Dr.

Caroline Tatua

IntroductionWhat would you do and why?

A 14 year old girl comes to you and says she has an

unplanned and unwanted pregnancy (6 weeks) and she wants you to terminate because she needs to stay in school. A 27 year old woman comes to you and says she is pregnant as a result of being raped and she wants to terminate on those grounds. A 40 year old woman is pregnant but has a heart condition that threatens her life if she carries the pregnancy to term, and wants to terminate.

The regulatory framework

LEGAL FRAMEWORK Sets the boundaries POLICY FRAMEWORK Provides direction within the boundaries

Law governing access to and provision of abortion care

CONSTITUTION Bill of Rights eg Right to life, dignity, equality, freedom of conscience LEGISLATION (SUBSIDIARY LEGISLATION, RULES OR REGULATIONS) Sections 149 151 read with Section 243 of the Penal Code Sections 10 12 Medical Practitioners and Dentists Act Medical Council of Malawi - Code of Ethics and Professional Conduct COURT DECISIONS COMMON LAW Eg Rex vs Bourne INTERNATIONAL HUMAN RIGHTS LAW Treaties eg. Protocol to the African Charter on the Rights of Women in Africa Decisions by judicial bodies OTHER Religious law eg. Canon Law (Catholic Church) Customary law Ethics

Offences Against the Person Act of England of 1861, section 58

This is the origin of Malawi abortion law word for word: Any person who, with intent to procure miscarriage of a woman, whether she is or is

not with child, unlawfully administers to her or causes her to take any poison or other noxious thing , or uses any force of any kind, or uses any other means whatever, is guilty of a felony and is liable to imprisonment for fourteen years.

The boundaries
THE PENAL CODE Any person who , with intent to procure a miscarriage of a woman whether she is or is without a child.shall be guilty of a felony and shall be liable for imprisonment for 14 years (Section 149)
Any woman who being with child, unlawfully terminates her

pregnancy is guilty of a felony and will be liable to 7 years imprisonment (Section 150)
Any person who unlawfully provides to means to terminate pregnancy

to the woman will be liable to 3 years imprisonment (Section 151)

A person will not be criminally liable if he/she in order to preserve the

womans life, does harm to the foetus (Section 243)

The Boundaries:
Code of Ethics and Professional Conduct (Medical Council of Malawi). The Laws of Malawi prohibit the termination of pregnancy on demand. Practitioners found guilty of procuring or attempting to procure abortions or miscarriages are liable to severe penalties under the Penal Code (Cap: 7:01). In all cases of illegal termination of pregnancies, the penalty shall be suspension or erasure from a register (Section 5.1)

Policy on abortion care: some important documents

Malawi Growth and Development Strategy 20062011 2007 Road Map for Accelerating the Reduction of

Maternal and Neonatal Mortality and Morbidity in Malawi Reproductive Health Strategy National Sexual and Reproductive Health and Rights Policy 2009 (SRHR Policy)

Policy highlights
Government will provide Post Abortion Care (various RH

documents) National SRHR Policy- Section 3.2 Maternal and Neonatal Health.
Service providers in the public and private sectors shall provide

or refer for safe abortion to the full extent of the laws of Malawi all women deemed to require or requesting the termination of their pregnancies (Article 3.2.2.11 of National SRHR policy)
All women who have complications of abortion shall have access

to quality post abortion services, including post abortion counselling and family planning to avoid repeat abortions. (Article 3.2.2.9 of SRHR Policy)

Policy Highlights:
Manual Vacuum Aspiration shall be the main method

for managing incomplete abortion where gestational age permits (Art.3.2.2.10 of SRHR Policy)

Abortion care to the full extent of the law in Malawi

Termination done in good faith with reasonable care to preserve the life of the pregnant woman Does this include: Girl who is too young to carry pregnancy (10 years old)? Girl who threatens to commit suicide if she does not have termination? Woman who is sickly because her immune system is compromised? A woman who gets pregnant at 54?

Interpretation for implementers

Law and policy on abortion in Malawi may not

offer clear guidance on what health professionals should do under a diversity of circumstances (compare with Ethiopia, Zambia and South Africa Law on abortion handouts) There is need for standards and guidelines which interpret the law and policies:
To make things clear and protect health

professionals from being accused of over-stepping boundaries To ensure quality of care

Effects of restricting safe abortion on maternal mortality: The case of Romania

200 180 160

Deaths per 100,000 live births

140 120 100 80 60 40 20 0

1960

1962

1964

1966

1968

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

Maternal mortality rate

Abortion related

Obstetrical risk

13

2002

From reality to the ideal

Law and policy out of touch with reality women and

girls continue seeking abortion for reasons other than stated by law. Due to fear of prosecution and stigma, abortions are usually clandestine. Clandestine abortions are more likely to be unsafe even if carried out by a skilled provider. Women and girls should have access to safe abortion when they need, not when the government thinks it is right Need for legal and policy reform

Abortion data:
Research: 3 studies Magnitude study Strategic assessment Cost study
Health systems improvement in 38 hospitals

in Central West Zone Support for policy change (COPUA)

Magnitude study summary findings:

Over 100,000 induced abortions annually in Malawi.
Over 30,000 women treated annually for induced abortion
8 of 10 women in study were married Half were under the age of 25. Half had attended at least primary school 2 of 3 women were from rural areas

complications in health facilities 31,021,( MoH Malawi, 2009)(9

Strategic assessment: Process

WHO human rights tool to review laws, policies and

regulations on abortion was adapted for Malawi.

Governmental bodies; human rights groups; NGOs

2-week field assessment by 24 stakeholders: Inputs from 485 people in 10 health districts In-depth interviews and focus group discussions; visits

to health facilities were some of the approaches used.

Strategic assessment: Findings

Nearly everyone knew or had heard about: Someone who had induced an abortion Women who had complications from unsafe abortion Methods used to induce abortion Where to seek abortion services Why women and girls choose to induce abortion That abortion is prohibited but not exactly what the law says

Strategic assessment: Findings (cont.)

Most respondents felt: Poor girls and women have unsafe abortions because they cant pay for a safe one elsewhere The strict law does not prevent abortion and is not enforced Despite personal opposition, it is necessary for government to increase indications for legal abortion Young women have particular challenges (lack of skills in SHR issues; lack of services; poor provider attitudes)

Strategic assessment: Findings (cont.)

PAC and Family Planning Service Findings:
Commodity stockouts (MVA kits, FP methods) Contraception uptake is low Insufficient staffing Long queues, delays in offering services Myths about FP methods Poor knowledge and use of EC

Public Health Facility Costs of Treatment of Abortion Complications in Malawi

The costs of unsafe abortion

Objectives if the study:
To determine how much money public health facilities

spend on resources directly related to providing of postabortion care (PAC) services

Medications Clinical supplies Staff time

To determine how much money could be saved and used

for other health care needs if we reduce morbidity from unsafe abortion

Eliminating unsafe abortion

After shifting to safe abortion, $435,000 per year could

become available to spend on other health care needs in public facilities in Malawi Shifting to safe abortion with WHO-recommended methods will decrease unsafe abortion complication rates This is better for women, families, and the health system

Dissemination of cost data

Policy makers- will help to change policy which will

reduce cost on management of unsafe abortion DHMT Promote health workers to scale up the cost effective technologies Community -they will have knowledge to demand the services -Early good health seeking behaviors

What do the studies bring out?

o Unsafe abortion is common and a well known SRH

problem

o Current laws are ineffective in preventing abortions and

lead to abortion complications

o Views are often conservative and influenced by religion

o Nevertheless, preference for abortion to be more

accessible to improve safety

Conclusions from studies (cont.)

Needs:
o Increase access to contraceptive services o Training in abortion-related care for

health care providers in both the public and private sectors o Reform abortion policies/law to allow for more indications for induced abortion

WHO Statement on Abortion Laws

Whether abortion is legally restricted

or available on request, a womans likelyhood of having an unwanted pregnancy is about the same.
The legal status of abortion has no

effect on a womans need for abortion. Legal restrictions and other barriers force women to seek abortion from unskilled providers, or self-induce it

Abortion Rates Are Similar Regardless of the Law

Region Africa Asia Europe North America World Rate 29 29 28 21 29

What can health providers do?

Facilitate bridging the gap between experience and

policy so that law and policy responds to lived realities of women and girls Provide services to the fullest extent of the law (Comprehensive Abortion Care); clarify boundaries, call for standards and guidelines on provision of abortion care For those who can - Advocate for policy and legal reform