The incidence of induced abortion in Malawi.

CONTEXT: Abortion is legally restricted in Malawi, and no data are available on the incidence of the procedure. METHODS: The Abortion Incidence Complications Methodology was used to estimate levels of induced abortion in Malawi in 2009. Data on provision of postabortion care were collected from 166 public, nongovernmental and private health facilities, and estimates of the likelihood that women who have abortions experience complications and seek care were obtained from 56 key informants. Data from these surveys and from the 2010 Malawi Demographic and Health Survey were used to calculate abortion rates and ratios, and rates of pregnancy and unintended pregnancy. RESULTS: Approximately 18,700 women in Malawi were treated in health facilities for complications of induced abortion in 2009. An estimated 67,300 induced abortions were performed, equivalent to a rate of 23 abortions per 1,000 women aged 15-44 and an abortion ratio of 12 per 100 live births. The abortion rate was higher in the North (35 per 1,000) than in the Central region or the South (20-23 per 1,000). The unintended pregnancy rate in 2010 was 139 per 1,000 women aged 15-44, and an estimated 52% of all pregnancies were unintended. CONCLUSIONS: Unsafe abortion is common in Malawi. Interventions are needed to help women and couples avoid unwanted pregnancy, reduce the need for unsafe abortion and decrease maternal mortality.

Reproductive health characteristics of young Malawian women seeking post-abortion care.

Abortion is illegal in Malawi except when the pregnancy endangers the mother's life, yet complications of abortion account for the majority of admissions to gynecological wards. This study collected data on all post-abortion care (PAC) cases reporting to all PAC-providing health facilities in Malawi over a 30-day period. Of a total of 2,028 PAC clients, 20.9% were adolescents (age 10-19) and 29.6% were young adults (age 20-24). More than half of adolescents and almost 80% of young adults were married. Less than 5% of adolescents and 22.5% of young adults reported using contraception when they became pregnant. Being unmarried was associated with previous abortion and contraceptive use among young adults. These statistics indicate a high proportion of unwanted pregnancy and lack of access to modern contraception among young women. Programs to increase access to pregnancy prevention services and protect young women from unsafe abortions are greatly needed.

Prevalence of obstetric fistula in Malawi.

OBJECTIVE: To estimate the prevalence of obstetric fistula in Malawi and explore the potential risk factors for developing the condition. METHODS: A community survey was conducted in 9 districts in Malawi, recruiting 3282 women aged at least 12 years using the sibling based method to identify cases of obstetric fistula. Hospital records from 9 district hospitals involved in the community survey and all hospitals offering fistula repair services in Malawi were reviewed. RESULTS: A total of 1107 women with obstetric fistula were identified: 575 from the community survey and 532 from hospital records. Median age was 29 years (range, 12-89 years). The prevalence of obstetric fistula was 1.6 per 1000 women. Women endured the condition for a median duration of 3 years. Comparison of women with and without obstetric fistula revealed significant differences in age (P=0.02), occupation (P<0.01), and tribal origin (P=0.02), but no differences in education level (P=0.73) or religion (P=0.08). CONCLUSION: Obstetric fistula remains a major problem in Malawi. Increased awareness of the condition, improvement of maternal care services, and an increase in skilled personnel to perform fistula repair are needed to reduce the burden of this condition.

Emergency obstetric care: how do we stand in Malawi?

OBJECTIVE: To assess the availability, accessibility, utilization, and quality of emergency obstetric care (EmOC) services in Malawi. METHODS: A complete enumeration was made of all hospitals and a 25% random sample of all health centers, in all districts of Malawi. Enumerators (nurses and midwives) collected data by reviewing facility registers and records, observations, and interviews with health workers to determine extent of utilization of services. In-depth interviews and focus group discussions were also held with key informants to identify barriers to utilization of services and explore participants' perceptions of quality of care. RESULTS: Almost twice the minimum number of recommended comprehensive EmOC facilities exist (1.8 facilities per 500,000 population), but only 2% of the recommended number of basic EmOC facilities. Met need was only 18.5%; cesarean delivery rate was less than 3%. The case fatality rate was 3.4% indicating poor quality of care, attributable partly to absence of skilled birth attendants and motivated staff, and the frequent shortage of drugs and medical supplies. CONCLUSION: Malawi needs to improve the provision of quality EmOC services by implementing evidence-based strategies for the reduction of maternal mortality. Consequently, the Malawi Road Map for accelerating improvement was developed through multidonor and multisector collaboration with the Reproductive Health Unit of the Ministry of Health. This Road Map is now being implemented in all districts of Malawi.