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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

MMJ VOL 29 (1): March 2017
Malawi Medical Journal 29 (1): March 2017
Special Section on Malawi Termination of Pregnancy Bill
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
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
the prevailing culture of tolerance towards gender
based and intimate partner violence leaves women
and girls with little choice in areas of reproductive
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
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
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 (
MMJ VOL 29 (1): March 2017
CMDF position 71
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
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
CMDF position 72
1. Colbourn T, Lewycka S, Nambiar B, Anwar I, Phoya A, Mhango
C. Maternal mortality in Malawi, 1977–2012. BMJ Open. 2013 Jan
2. Bazile J, Rigodon J, Berman L, Boulanger VM, Maistrellis E,
Kausiwa P, et al. Intergenerational impacts of maternal mortality:
Qualitative ndings from rural Malawi. Reprod Health. 2015;12(1):S1.
3. Gerdts C, Vohra D, Ahern J. Measuring Unsafe Abortion-Related
Mortality: A Systematic Review of the Existing Methods. PLoS ONE
[Internet]. 2013 Jan 14 [cited 2016 Nov 13];8(1). Available from: http://
4. Vink NM, de Jonge HCC, Ter Haar R, Chizimba EM, Stekelenburg
J. Maternal death reviews at a rural hospital in Malawi. Int J Gynaecol
Obstet O Organ Int Fed Gynaecol Obstet. 2013 Jan;120(1):74–7.
5. Koch E, Chireau M, Pliego F, Stanford J, Haddad S, Calhoun B, et
al. Abortion legislation, maternal healthcare, fertility, female literacy,
sanitation, violence against women and maternal deaths: a natural
experiment in 32 Mexican states. BMJ Open. 2015 Jan 2;5(2):e006013.
6. Choice on Termination of Pregnancy Act 92 of 1996 – Act92of1996.
pdf [Internet]. [cited 2016 Nov 15]. Available from:
7. Abortion statistics, England and Wales: 2015 – Statistical data sets –
GOV.UK [Internet]. [cited 2016 Nov 15]. Available from: https://www.
8. Gender-based Violence in Malawi: A Literature Review to Inform the
National Response 436_FINALHPPMalawiGBVLiteratureReview
.pdf [Internet]. [cited 2016 Nov 15]. Available from: http://
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.
Full-text available
More research is needed to document both the value of eHealth for strengthening resource-limited health systems and the challenges involved in their implementation and adoption, so that insights from such research may be used to inform future initiatives. While many studies of eHealth for patient care in low- and middle-income countries (LMIC) are taking place, evidence of its role in improving administrative processes such as financial management is lacking, despite the importance of ‘good governance’ (transparency and accountability) for ensuring strong and resilient health systems. The overall objective of this PhD was to elucidate the enablers, inhibitors and outcomes characterising the implementation and adoption of a modular eHealth system in a group of healthcare facilities in rural Malawi. The system included both clinical and billing modules. The specific objectives were (i) to understand the socio-technical, organisational and change management factors facilitating or hindering the implementation and adoption of the eHealth system, (ii) to assess the quality of data captured by the eHealth system compared with conventional paper-based records, and (iii) to understand how information within the eHealth system was used for service delivery, reporting and financial management. A further aim was to contribute to the corpus of mixed-methods case studies exploring eHealth system implementation processes and outcomes (including data quality) in LMIC. As described in the following chapters, the research also gave rise to unanticipated and serendipitous findings, which led to new lines of enquiry and influenced the theoretical perspectives from which the analysis drew. For the hospital case study (Case Study 1), a retrospective single-case embedded design was employed, with outpatient and inpatient departments being the two units of analysis. Qualitative data included document review and in-depth key informant interviews, while quantitative data was obtained from the web-based District Health Information System (DHIS2), patient files and the hospital’s finance records. For the study of primary health centres (Case Study 2), a single-case embedded design was also used, with the rollout project as the case and the three units of analysis being 3 Early Adopter Facilities, 4 Late Majority facilities and 2 Laggard facilities. This case study used a prospective design, with data being collected 7 months and 24 months after implementation of the eHealth system due to a mismatch between the independent eHealth implementation project and the PhD research. Data sources included documentation screened against the criteria listed in the Performance of Routine Information System Management (PRISM) tools, information extracted from the eHealth system, health indicators drawn from DHIS2 and qualitative data from focus group discussions. In both case studies, framework analysis was used for qualitative data with the aid of NVivo, while quantitative data was analysed by calculating data completeness, accuracy and agreement. Descriptive statistics and the Mann-Whitney U-test were used for analysing finance data in Case Study 1. Content analysis was also used to gain insights from Case Study 2 aided by SPSS. Converging the results of these two case studies illustrates the potential of eHealth to strengthen LMIC health systems through developing human resource capacity (skills, staff roles), facilitating service delivery, and improving financial management and governance. However, realising such improvements is dependent upon understanding the socio-technical interactions mediating the integration of new systems into organisational processes and work practices, and implementing appropriate change management interventions. The results of this study suggest that, for effective implementation and adoption of eHealth systems, healthcare leaders should (1) recruit data entry clerks to relieve clinical staff, improve workflow and avoid data fraud, (2) facilitate appropriate data use among system users and an information culture at the facilities, and (3) strengthen knowledge and skills transfer from eHealth system developers to local implementers and system champions, to optimise responsiveness and ensure sustainability. Further interdisciplinary research is needed to obtain additional insights into factors affecting the quality of eHealth data and its use in the management of LMIC health systems, including the role of social, professional and technological influences on financial good-governance.
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Maternal mortality, although largely preventable, remains unacceptably high in developing countries such as Malawi and creates a number of intergenerational impacts. Few studies have investigated the far-reaching impacts of maternal death beyond infant survival. This study demonstrates the short- and long-term impacts of maternal death on children, families, and the community in order to raise awareness of the true costs of maternal mortality and poor maternal health care in Neno, a rural and remote district in Malawi. Qualitative in-depth interviews were conducted to assess the impact of maternal mortality on child, family, and community well-being. We conducted 20 key informant interviews, 20 stakeholder interviews, and six sex-stratified focus group discussions in the seven health centers that cover the district. Transcripts were translated, coded, and analyzed in NVivo 10. Participants noted a number of far-reaching impacts on orphaned children, their new caretakers, and extended families following a maternal death. Female relatives typically took on caregiving responsibilities for orphaned children, regardless of the accompanying financial hardship and frequent lack of familial or governmental support. Maternal death exacerbated children's vulnerabilities to long-term health and social impacts related to nutrition, education, employment, early partnership, pregnancy, and caretaking. Impacts were particularly salient for female children who were often forced to take on the majority of the household responsibilities. Participants cited a number of barriers to accessing quality child health care or support services, and many were unaware of programming available to assist them in raising orphaned children or how to access these services. In order to both reduce preventable maternal mortality and diminish the impacts on children, extended families, and communities, our findings highlight the importance of financing and implementing universal access to emergency obstetric and neonatal care, and contraception, as well as social protection programs, including among remote populations.
Full-text available
To test whether there is an association between abortion legislation and maternal mortality outcomes after controlling for other factors thought to influence maternal health. Population-based natural experiment. Official maternal mortality data from 32 federal states of Mexico between 2002 and 2011. Maternal mortality ratio (MMR), MMR with any abortive outcome (MMRAO) and induced abortion mortality ratio (iAMR). Abortion legislation grouped as less (n=18) or more permissive (n=14); constitutional amendment protecting the unborn (n=17); skilled attendance at birth; all-abortion hospitalisation ratio; low birth weight rate; contraceptive use; total fertility rates (TFR); clean water; sanitation; female literacy rate and intimate-partner violence. Over the 10-year period, states with less permissive abortion legislation exhibited lower MMR (38.3 vs 49.6; p<0.001), MMRAO (2.7 vs 3.7; p<0.001) and iAMR (0.9 vs 1.7; p<0.001) than more permissive states. Multivariate regression models estimating effect sizes (β-coefficients) for mortality outcomes showed independent associations (p values between 0.001 and 0.055) with female literacy (β=-0.061 to -1.100), skilled attendance at birth (β=-0.032 to -0.427), low birth weight (β=0.149 to 2.166), all-abortion hospitalisation ratio (β=-0.566 to -0.962), clean water (β=-0.048 to -0.730), sanitation (β=-0.052 to -0.758) and intimate-partner violence (β=0.085 to 0.755). TFR showed an inverse association with MMR (β=-14.329) and MMRAO (β=-1.750) and a direct association with iAMR (β=1.383). Altogether, these factors accounted for (R(2)) 51-88% of the variance among states in overall mortality rates. No statistically independent effect was observed for abortion legislation, constitutional amendment or other covariates. Although less permissive states exhibited consistently lower maternal mortality rates, this finding was not explained by abortion legislation itself. Rather, these differences were explained by other independent factors, which appeared to have a more favourable distribution in these states. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to
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Millennium Development Goal 5 (MDG 5) targets a 75% reduction in maternal mortality from 1990 to 2015, yet accurate information on trends in maternal mortality and what drives them is sparse. We aimed to fill this gap for Malawi, a country in sub-Saharan Africa with high maternal mortality. We reviewed the literature for population-based studies that provide estimates of the maternal mortality ratio (MMR) in Malawi, and for studies that list and justify variables potentially associated with trends in MMR. We used all population-based estimates of MMR representative of the whole of Malawi to construct a best-fit trend-line for the range of years with available data, calculated the proportion attributable to HIV and qualitatively analysed trends and evidence related to other covariates to logically assess likely candidate drivers of the observed trend in MMR. 14 suitable estimates of MMR were found, covering the years 1977-2010. The resulting best-fit line predicted MMR in Malawi to have increased from 317 maternal deaths/100 000 live-births in 1980 to 748 in 1990, before peaking at 971 in 1999, and falling to 846 in 2005 and 484 in 2010. Concurrent deteriorations and improvements in HIV and health system investment and provisions are the most plausible explanations for the trend. Female literacy and education, family planning and poverty reduction could play more of a role if thresholds are passed in the coming years. The decrease in MMR in Malawi is encouraging as it appears that recent efforts to control HIV and improve the health system are bearing fruit. Sustained efforts to prevent and treat maternal complications are required if Malawi is to attain the MDG 5 target and save the lives of more of its mothers in years to come.
Full-text available
The WHO estimates that 13% of maternal mortality is due to unsafe abortion, but challenges with measurement and data quality persist. To our knowledge, no systematic assessment of the validity of studies reporting estimates of abortion-related mortality exists. TO BE INCLUDED IN THIS STUDY, ARTICLES HAD TO MEET THE FOLLOWING CRITERIA: (1) published between September 1(st), 2000-December 1(st), 2011; (2) utilized data from a country where abortion is "considered unsafe"; (3) specified and enumerated causes of maternal death including "abortion"; (4) enumerated ≥100 maternal deaths; (5) a quantitative research study; (6) published in a peer-reviewed journal. 7,438 articles were initially identified. Thirty-six studies were ultimately included. Overall, studies rated "Very Good" found the highest estimates of abortion related mortality (median 16%, range 1-27.4%). Studies rated "Very Poor" found the lowest overall proportion of abortion related deaths (median: 2%, range 1.3-9.4%). Improvements in the quality of data collection would facilitate better understanding global abortion-related mortality. Until improved data exist, better reporting of study procedures and standardization of the definition of abortion and abortion-related mortality should be encouraged.
Objective: To analyze maternal deaths at Nkhoma Church of Central Africa Presbyterian (CCAP) Hospital and identify factors causing delays in care. Methods: Maternal death audits are performed after every maternal death at Nkhoma CCAP Hospital. Information regarding the care provided at the health facility, the referral process, and any delays in the community was collected by an audit team using a structured approach. Data from August 2007 to September 2011 were analyzed retrospectively. Results: In total, 61 maternal deaths occurred during the study period, of which 58 were analyzed. Most deaths were categorized as indirect (n=34 [58.6%]). Non-pregnancy-related infections were the leading cause of indirect death (n=22), with meningitis the most common (n=13). 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%]). Conclusion: Most maternal deaths had indirect causes and were associated with delays in all phases. An audit makes clear which part of the referral chain needs to be strengthened. Nkhoma CCAP Hospital has taken steps to address all phases of delay.
As part of efforts to achieve Millennium Development Goal 5--to reduce maternal mortality by 75% and achieve universal access to reproductive health by 2015--the Malawi Ministry of Health conducted a strategic assessment of unsafe abortion in Malawi. This paper describes the findings of the assessment, including a human rights-based review of Malawi's laws, policies and international agreements relating to sexual and reproductive health and data from 485 in-depth interviews about sexual and reproductive health, maternal mortality and unsafe abortion, conducted with Malawians from all parts of the country and social strata. Consensus recommendations to address the issue of unsafe abortion were developed by a broad base of local and international stakeholders during a national dissemination meeting. Malawi's restrictive abortion law, inaccessibility of safe abortion services, particularly for poor and young women, and lack of adequate family planning, youth-friendly and post-abortion care services were the most important barriers. The consensus reached was that to make abortion safe in Malawi, there were four areas for urgent action--abortion law reform; sexuality education and family planning; adolescent sexual and reproductive health services; and post-abortion care services.
Available from: http:// 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:// 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.