University of Malawi

Kamuzu College of Nursing

BY

CHARLES MHANGO

Student - MSc.RH,

BSc.NM

LEGALISATION OF ABORTION IN

MALAWI: PRO-LIFE OR PRO-CHOICE?

DATE: 4TH DECEMBER, 2015

TABLE OF CONTENTS

1 Introduction .......................................................................................................... 1

2 Background .......................................................................................................... 1

3 Arguments supporting abortion ........................................................................... 3

4 Arguments against abortion ................................................................................. 6

5 Ethical considerations .......................................................................................... 9

5.1 Autonomy ......................................................................................................................... 9

5.2 Beneficence ...................................................................................................................... 9

5.3 Non-Maleficence ............................................................................................................ 10

5.4 The sanctity of life vs quality of life .............................................................................. 10

6 Personal stand ....................................................................................................10

7 Conclusion .........................................................................................................12

Reference..................................................................................................................14

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1 INTRODUCTION

Abortion is the termination of pregnancy by any means, resulting in removal or expulsion of an

immature non-viable foetus or embryo of less than 28 weeks (Cunningham et al., 2009; Jeffcoate

& Tindall, 2014; Konar, 2014). An abortion can be spontaneous or purposely induced.

Spontaneous abortion, commonly referred to as miscarriage, is the unintentional expulsion of an

embryo or foetus before the 28th week of gestation. Worldwide approximately 210 million

pregnancies occur each year and about 75 million of these end in stillbirth, or spontaneous or

induced abortion (WHO, 2011). Induced abortion can be legal or illegal depending on individual

country laws. In most African countries including Malawi induced abortions are illegal with

exceptions in situations where the pregnancy threatens the life of the mother. There is high debate

as to whether abortion should be made legal so as to allow people decide whether to terminate

pregnancy or not. While other people fill that it is necessary to legalise abortion, others feel it is

not proper to permit it. Those who are in support of legalization of abortion are usually referred to

as ‘prolife’ while those against are referred to as ‘prochoice’. This paper sort to discuss the views

of the prolife as well as the prochoice and reviews the ethical considerations necessary in deciding

the way to go. It also gives the position of the writer of this paper as regards to the legalisation of

aborting in Malawi.

2 BACKGROUND

Induced abortions continue to occur in measurable numbers in all regions of the world, regardless

of the status of abortion laws (World Health Organisation, 2012). Induced abortions can be safe of

unsafe. The World Health Organization (2011) defines unsafe abortion as a procedure for

terminating a pregnancy that is performed by an individual lacking the necessary skills, or in an

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environment that does not conform to minimal medical standards, or both. In Malawian laws any

person administering an abortion is guilty under section 149 of the penal code and can be sentenced

up to 14 years imprisonment while a woman who solicits an abortion can be sentenced to 7 years

imprisonment under Section 156. With the legal restrictions in place on abortion in Malawi, the

practice still occur and usually performed by untrained personnel or induced by women

themselves. It is estimated that 20 million of the 42million abortions happening across the world,

each year, are unsafe induced abortions with 70 000 of these ending in maternal death and 5 million

women suffering from temporary or permanent disability(Shah & Ahman, 2009). In Malawi, an

estimated 67 300 women had an induced illegal abortion in 2009 with approximately 18 700

women receiving abortion related complications treatment in the health facilities (Levandowski et

al., 2013).

Africa has one of the highest maternal mortality rate (MMR) in the world. While the global MMR

was 251 per 100 000 live births as of 2008, it was 1000 per 100 000 live births in African with 13

percent resulting from induced abortions. According to Malawi Demographic Health Survey 2010,

Malawi is one of the countries with the highest MMR of 675 per 100 000 live births (National

Statistical Office & IFC Macro, 2011) with 17 percent of these cases resulting from abortions

(Masina, 2012). Maternal mortality ratios due to complications of unsafe abortion are higher in

regions with restricted abortion laws than in regions with no or few restrictions on access to safe

and legal abortion (Shah & Ahman, 2009).

Around the world, women seek abortion for several reasons. In a report by Family Planning

Association of Malawi presented at the Third African Conference on Sexual Health and Rights, in

Abuja, Nigeria, in 2008, it was reported that women in Malawi seek abortion for a variety of

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reasons, including poverty, unplanned pregnancy, coercion, shame, and fear of being forced out of

school. Apart from unwanted pregnancy, contraceptive failure and fear of parents by young people

are also among the primary reasons (Levandowski, Kalilani-Phiri, Kachale, Awah, & Kangaude,

2012). Decisions about abortion are usually done by women themselves and though sometimes

they consider decision with their partners, friends or in very limited cases their family, the final

decision is usually theirs (Juarez & Bayer, 2011).

3 ARGUMENTS SUPPORTING ABORTION

The fact that induced abortions still take place in countries where it is illegal, the prochoice groups

have built their arguments from this. However, since the procedure is illegal in these countries,

women perform secretive and unsafe abortions so as to maintain their confidentiality

(Levandowski et al., 2012) are usually performed by unqualified and unskilled providers or are

self-induced (Shah & Ahman, 2009). These normally end up in complications. In view of this, the

prochoice groups ask questions like “if people can still seek the service with legal restrictions, why

not legalise it to prevent the complications?” These complications have severe consequences on

individual, families, communities and the country as the whole. One clear serious consequence of

unsafe induced abortion is maternal death and as Shah and Ahman (2009) indicate Maternal

mortality ratios due to complications of unsafe abortion are higher in regions with restricted

abortion laws than in regions with no or few restrictions on access to safe and legal abortion. And

as indicated earlier on in the background, Malawi has one of the highest MMR of 675 deaths per

100 000 live births with 17 percent of these resulting from unsafe abortions. Legalising abortion

would probably translate to saving lives almost 17 percent of the 675 women dying per every 100

000 live births.

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Furthermore, following unsafe abortions, those women who develop complications still go to

health facilities seeking health care in form of post abortion care. Unfortunately, most of these

unsafe abortions which have the potential of developing into complications occur in much in

developing countries like Malawi than the developed countries. As Vlassoff, Walker, Shearer,

Newlands, and Singh (2009) state, the costs of treating medical complications from unsafe abortion

constitute a significant financial burden on public health care systems in the developing world.

According to estimates by WHO (2011), in 2008 the world experienced 21.6 million unsafe

abortions with 21.2 million of these occurring in developing countries. And while Africa registered

6.2 incidences, the sub-Saharan Africa, the region where Malawi is located, recorded 5.5 million

case. Worse still Malawi registered an estimated 67 300 cases in 2009 with approximately 18 700

women seeking post abortion care services in the health facilities (Levandowski et al., 2013). The

most critical thing is that these developing countries like Malawi are resource strained countries.

The increase in unsafe abortions followed by complications see governments spending a lot on the

already limited resources for post abortion care which could be minimized if legalized. In Malawi,

it is estimated that if abortion is legalized and safe abortion services made available to women,

approximately US $ 435 000 would be saved from the provision of post abortion care services in

public health care facilities each year and diverted to other health care needs (Masina, 2012).

On the point that the foetus has life and terminating pregnancy is taking life, the prochoice argue

that the foetus may be alive, but so are ova and sperm. Additionally, just like the ova and the sperm

are alive and capable of becoming a human being, the foetus is also just a potential human being

and not an actual human being (Alcorn, 2012). The foetus may be equated to a blue print which

just has the potential of being developed into a house but it is not a house. At this level the foetus

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is just a product of conception and not a child hence an abortion is just termination of pregnancy

and not killing a child.

As indicated in the background, people seek abortion for several reasons including poverty,

unplanned/unwanted pregnancy, and fear of parents and/or being forced out of school. Therefore,

with these reasons, if people are forced to keep their pregnancies, usually their lives are affected

negatively. For example, if a young girl is denied the opportunity to terminate an unplanned

pregnancy and gets expelled from school her future is ruined. This has great catastrophic effects

on both the girl and the pregnancy, the child to be born, the family and the nation. In a qualitative

study done by Juarez and Bayer (2011) in Mexico 63 percent of female participants and 40 percent

of male participants were in favour of abortion without any limitations, repeatedly mentioning the

future quality of life for the child as one of the primary reasons for agreeing with abortion. They

were of the view that if the parents were not going to be able to raise the child well, they should

not have the child (Juarez & Bayer, 2011). It is much better to allow the woman terminate the

pregnancy if she feels there are other factors that would not favour keeping the baby as raising a

child requires a lot.

Like any other human being, women also have human rights. These women, among others, they

are autonomous and entitled to right to informed consent and choice. As one of their reproductive

health rights they have the right to decide whether to have a child or not. In its letter to the

committee members dated June 12, 2014, The Centre for Reproductive Rights, a global legal

advocacy organization, wrote “a key element of women’s right to equality and non-discrimination

is their ability to exercise reproductive autonomy - that is, to make decisions regarding whether

and when to have a child without undue influence or coercion. For women to enjoy reproductive

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autonomy, their options must not be limited by lack of opportunities or results. To this end, it is

crucial that women have access to reproductive health services, and that those services can be

accessed with their consent alone. In addition, reproductive health services must “be consistent

with the human rights of women, including the rights to autonomy, privacy, confidentiality,

informed consent and choice.” Autonomy does not come with limitations or exceptions when the

individual is mentally stable as such women need to be given a chance to express their autonomy

in choosing whether to terminate a pregnancy or not while also exercising their right chose whether

to have a child or not.

4 ARGUMENTS AGAINST ABORTION

The prolife are those that opposite abortion and strongly disagree with legalization of abortion.

Among their arguments, one of their strong stand is that abortion is killing. Some claim that it is

against their culture and/or religion. In one qualitative study in South Africa, Macleod, Sigcau,

and Luwaca (2011) found out that abortion is viewed as killing, culturally unacceptable, and a

source of shame. In some Malawian communities, women who had undergone an induced abortion

were viewed as sinners and evil and that infected the communities (Levandowski et al., 2012). The

prolife believe that life begins at conception. And it is scientifically right to say that an individual

human life begins at conception when a 46-chromosomed individual is formed (Alcorn, 2012).

The bible says “do not kill” (Exodus 20:13 King James Version). With these views, termination

of pregnancy at any age is definitely killing and legalizing abortion is legalizing killing.

Women who undergo an abortion experience a lot of emotional challenges. In a review of studies,

Lie, Robson, and May (2008) found out that abortion was associated with a complex of emotional

experiences. These experiences included regret, guilt, distress, anxiety, grief, loss, emptiness and

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suffering. These experience can cause an emotional breakdown in an individual and sometimes

even require professional support to recover. Lie et al. also discovered that these experiences were

influenced by the moral context in which the women were located, for example in Indonesia it was

influenced by the Islamic view that foetus ensoulment occurs at 120 days and in the United States

was influenced by the pro-life activists who explicitly indicate that abortion is murder regardless

of gestation age.

In reaction to the arguments that for several reasons including poverty, and unwanted pregnancy

among others, prolife activists argue that adoption is one best viable alternative to abortion and

believe that it accomplishes the same result in in a much best way. They argue that there is no

single child who is completely unwanted as while you do not want that child there are other people

who was the child and are willing to adopt. In American it is estimated that there are more than

1.5 million families wanting to adopt a child (Morris, 2014). And while the woman is bringing

happiness to a family needing a child by adoption, she is also giving the child a chance to live by

not conducting an abortion. Much as adoption may be a hard decision to make but it usually brings

relief and happiness knowing that someone is out there living happily because you did not abort

him/her despite the fact that you did not want him/her. One woman who had had two abortions as

a young girl and gave one for adoption said, “The two I aborted fill me with grief and regret. But

when I think of the one I gave up for adoption, I’m filled with joy, because I know he’s being

raised by a family that wanted him” (Alcorn, 2012, p. 100).

Abortion can present with several complications. Usually post abortion complications develop as

a result of three major mechanisms; incomplete evacuation of the uterus and uterine atony, which

leads to haemorrhagic complications; infection; and injury due to instruments used during the

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procedure. These complications include, complications of anesthesia, returned products of

conception, uterine perforation, septic abortion and cervical laceration (Gaufberg, 2013). These

complications put the woman at health risks and if not treated early some of these complications

may lead to serious consequences such as removal of the uterus and in severe cases loss of the

mother’s life. It may also result in long term medical complications later in life like increased risk

of ectopic pregnancies, miscarriage and pelvic inflammatory disease (Morris, 2014). For some

women despite having an abortion they still would like to have a child of their own someday.

Complications like ectopic pregnancy, miscarriage and consequently hysterectomy may deny

these women a child when they feel the time is right for them to have a child.

The prochoice have argued that women should be allowed to have control over their body.

However, why should we only claim this control only when it is abortion involved? As regards to

pregnancy there are severe stages at which the woman need to control her body including

preventing unwanted pregnancy. Morris (2014), states that for women who demand complete

control of their body, control should include preventing the risk of unwanted pregnancy through

the responsible use of contraception or, if that is not possible, through abstinence. In this case we

might as well say that instead of legalising abortion, the government has the responsibility to

provide birth control measures including making contraceptives available to the women to prevent

the unwanted pregnancies. And if contraceptives are made available, not only does the government

help prevent unwanted pregnancies, it also saves money spent on abortions as well as its

complications. If women chose to get pregnant they should be able to take responsibility for taking

care of what they have created. Because the woman and her partner responsible for the existence

of the pregnancy, these prospective parents have a moral obligation to care for its life (Tooley,

Jaggar, Devine, & Wolf-Devine, 2009).

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5 ETHICAL CONSIDERATIONS

5.1 Autonomy

(Welfel, 2006, p. 32) defines autonomy as “respect for the inherent freedom and dignity of each

person.” On the side of the prochoice, it can be argued that the pregnant woman is an autonomous

being with the autonomy to protect own health, happiness, freedom, and even own life, by

terminating an unwanted pregnancy. That is by allowing a woman to choose between having an

abortion and bringing her pregnancy to term, her personal autonomy is respected (Denbow, 2013).

On the other hand, the prolife demean a pregnant woman’s autonomy if human life is involved.

They argue that right to life is a fundamental principle, the condition for all others because it does

not belong to society or any public authority to recognise this right for some and not others. With

this view they believe that no one is justified to deny any one the right to for what he or she calls

personal autonomy.

5.2 Beneficence

The principle of beneficence is concerned with doing good (Pera & van Tonder, 2005). Prochoice

activists apply beneficence in the context of legalising abortion to liberate the physician to be able

to perform a safe abortion for the good of the pregnant woman if she chooses to have an abortion.

If the woman feels that having a child will bring more misery to her life, one better thing that might

benefit her is an abortion as all the anticipated challenges accompanied with having the baby are

eliminated. However, with this view, an immediate contradiction that surfaces is that while the

physician does good to the pregnant woman the foetus gets harmed. The prolife activists argue that

the pregnant woman has the responsibility of doing what benefits the unborn child, a life she

created with her partner. It is at this angle that the prolife also apply the principle of beneficence.

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5.3 Non-Maleficence

This principle is based on the premise that do no harm. While taking a prolife view it is clear that

abortion permanently harms the foetus as such basing on this principle abortion should never be

permitted.

5.4 The sanctity of life vs quality of life

The principle of sanctity of life is based on religious belief that every human life is sacred and holy

with certain inviolability or infinite value. Human life is holy, sacred and of immeasurable value

regardless of the physical and/or mental state (McManaman, 2009). As human life is viewed to

begin right from conception, embracers of sanctity of life principle lobby on behalf of legislations

to protect the unborn and strongly oppose abortion legislation. On the other hand, the prochoice

activists are for the quality of life. In quality of life, human life is valued on the basis of its physical

and/or mental state or quality. McManaman explains that in quality of life person are valued for

their usefulness, productivity, and ability to be of some use to society. They are not valued for their

own sake, but for the sake of what they can do for society as a whole. In this regard losing a

pregnancy is not of great deal to them as the foetus does not contribute anything to the society

rather it may prevent the pregnant woman from actively participating in the society.

6 PERSONAL STAND

Basing on the arguments presented above it is very difficult to isolate which one is the right or best

position to take. However, weighing the two and in my personal opinion I think the prochoice have

many strong points than their counterparts. The strongest and if not the only viable argument that

the prolife have is the idea that termination of a life is involved in termination of pregnancy. Much

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as in my person view I would agree with them that a life is involved, I also go with the prochoice

view that the foetus, like an ovum and sperm, is alive and capable of becoming a human being but

it is not yet a human being. In this regard terminating a pregnancy is not killing but rather I would

say “disturbing the process of creating a human being” just like we disturb the same process

through the use of contraceptives by denying the gametes from developing into a human being.

On the economic side of it, I think abortion is economically viable and would promote

development. It has already been argued by the prochoice legalising and providing safe abortion

services would reduce governments expenditure on post abortion care, for instance Malawi would

approximately save US $ 435 000 spent in public health care facilities each year. This money

would be used to purchase other essential drugs in the public health facilities. I also hypothesis

that school dropouts due to pregnancy would reduce contributing to more girls being educated and

as the saying goes “educating a girl child is educating the nation.” There are a lot of benefits as

regards to promotion of girl child for example, it promotes women’s involvement in decision

making process at all levels. It is also expected that the number of street kids would reduce as

unwanted pregnancies, and poverty are some of the contributing factor to street kids. If people are

forced to have children they cannot afford to raise one end result is dumping them into the streets

and their quality of life is affected. This also promotes crime hence slowing development.

In her book ‘it takes a village,’ Clinton (2006) adopted an African proverb which says that ‘it takes

two people to bear a child but the whole village to raise,’ she emphasised the importance of the

community of the raising of a child and his/her wellbeing. The prolife good at advocating for

keeping of the pregnancies but they are not there for support after the babies are born creating a

burden on the parents which could have been avoided.

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The argument of prolife activists on adoption being an alternative to abortion is vague in the

context of developing countries like Malawi. Though statistics of the number of families wanting

to adopt children is not known, for example, in Malawi, it is clear that the numbers are very

minimal. This can be evidenced by a lot of children suffering in the streets and in the orphanages.

Hence we cannot guarantee women to keep their unplanned/unwanted pregnancy so that they can

give up the babies for adoption.

We cannot underestimate the role legalisation of abortion would play in reducing MMR. It is

unarguably and scientifically clear that provision of safe abortion services would reduce the MMR

by a significant percentage. With this it simply show how legalisation of abortion would promote

the health of women and save a lot of lives that are lost each year. One important this to be taken

into account is that whether restricted by law or anyone, if a woman decides to terminate her

pregnancy she will but this time in an unsafe way putting her life in danger.

So, to whose benefit should we restrict abortion? I think abortion should be legalised and services

made available to everyone for the benefit of the pregnant woman as well as the country as a whole.

I therefore stand on the side of the prochoice activists.

7 CONCLUSION

Abortion is currently a very hot contemporary issue raising a lot of debate among different groups

of people. This topic has divided the people into two main groups, the prochoice and the prolife,

advocating for abortion as well as against abortion respectively. There is no clear scientific

explanation to help solve this debate as such people are required to make moral judgements if they

are to decide which way to go. Among other considerations, ethical considerations are necessary

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to help people make this moral decision. These decisions are usually embedded in one’s beliefs as

such no single better solution would be present to fully convince everyone. Nevertheless,

considering the arguments presented above, I stand with the view that abortion services should be

legalised and made available to the public.

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