Unsafe terminations in Malawi may be curbed after a new law is enacted, but it’s just the first step.
Christina Olofala’s* mother, Eda*, tried to stifle the young woman’s loud groans as she writhed about on the mud floor of Eda’s hut in eastern Malawi, her body wracked with pain. The early morning sun was still hanging pale and low on the horizon and it was cool inside, but Christina (25) was drenched in sweat. Eda feared the noise would attract attention: Malawian culture demands that neighbours rush over to offer comfort when they hear someone crying out loud.
The previous night Eda had helped her daughter to drink a potion they had been told would terminate Christina’s pregnancy. They were given the concoction by a traditional birth attendant and thought it would be safe.
If anyone found out about it, Eda and Christina could be reported to the police and arrested.
Under Malawi’s penal code, abortion is only allowed if it will save the life of a pregnant woman or girl. Not even women who have been raped qualify for abortions. Anyone helping a woman to abort is guilty of a felony and may be jailed for up to 14 years.
Christina became uncontrollable. She was bleeding heavily. When she fainted, she was rushed to the Mangochi district hospital, where she had an emergency procedure to clear the uterine lining from inside the uterus.
With Eda by her side, she is now recovering in the hospital. Christina decided that she wanted to abort the foetus because her family is poor. “I have a three-month-old baby. We are struggling to raise our three children. The baby is too small and needs all my attention,” she explains.
The Malawian government has come under increasing pressure to relax its stringent conditions on abortion. In 2015, the United Nations committee on the elimination of discrimination against women called on the government to implement laws and policies to expand access to safe and legal abortion. It pointed to the high number of teenage pregnancies as well as the country’s limited access to modern contraceptives.
Christina’s husband doesn’t know about her pregnancy, let alone the unsafe abortion.
“I told him I had terrible menstrual pains before. I took advantage of our culture. Men don’t get involved … Even staying as a guardian at the hospital is taboo,” Christina says, pulling her faded yellow gown tight around her shoulders.
Reform does not come easy
Medical staff at the Mangochi district hospital are used to seeing women like Christina. Each month the female ward admits 40 to 70 women for post-abortion care, says Euvintio Kambalane, the hospital’s clinical officer and safe motherhood co-ordinator. The women are mostly aged between 16 and 25.
“It’s hard to know whether the abortions were spontaneous or induced until we look at their history. Most of them hide whether they induced the abortion because they are afraid of being arrested,” he explains.
Malawi’s restrictive anti-abortion law has led to nearly 70 000 Malawian women seeking unsafe abortions each year, according to a 2013 study published in International Perspectives on Sexual and Reproductive Health. More than 18 000 women were treated in health facilities for complications from unsafely performed abortions in 2009.
Yet there has been strong opposition to the government’s current efforts to liberalise its abortion law to reduce unsafe abortions.
A special law commission was set up in 2013 to rewrite the law and the government has worked with several partners, including the Coalition for the Prevention of Unsafe Abortion, to reform the process. Traditional and religious leaders in particular have been hard to convince.
The Termination of Pregnancy Bill, which was drafted in 2015, will allow women to seek abortion in circumstances that include rape, incest or defilement or when the pregnancy poses a threat to the woman’s health. It will also extend to cases where there is severe malformation of the foetus.
The head of the influential Catholic Church in Malawi has reportedly condemned the Bill, calling on the Catholic faithful to oppose it. Church leaders have accused the government of caving in to foreign pressure and promoting a “culture of death”.
Women suffer in silence
Esnart Kasau* (28) is also recovering in the Mangochi district hospital. Esnart has had two abortions, both with the help of traditional birth attendants. These women were traditional community midwives, but the government banned them from delivering babies. Instead, they were told to encourage women to give birth at health facilities and to do antenatal visits.
“The minimum charge [for a backstreet abortion] is K10 000 [about $14], depending on how advanced the pregnancy is,” Esnart says.
Black-market abortion providers not only dish out concoctions of mysterious ingredients, she explains, but also issue patients with sticks from the cassava plant and others to assist with aborting the foetus.
“I was given a nkhadze stick [a local plant] to insert. It was painful … but I had no choice,” she says, as a slow trickle of tears make its way down her face. “Days later things worsened.”
It was too late to save her uterus. Esnart is lucky doctors could save her life.
Unsafe abortion is mainly a burden of women in rural areas, according to Laston Chikoti, reproductive health officer in Malawi’s ministry of health. In his experience, women also attempt home abortions by drinking washing powder and inserting wire into their vaginas.
“Usually, women suffer in silence until these objects rot. Chances of them taking poisonous [substances]are very high, hence the many deaths,” he says.
The stigma associated with abortion drives women underground, says Luke Tembo, policy adviser for the Coalition for the Prevention of Unsafe Abortion. “Sadly, most of them either live with permanent disability or die as a result of not seeking post-abortion care.”
Esnart says she had to risk her life and received no support from her boyfriend. Like many other women in rural areas, she had no access to suitable contraceptives.
Malawian women have roughly 487 000 unintended pregnancies each year, a November 2014 study by the Guttmacher Institute found. Most of these — nearly nine out of 10 — were among women not using contraception. Four in 10 women who are at risk of falling pregnant still use no contraceptive method or only an ineffective traditional one, according to the study. Reasons cited for not using contraception include the cost, untrained family planning service providers as well as frequent stockouts of contraceptives.
An unlikely ally
Reproductive health rights groups have criticised the country’s Termination of Pregnancy Bill, saying it does not provide for termination of pregnancy on socioeconomic grounds or include abortion on demand. They have also complained about the proviso that rape victims will have to report it to the police before they can ask for an abortion.
At the earliest, the Bill could become law in 2017, when it will likely have been passed by Malawi’s Parliament.
Meanwhile, some support has emerged from what was previously thought to be an unlikely ally: the Malawi Council of Churches (MCC), an umbrella organisation of 25 churches.
The body announced it was backing the amendment at the beginning of November. This has been described as an important development, as the MCC is Malawi’s largest grouping of churches.
“The support of the MCC is very significant in cementing the support needed to have the Bill debated and passed in Parliament,” says Tembo.
He expects the law to be enacted next year, but admits it will only be “the first step in the unsafe abortion scourge”.
“We are very aware of the attitude and stigma associated with abortion as one of the barriers,” Tembo says.
“We are working with traditional leaders … to address the attitudes and stigma at community level.”
The aim is to demystify abortion, he explains, so that termination of pregnancy can be discussed freely once the law has been changed — and so that women can use the services.
— Additional reporting by Adri Kotze
* Not their real names