This week, President Trump signed an executive order banning the use of government funding for any organisation which provides abortion services or information, not just within his own country, but particularly in the developing world. The implications of the order are best observed in those countries where abortion is currently illegal, like Malawi for example, which still applies a colonial law drafted by the British in 1861 and introduced in 1929.
At present in Malawi, 23 out of 100 sexually-active women aged between 15 and 44 terminate their pregnancies. Over the last four years, 70, 833 Malawian women have sought medical treatment following unsafe abortions. In 2015, health centres in Karonga alone treated 3,676 women who almost died from complications following abortions. Health workers at Karonga District Hospital say that two or three women die there every day from such complications. Post-abortion care costs Malawi's government K300 million annually (£330 million).
Of course, these are the cases which have come to the attention of medical staff. They do not include the numerous cases of undisclosed abortion, many resulting in life-changing physical and psychological consequences or, indeed, death.
Dr Owen Msopole, Northern Region zone manager, is quoted in The Nation as saying that 'the silent carnage could be graver still as some either conceal their agony or die in silence due to restrictive laws, cultural taboos and religious don'ts that label those that terminate pregnancy as murderers, sinners and misfits.'
And, of course, there are the unwanted babies, often abandoned or victims of infanticide.
The post-abortion mortality rate was one of the reasons why last year Malawi failed to reach its Millennium Development Goal target to slash maternal deaths to less than 155 out of 100,000 live births. Indeed, for every 100,000 babies born alive in Malawi, a shocking 620 mothers have died - from bleeding, sepsis, hypertension and unsafe abortion. (Figures from USAid) Of these, the Ministry of Health say that abortions kill 17 in every 100 girls or women out of a rather higher overall maternal death rate of 675 per 100,000.
In Britain, before the law changed, clandestine abortions used to be achieved using coat hangers, gin and hot baths. In Malawi, women use sharp objects such as sticks or poisonous herbal concoctions.
Some of those terminating their pregnancies are just girls, barely past puberty, victims of male harassment, exploitation, manipulation or rape. The euphemism for rape of young girls is 'defilement', a word which denigrates the victim. The girls are considered 'dirtied', 'spoiled goods'. What must it be like for a raped fifteen-year-old to have to give birth to the child of her attacker? And how will she then support that child?
Sixty four per cent of Malawian girls have children before the age of 19, 17% before they are 16. Many of these girls are already smaller than they should be, because of poor nutrition. If they attempt to deliver a living child, their birth passages are at significant risk of tearing, resulting in fistula, incontinence and social ostracisation or, indeed, death from lengthy labour or blood loss. Such an outcome is appalling enough, but to suffer in this way following rape must be unbearable.
Most women undergoing abortions, however, are more mature. Indeed, 80% of the women procuring unsafe abortions are married. They are women for whom effective contraception is often out of reach because of male opposition, inability to pay, distance from health clinics or ignorance. They are usually poor, perhaps living in remote rural areas, worn out by multiple pregnancies and unable to feed, clothe and educate their existing children, let alone support a new life.
Dr Lastone Chikuni, the Reproductive Health Manager at the Ministry, commenting on the high death rate said, 'The majority of them are rural women. Usually they come to hospitals in a very critical condition.'
Such women are also at significant risk of dying during labour. Indeed, Malawi is one of the most dangerous places on earth, and the most dangerous in Central and Southern Africa, for any woman to give birth, let alone those whose health is already compromised. (David Nkhwazi of the No Woman Should Die Giving Birth initiative.)
Women's livers may function poorly because of repeated attacks of malaria. Their uterus and birth passage may be damaged by previous deliveries. Their health may be affected by serious diseases such as tuberculosis. Such mothers are likely to be delivered by an illegal traditional birth attendant. If the mother is HIV positive, the attendant may not know how to prevent the virus being passed to the baby. The baby may be premature or the labour too long. The exhausted mother may well die in labour, in which case the baby will die too. Mortality is worse in rural areas. The figures for Mzimba show an average of 19 neonatal deaths out of an average of 44 babies born. Nationally, the Malawi Demographic Survey of 2015-2016 found that the neonatal mortality rate was 27 per 1000 live births.
If a mother from a poor family dies, what happens to her children?
They may either bring each other up with little or no adult help and little chance of schooling, or be shared among the extended family, lucky to have a sleeping mat and a bowl or two of maize porridge (nsimba). They may be expected to pay for their own care by engaging in domestic or agricultural labour which prevents them from continuing in education. Toddlers may be unlikely to survive, dependent as they are on the care and nutrition they receive from their mothers. In Malawi, toddlers are often still breast fed. Girls will probably be sold off to older men in exchange for a bride price. What is certain is that the cycle of poverty will continue.
All of these women, whatever their age or circumstances, are desperate, for no one takes lightly the decision to perform an abortion on herself or to ask someone else to perform it.
And yet, I hear you say, how can the illegal abortion rate be so high in such a 'god-fearing' country. Almost the entire population of Malawi claims membership of some faith group or other. A government study from 2009 reported that almost all the 70,000 women terminating pregnancies belonged to a religious group. In fact, of the women seeking help following unsafe abortions, 28.5% were Protestant, 23.3% were Catholic, 22.7% were other Christians (mostly Evangelicals and Pentecostalists), 14.5% were 'other faiths' (perhaps traditional African religions or Hindus), 10.3% were Muslim and only 0.7% had no religious faith. (Data from the Edith Mutharika Maternity Wing of Kamuzu Central Hospital, Malawi's main referral hospital, 2015-2016, presented by the gynaecologist Dr Grace Chiudzu.)
If convinced Christians and Muslims are seeking abortions, that tells us how desperate they are. As the Nation put it, 'The official figures subtly confirm that sermons and legal restrictions will not stop a woman from eliminating an unwanted pregnancy if she decides to.'
The Nation's source at Karonga District Hospital said, 'Religious leaders, especially men, have been condemning abortion for years, but women are still suffering terrible conditions. This will continue until we take a new approach to confront this problem.'
Fortunately, the situation in Malawi is improving. The marriage age has been raised to 18. Although parents can still marry off their daughters before then, social pressure may reduce child marriage. Fewer early pregnancies should reduce the incidence of fistula. Furthermore, the government is in the process of introducing the Termination of Pregnancy Bill, which, while still stating that abortion is illegal, would allow termination if certain restricted conditions are met:
1. to prevent injury to the physical or mental health of the expectant woman;
2. where the pregnancy is the result of rape, incest or defilement; or
3. where there is severe malformation of the foetus.
The Bill was drafted in 2012 but is still wending its slow way through parliament, having recently been reviewed by the Malawi Law Commission.
Also fortunately, the government is receiving valuable support from organisations such as the Coalition for the Prevention of Unsafe Abortion, which has stated, 'This debate over morality has not helped reduce preventable deaths and injuries due to unsafe abortion. The problem demands a practical response.'
Unfortunately, however, some conservative Christian groups in Malawi have been adopting a similar confrontational tone to that used by pro-life demonstrators in the States. In response to this quite conservative legislation, the Ethics, Peace and Justice Commission, an arm of the Evangelical Association of Malawi, has organised 'citizens' marches' to '...publicly affirm that sex and marriage is between man and woman and that life begins at conception'. (Note the conflation of opposition to homosexuality with opposition to legalised termination.) The organisation has asserted, unsupported by evidence, that these are 'truths, facts and values we collectively share as a Malawi society'.
Bishop Thomas Msusa, addressing the Catholic Episcopal Conference of Malawi (ECM), said, 'Human life is sacred, because from its beginning to the end, no one can, under any circumstances, claim for himself the right directly to destroy an innocent human being.' He accused Malawians of 'grave moral disorder'.
Sadly the 'innocent human beings' referred to by Bishop Msusa do not include the already born siblings of a foetus, or, indeed, the mother herself. One wonders how a small clump of fertilised cells can be considered more important than the survival, education, health and wellbeing of existing children. As pointed out above, 23% of women undergoing abortion are adherents to Bishop Msusa's Church.
A pastoral letter circulated by ECM accuses proponents of the Bill as promoting 'a culture of death instead of life'. No health facilities under the Christian Health Association of Malawi will provide for terminations.
The Christian Family Movement categorically states, 'Abortion is a sin', quoting Deuteronomy Chapter 5, written 3,000 years ago, and predicting 'calamities' if the Biblical position is not followed.
The Malawi Council of Churches (MCC) at first refused to take a position after two days of discussion, while the Vice-Moderator of the Church of Central Africa Presbyterian (CCAP) said the church has chosen not to speak out about abortion, neither does it 'tolerate abortion among its doctrines', but the fact remains that 'its people are procuring abortions.' Since then, the MCC has taken up a position supportive of the government, if somewhat disingenuous. 'Government has maintained that abortion is illegal and we also share the same view. Both sides also realise the need to protect and save the lives of expectant women faced by pregnancy complications....The Church also values life.'
Also tying himself in knots, but fundamentally supportive of the government's position, Bishop Joseph Bvumbwe of the Evangelical Lutheran Chirch of Malawi stated, 'With all things being equal, the country shouldn't go this route, but knowing that there are so many cases of unsafe abortion, we may go that route. We may not stand by the law, but allow it to face the challenge we are facing.'
However, also in Malawi, brave and knowledgeable health professionals are doing their best to stand against this line. Dr Chisale Mhango, senior lecturer in gynaecology, is quoted as saying that if the Christian bodies are saying 'let both the mother and baby die, then that is not being Christian'.
So, that is the current position in Malawi, soon to improve once the Bill is enacted. However, who is going to help a dreadfully poor country like Malawi to develop the heath facilities it needs to support the girls and women who desperately need them?
Some of the key providers of advice and support on family planning, safe pregnancy and diseases which affect maternal and child health receive significant funding from the UK and the USA. Such organisations include PEPFAR (the President's Emergency Plan for AIDS Relief, probably the best achievement of George W Bush), the Melinda Gates Foundation, the Global Fund to fight AIDS, Tuberculosis and Malaria, Marie Stopes International and the global organisation Planned Parenthood, to name but a few.
The US currently provides $575 million in funding to reproductive rights causes worldwide, more than any other country. The gag rule may even threaten its wider global health funding which amounts to more than $9 billion. The USA's reputation in this field is unsurpassed. The Guttmacher Institute found that last year’s US aid budget for family planning gave 27 million women and couples access to contraceptives, prevented more than 2 million unsafe abortions and 6 million unintended pregnancies, and helped prevent 11,000 maternal deaths worldwide.
On Monday, President Tump reinstated and signed the 'global gag rule', which withholds USAid funding from any organisation which offers abortion services or information. This ban also affects any organisations providing contraception, family planning advice or working to combat HIV/AIDS or the Zika virus if they are known to have referred women elsewhere to receive terminations, engaged in lobbying to liberalise restrictions on abortion law, or engaged in public education on safe legal abortion. This rule, also known as the Mexico City policy, was first imposed by Ronald Reagan in 1984, then rescinded by Bill Clinton, then reinstated by George W Bush and then rescinded again by Barack Obama.
The policy will remove funding from organisations like the International Planned Parenthood Foundation and Marie Stopes International. Organisations like these may work with 15 or more local partners whom the US will not even allow to use their own funding for abortion services. Removal of access to abortion services does not stop abortion. As we can see from Malawi, it just forces women to procure risky clandestine abortions.
Trump's decision was quite surprising, given that he hasn't talked much about abortion access. In 2013 he said, 'It’s never been my big issue.' However, the position of Mike Spence, the Vice President, is well known.
The World Health Organization (WHO) has said that without access to abortion 289,000 women may die in pregnancy or childbirth. WHO states that 21 million unsafe abortions are performed globally each year, resulting in nearly 13% of all maternal deaths globally. Every day 840 women die from pregnancy-related cases. Each year, 225 million women in developing countries don’t want to be pregnant. Globally, roughly 16 million girls aged 15-19, with an additional 1 million girls under 15, give birth each year, the majority from low- and middle-income countries. Many lack access to sex education and contraception. Roughly three million unsafe abortions among 15- to 19-year-old girls take place each year, leading to lasting health problems and sometimes death. (WHO)
Marie Stopes International estimates the loss of its services alone could mean 6.5 million unintended pregnancies, 2.1 million unsafe abortions, and 21,700 maternal deaths in Trump’s first term alone.
In Uganda, 78% of the population is under 30 and fertility rates are among the world's highest. Jackson Chekweko, executive director of Reproductive Health Uganda said that removal of funding will severely restrict access to much-needed contraceptives, particularly in rural communities. A successful pilot initiative that distributes Sayana Press, a three-month injectable contraceptive will almost certainly be discontinued. Also in Uganda, the organisation Reach a Hand, a non-profit organisation which addresses sexual health, family planning and HIV among young people, is also likely to lose funding.
Population Action International (PAI) has reported that the inability to provide even advice on contraception could result in the collapse of the maternal health networks in individual countries. 'The only goal the policy will achieve is to punish women in already challenging circumstances by blocking access to essential care.'
Projects will need to decide whether to do without US funding or end abortion advice. However, the White House memorandum implied that all global health assistance could be affected by the removal of funding: HIV, tuberculosis, malaria, public and child health. So, no testing kits for HIV, then. No HIV prevention, care or treatment, no integrated maternal services, no contraception, no counselling on the risks of Zika.
Fortunately, the government of the Netherlands is stepping into the breach. It has announced that it will set up an international fund to which other governments, businesses and charities can donate.
Mrs Ploumen, the Dutch minister for foreign trade and development co-operation, said the Dutch government was aiming to support groups that could be affected.
She said banning abortions would not result in fewer take place, but rather it would lead to 'more irresponsible practices in back rooms and more maternal deaths....In the Netherlands, I would suggest that there is firm support for the rights of women and girls - and there is a lot of support for promoting, but also protecting those rights.'
Abortion is a last resort for any woman. Women in the States already have to run the gauntlet of chanting gangs of anti-abortion protestors, misleadingly called 'pro-life'. However at least American women have had the opportunity to vote on the issue. The result of their votes, however, have been to remove rights from other women across the world. By so doing, they will bring about yet more poverty and death among existing children and, of course, among their mothers.
Just when women in Malawi are being given the right to save their own lives and to protect their families, the President of the richest country in the world is taking it away.
Information for this post came from the following sources