How a Change in U.S. Abortion Policy Threatens Lives in Malawi

“On average, in a day, sometimes we handle about ten women related to abortion cases,” Sylvester Zimba explains to a reporter from Vice News in August of 2017. Zimba is a nurse who specializes in post-abortion care at Kasungu District Hospital, a small clinic in rural Malawi and the sole medical facility for 600,000 people.

Zimba explains that many women come to the clinic claiming they have experienced a spontaneous abortion despite what a later examination usually reveals: informal, induced procedures generally referred to as “back alley abortions” commonly cause life-threatening complications for which professional medical attention is required.

Abortion is illegal in Malawi and punishable by seven to 14 years in prison. Because of this, many women turn to local “witchdoctors” or try to abort at home–dangerous alternatives that usually result in severe health complications. “We find objects like bicycle spokes, cassava sticks, herbs—all sorts of foreign objects,” Zimba says.

Abortion is quite common in Malawi, but the majority of these procedures are performed under “clandestine and unsafe conditions.” For example, some researchers have concluded that over 141,000 back alley abortions were performed in Malawi in 2015 alone. Largely due to severe poverty, legal restrictions on abortion, and cultural stigmas associated with reproductive care, Malawi has some of the highest maternal mortality rates in the world. Unsafe abortions are estimated to account for 6%-18% of all maternal deaths in the country.

In light of these disturbing statistics, Malawi’s government has introduced a bill that would decriminalize abortion in the case of rape, fetal anomaly, and mental health, effectively upending the country’s 157-year-old abortion ban and offsetting some of the high costs associated with post-abortion care. Chisale Mhango, an obstetrician at Malawi’s largest referral health facility, Queen Elizabeth Central Hospital, reported that “In 2015, the studies suggested that we were spending more than $2 million just to manage complications of unsafe abortion and yet the Ministry of Health budget is not increasing.” Currently, it is estimated that the Malawi government spends about $1 million annually on post-abortion care.

While the bill has not yet passed, there has already been a major backlash from organizations interested in keeping abortion illegal, despite the significant public health and fiscal implications the current restrictions pose. Additionally, interference from a U.S. policy perspective has weighed significantly in both political and cultural terms.

The Global Gag Rule (also known as the Mexico City Policy) is a U.S. policy which states that any foreign organization will lose its funding when it uses its own money to offer abortion services, provide information about abortion or referrals, or advocate to change abortion laws. The policy, first introduced in 1984, is highly partisan: it has always been rescinded by incoming Democratic presidents and immediately imposed by Republican ones. However, under Trump’s expanded version, funding restrictions apply to all global health programs, not just those focused on family planning. This means that over sixteen times the amount of health aid is at stake, and affects groups working on HIV, TB, malaria, and maternal and child health as well.

As a consequence of this policy, organizations such as the Kasungu District Hospital and Queen Elizabeth Central Hospital must now choose whether to receive U.S. funding despite being forced to provide their patients with incomplete information and limited reproductive healthcare, or whether to refuse vital U.S. funding entirely—the latter resulting in massive employment cuts and widespread facility shutdowns. And, when facilities in poor regions close down, many women lose access to contraceptives, cervical cancer screenings, HIV/AIDS treatment, and other essential services not related to abortion.

The effects of restrictive abortion laws throughout the world, and in particular in Malawi, present an interesting juxtaposition. The intent behind banning abortions is ostensibly to reduce their occurrence. However, past impositions of the Global Gag Rule suggest that the policy actually increased the incidence of abortion in sub-Saharan African countries that received substantial amounts of aid for family planning programs (see chart).

Abortion rates spiked when George W. Bush imposed the policy, which crippled family planning programs and led to an increase in unintended pregnancies, unsafe abortions, and maternal deaths. Sadly, The impact of Trump’s policy will likely be much worse. The countries most affected by the Global Gag Rule are home to some of the world’s most vulnerable people. They are typically places with precarious governments and rudimentary healthcare, struggling to deal with rapidly increasing populations.

“Restrictive abortion laws do not stop abortion from occurring, they just drive it underground, forcing women to resort to clandestine procedures, which are often unsafe,” says study coauthor Dr. Chisale Mhango, senior lecturer at the University of Malawi College of Medicine and former director of National Reproductive Health Service. “Addressing unsafe abortion is an urgent public health priority.”

In his interview with Vice News, Zimba acknowledged that he is already struggling to keep up with the number of women who are having unsafe abortions. He predicts this will worsen as a result of the Global Gag Rule, which has caused his clinic to lose all USAID.

When asked about the impact of the policy on his clinic, Zimba struggled to reconcile his religion’s ideology with the reality he experiences each day. “I am Christian,” Zimba admits. “But this ‘pro-life’ approach is different when a woman comes here who has already aborted and is going through complications.”

Zimba ended the interview with a solemn reflection. “I can’t even count how many have died,” he said. “So many have died.”

Please work with us to ensure everyone has proper access to reproductive healthcare.

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