to assess these criteria. This
leaves the clause wide open to individual interpretation–a
licence to practise abortion on demand for those who see t.
e prevailing culture of tolerance towards
gender-based and intimate partner violence
leaves women and girls with little choice in
areas of reproductive health
Gender-based violence in Malawi is common and accepted.
National surveys report that 25% of women report
experiencing sexual violence and 38.1% of girls aged 12 to
19 years report that their rst sexual experience was against
their will.8 In this debate, access to abortion is frequently
proposed as the solution to this problem, giving women
“rights”, yet nothing is heard about male responsibility,
and the rights of the unborn are dismissed as of little
consequence. Men are complicit in every pregnancy. Practises
involving coercive sexual intercourse were cited as a reason
for procuring abortion in the strategic review of unsafe
abortion by Jackson et al. published in 2011.9 Traditional
practises and power dynamics often force women and
girls into positions of extreme vulnerability in terms of
negotiating family planning and sexual intercourse itself.
The resulting unwanted pregnancies leave women and girls
with the consequences, knowledge, and experience all their
lives, while men seemingly have nothing to lose and bear no
responsibility for their actions. This bill upholds the current
status quo of male domination in sexual relationships,
with inadequate assessment, consent, and management of
abortion and its complications being just another form of
gender-based violence against women and girls, who would
once again pay the price for “man-made” choices.
There is no provision in the proposed legislation for society
to protect its most vulnerable. Civil society (including
communities of faith) needs to strengthen and implement
messages and activities that reduce gender-based violence.
Women and girls should be equipped with skills and
empowered to negotiate in areas of sexual and reproductive
health. Women should be supported to carry pregnancies to
term and place their children for adoption if they choose.
Malawi is founded on principles of Ubuntu: this should be
upheld in reproductive health to ensure the right to life for
all.
Conclusions
While welcoming the clear process of determination of
suitable laws and involvement of all sectors of the Republic
of Malawi, CMDF does not support the current proposed
legislation on termination of pregnancy. We recommend
that the law continues to support abortion only if the life
of the mother is at risk and call for the removal of the
other clauses. To reduce maternal mortality, CMDF calls
for and works towards access to essential health services,
including the urgent need for improved access to family
planning and more attention to (and management of) the
delays associated with poor pregnancy outcomes. Reduction
in violence against women and girls and better provision
of adoption services are required. Such measures provide
a safe and ethical strategy to reduce the incidence of unsafe
abortion, benetting all sectors including the men, women,
and children (including those yet to be born) of Malawi.
[i] CMDF Malawi is a national inter-denominational fellowship of Christian
doctors and dental surgeons. Since its beginning in 1998 it has been bringing
together Christian medical and dental professionals for mutual encouragement
and fellowship ‘to spur each other on toward love and good deeds’ by optimis-
ing the gifts and resources of our Christian medical and dental fraternity, to
sharpen each other in our faith and walk as Christian doctors and dental sur-
geons. CMDF Malawi is a member of the International Christian Medical and
Dental Fellowship (ICMDA), a global movement of over 80 countries.
MMJ VOL 29 (1): March 2017
Malawi Medical Journal 29 (1): March 2017
Special Section on Malawi Termination of Pregnancy Bill
http://dx.doi.org/10.4314/mmj.v29i1.18
CMDF position 72
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Available from: http:// www.healthpolicyproject.com/pubs A strategic assessment of unsafe abortion in Malawi
  • Br Johnson
  • H Gebreselassie
  • Gd Kangaude
  • C Mhango
Gender-based Violence in Malawi: A Literature Review to Inform the National Response-436_FINALHPPMalawiGBVLiteratureReview .pdf [Internet]. [cited 2016 Nov 15]. Available from: http:// www.healthpolicyproject.com/pubs/436_FINALHPPMalawi GBVLiteratureReview.pdf 9. Jackson E, Johnson BR, Gebreselassie H, Kangaude GD, Mhango C. A strategic assessment of unsafe abortion in Malawi. Reprod Health Matters. 2011 May;19(37):133-43.