Since January, my Fellowship in Global Health & Vulnerable Populations has taken me to St. Gabriel's Hospital, a rural district hospital in Malawi. For the past two months, I’ve been tending to the bedside of patients in St. Gabriel’s Female Ward. Those admitted here come either because of an internal medicine or gynecological problem (labour & delivery has it’s own dedicated unit). A pattern I’ve observed these past months has been the disproportionate number of women admitted with incomplete abortions – miscarriages in which only part or none of the non-viable fetus has been delivered. Digging a little deeper has led me to the conclusion that the criminalization of therapeutic or induced abortions plays a significant role in this unexpected trend.
Malawi suffers from one of the highest maternal mortality and pregnancy associated death rates in the world. At 1120 deaths per 100 000 births , it is stands in stark contrast to the rate of 7.8 per 100 000 in Canada . Of these pregnancy related deaths, unsafe abortions represent the second leading cause of mortality (18%) and are the leading cause of obstetric complications . Malawi is also a socially conservative society, one in which induced abortions are criminal acts. It is a country that has only recently engaged in a public debate on the decriminalization of homosexuality . Abortion however, remains off the public policy radar. For the near future, it will remain a criminal act with up to seven years imprisonment for women soliciting it and fourteen for those providing it.
Though the statistics speak for themselves, they cannot be divorced from the harsh realities on the ground. Women desperate for the procedure, whether because of financial circumstances, a desire to stay in school or partner insistence, find a way to receive it. There are apparently some, though very few, trained health professional willing to risk imprisonment. Those women that find them are the wealthy or well-connected few. Others find health providers, trained or untrained, willing to provide less risky half-measures. They will initiate the first part of the induced abortion by administering medication causing fetal non-viability. Women are then instructed to present to hospital and recite a history consistent with a miscarriage. Clinicians find a non-viable pregnancy and carry out the second, instrumented part of the procedure. Other women, the most socially and/or geographically isolated, are left with even fewer options – they take a chance with shockingly unsafe ‘home-based’ procedures. These are the most heart breaking patient stories.
One of these stories comes from a teenager on the cusp of finishing her schooling. Only 19 years old, she presented to St. Gabriel’s with vaginal bleeding and having gone 12 weeks without a period. Initially evasive with the admitting clinician, after support from her parents she volunteered that the bleeding was the result of an unskilled and unsafe abortion. The ‘procedure’ was done with a stick of cassava, the same that litter the ground on market days. By the time she presented to hospital, her uterus had perforated and the tissue that remained inside harboured a massive infection. To save her life, a hysterectomy was performed (her uterus was removed). She is one of the fortunate, having accessed hospital based care at the insistence of supporting parents. And though she will not be counted in pregnancy associated mortality rates, she is now a 19 year old with no chance of bearing her own children, and must live with the psychological consequences and social stigma such a label carries.
For those who staunchly support criminalization laws like the ones on the books here, it may tempting to condemn women like the teenager I’ve just described. Others who hold strong personal beliefs about when life begins and offer silent consent to those advancing unsafe public policy may feel the moral conviction to do the same. But neither attitude will change the reality that induced abortions will always occur. As long as segments within global society encourage finger waving over action aimed at reducing abortion-associated death and disfigurement, women will continue to suffer enourmous physical and psychological harm. And though I have only now, in Malawi, seen such consequences, as a Canadian I am hardly a passive observer. Though abortion laws in Malawi and Canada are very different, the Canadian government gives its tacit support to criminalization abroad. Prime Minister Harper’s ‘Muskoka Initiative’ supports maternal health only in countries where abortion is illegal . This is unacceptable and has consequences in countries like Malawi, where Canadian foreign aid flows and access to safe abortion services go hand-in-hand with reducing maternal mortality.
This post originally appeared at http://malawimd.wordpress.com/ where I've been writing since my arrival in Malawi. It has been cross-posted it because of its common 'Politics & Health' theme.