The United States Supreme Court in on 24th June, 2022 reversed the Abortion Law enacted in 1973 which made safe abortion available to women in that country. It now depends on the individual States to decide which way to go. Almost immediately, 22 of the 50 States reversed the law and outlawed abortion. The argument for the reversal is largely religious describing abortion as egregiously wrong.

(BJOG. 2020;127:416–423) Although maternal sepsis is the third most common cause of global maternal mortality, there are no internationally recognized sepsis care bundles directed toward pregnant women that can be implemented in a low-resource setting. While the Surviving Sepsis Campaign’s (SSC) care bundle has been associated with reduced mortality for the general population, only 1.5% of health care facilities in Africa are able to implement the SSC guidelines in their entirety. The need to develop and implement effective strategies to reduce the global burden of maternal and neonatal sepsis in low-resource settings has become increasingly important, as demonstrated by a recent global directive by the World Health Organization (WHO) and Jhpiego. This study aimed to accomplish this directive by developing a care bundle for the initial management of maternal sepsis in low-resource settings.

ObjectiveTo develop a sepsis care bundle for the initial management of maternal sepsis in low resource settings.DesignModified Delphi process.SettingParticipants from 34 countries.PopulationHealthcare practitioners working in low resource settings (n = 143; 34 countries), members of an expert panel (n = 11) and consultation with the World Health Organization Global Maternal and Neonatal Sepsis Initiative technical working group.MethodsWe reviewed the literature to identify all potential interventions and practices around the initial management of sepsis that could be bundled together. A modified Delphi process, using an online questionnaire and in‐person meetings, was then undertaken to gain consensus on bundle items. Participants ranked potential bundle items in terms of perceived importance and feasibility, considering their use in both hospitals and health centres. Findings from the healthcare practitioners were then triangulated with those of the experts.Main outcome measureConsensus on bundle items.ResultsConsensus was reached after three consultation rounds, with the same items deemed most important and feasible by both the healthcare practitioners and expert panel. Final bundle items selected were: (1) Fluids, (2) Antibiotics, (3) Source identification and control, (4) Transfer (to appropriate higher‐level care) and (5) Monitoring (of both mother and neonate as appropriate). The bundle was given the acronym ‘FAST‐M’.ConclusionA clinically relevant maternal sepsis bundle for low resource settings has been developed by international consensus.Tweetable abstractA maternal sepsis bundle for low resource settings has been developed by international consensus.

Background There is ongoing debate on the clinical benefits of antibiotic prophylaxis for reducing pelvic infection after miscarriage surgery. We aimed to study the cost-effectiveness of antibiotic prophylaxis in the surgical management of miscarriage in low-income countries. Methods We did an incremental cost-effectiveness analysis using data from 3412 women recruited to the AIMS trial, a randomised, double-blind, placebo-controlled trial designed to evaluate the effectiveness of antibiotic prophylaxis in the surgical management of miscarriage in Malawi, Pakistan, Tanzania, and Uganda. Economic evaluation was done from a health-care-provider perspective on the basis of the outcome of cost per pelvic infection avoided within 2 weeks of surgery. Pelvic infection was broadly defined by the presence of clinical features or the clinically identified need to administer antibiotics. We used non-parametric bootstrapping and multilevel random effects models to estimate incremental mean costs and outcomes. Decision uncertainty was shown via cost-effectiveness acceptability frontiers. The AIMS trial is registered with the ISRCTN registry, number ISRCTN97143849. Findings Between June 2, 2014, and April 26, 2017, 3412 women were assigned to receive either antibiotic prophylaxis (1705 [50%] of 3412) or placebo (1707 [50%] of 3412) in the AIMS trial. 158 (5%) of 3412 women developed pelvic infection within 2 weeks of surgery, of whom 68 (43%) were in the antibiotic prophylaxis group and 90 (57%) in the placebo group. There is 97-98% probability that antibiotic prophylaxis is a cost-effective intervention at expected thresholds of willingness-to-pay per additional pelvic infection avoided. In terms of post-surgery antibiotics, the antibiotic prophylaxis group was US$ 0.27 (95% CI -0.49 to -0.05) less expensive per woman than the placebo group. A secondary analysis, a sensitivity analysis, and all subgroup analyses supported these findings. Antibiotic prophylaxis, if implemented routinely before miscarriage surgery, could translate to an annual total cost saving of up to $ 1.4 million across the four participating countries and up to $ 8.5 million across the two regions of sub-Saharan Africa and south Asia. Interpretation Antibiotic prophylaxis is more effective and less expensive than no antibiotic prophylaxis. Policy makers in various settings should be confident that antibiotic prophylaxis in miscarriage surgery is cost-effective.

(Abstracted from N Engl J Med 2019;380:1012–1021) Ten percent to 20% of pregnancies end in spontaneous abortion. Products of conception are retained in some cases of spontaneous abortion, and surgical intervention is needed for their removal.

(N Engl J Med. 2019;380:1012–1021) It is unclear whether or not antibiotic prophylaxis prior to surgery to complete spontaneous abortion (removal of retained products of conception) can reduce postoperative pelvic infection. Evidence is lacking and international guidelines regarding this issue are also inconsistent. This issue is particularly concerning for women in low-income and middle-income countries, where rates of surgery for incomplete spontaneous abortion are high, and where pelvic infection can lead to serious illness and death. In order to help clarify this issue, the authors of the present study assessed the use of antibiotic prophylaxis (doxycycline and metronidazole, both inexpensive, heat-stable, and widely available) in women undergoing surgery to complete spontaneous abortion in low-resource settings.

The estimated annual global burden of miscarriage is 33 million out of 210 million pregnancies. Many women undergoing miscarriage have surgery to remove pregnancy tissues, resulting in miscarriage surgery being one of the most common operations performed in hospitals in low-income countries. Infection is a serious consequence and can result in serious illness and death. In low-income settings, the infection rate following miscarriage surgery has been reported to be high.

Objective: To assess the availability of key resources for the management of maternal sepsis and evaluate the feasibility of implementing the Surviving Sepsis Campaign (SSC) recommendations in Malawi and other low-resource settings. Methods: A cross-sectional study was conducted at health facilities in Malawi, other low-income countries, and lower-middle-income countries during January-March 2016. English-speaking healthcare professionals (e.g. doctors, nurses, midwives, and administrators) completed a questionnaire/online survey to assess the availability of resources for the management of maternal sepsis. Results: Healthcare centers (n=23) and hospitals (n=13) in Malawi showed shortages in the resources for basic monitoring (always available in 5 [21.7%] and 10 [76.9%] facilities, respectively) and basic infrastructure (2 [8.7%] and 7 [53.8%], respectively). The availability of antibiotics varied between Malawian healthcare centers (9 [39.1%]), Malawian hospitals (8 [61.5%]), hospitals in other low-income countries (10/17 [58.8%]), and hospitals in lower-middle-income countries (39/41 [95.1%]). The percentage of SSC recommendations that could be implemented was 33.3% at hospitals in Malawi, 30.3% at hospitals in other low-income countries, and 68.2% at hospitals in lower-middle-income countries. Conclusion: The implementation of existing SSC recommendations is unrealistic in low-income countries because of resource limitations. New maternal sepsis care bundles must be developed that are applicable to low-resource settings.

Despite adopting a progressive legal and policy framework informed by internationally recognized human rights norms and values, Malawi has not complied with the obligation to explain its abortion law in accordance with legal and human rights standards. In 1930, the colonial government adopted a Penal Code derived from English criminal law, containing provisions regulating access to abortion, but has not undertaken measures to explain when abortion is lawful. What constitutes legal abortion has never been clarified for health providers and potential clients. Consequently, eligible girls and women fail to access safe and legal abortion. The Malawi Law Commission, following its review of the colonial abortion law, has proposed liberal changes which, if implemented, would expand access to safe abortion. However, the immediate step the government ought to take is to clarify the current abortion law, and not to wait for a new law expected to materialize in the indeterminate future.

BACKGROUND:In Malawi, abortion is legal only if performed to save a woman's life; other attempts to procure an abortion are punishable by 7-14 years imprisonment. Most induced abortions in Malawi are performed under unsafe conditions, contributing to Malawi's high maternal mortality ratio. Malawians are currently debating whether to provide additional exceptions under which an abortion may be legally obtained. An estimated 67,300 induced abortions occurred in Malawi in 2009 (equivalent to 23 abortions per 1,000 women aged 15-44), but changes since 2009, including dramatic increases in contraceptive prevalence, may have impacted abortion rates.METHODS:We conducted a nationally representative survey of health facilities to estimate the number of cases of post-abortion care, as well as a survey of knowledgeable informants to estimate the probability of needing and obtaining post-abortion care following induced abortion. These data were combined with national population and fertility data to determine current estimates of induced abortion and unintended pregnancy in Malawi using the Abortion Incidence Complications Methodology.RESULTS:We estimate that approximately 141,044 (95% CI: 121,161-160,928) induced abortions occurred in Malawi in 2015, translating to a national rate of 38 abortions per 1,000 women aged 15-49 (95% CI: 32 to 43); which varied by geographical zone (range: 28-61). We estimate that 53% of pregnancies in Malawi are unintended, and that 30% of unintended pregnancies end in abortion. Given the challenges of estimating induced abortion, and the assumptions required for calculation, results should be viewed as approximate estimates, rather than exact measures.CONCLUSIONS:The estimated abortion rate in 2015 is higher than in 2009 (potentially due to methodological differences), but similar to recent estimates from nearby countries including Tanzania (36), Uganda (39), and regional estimates in Eastern and Southern Africa (34-35). Over half of pregnancies in Malawi are unintended. Our findings should inform ongoing efforts to reduce maternal morbidity and mortality and to improve public health in Malawi.

Induced abortion has been a universal phenomenon in the history of humanity. The first recorded evidence was found in an Egyptian papyrus from 1550 BC. The debate on the proposed Termination of Pregnancy Bill is mired in misconception. Many, including the Christian doctors’ group, make the assumption that the prohibition of abortion is biblical. In fact, prohibition of abortion predates all monotheist religionsi. Since the 5th century, doctors have been required to take the Hippocratic oath, which was authored in 2030 BCE and modified over the years. Among the things the doctors swore in the original oath was the following: I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion. The message is clear. Even when performed by medical doctors, abortion was fatal before analgesia, asepsis, and antibiotics were introduced. These pagan civilisations, more than two millennia before the Christian era, were morally bound to forbid doctors induce abortion. The physicians did not swear to Yahweh, as the opening statement of the oath reads: I swear by Apolloii the physician, and Asclepius [son of Apollo and patron of healing], and Hygieia [the goddess of health], and Panacea [cure-all and sister of Hygieia], and all the gods and goddesses as my witnesses, that, according to my ability... The issue is not about the rights and wrongs of abortion. It is about women dying from unsafe abortion in increasing numbers, and using increasingly more resources before they die. This is despite Malawi, in 1930, enacting a law designed specifically to eliminate abortion deaths. In medicine, doctors use the best of what they have to treat illness. The best may be toxic and hazardous, but doctors use it while they search for better options. The moment they discover or invent a better option, they abandon the less acceptable option. Termination of pregnancy to eliminate abortion deaths will follow the same path. A doctor who would leave a woman to die, rather than sacrifice the foetus for the mother’s life, is guilty of malpractice. Lately, Malawi has reformed a number of Acts. For example, the Age of Marriage Act was revised because the consensus was that it was not serving Malawi well, and the age of marriage was subsequently raised from 16 years to 18. The current Malawi Penal Code prohibits abortion, except when the pregnant woman’s life was threatened. As a result of this restriction, women are dying from unsafe abortions obtained outside the medical service. The Ministry of Health (MOH) requested the Malawi Law Commission to review the sections of the Penal Code related to abortion to make the law more effective in eliminating abortion deaths, which currently account for 17% of all Commentary Proposed Termination of Pregnancy Bill in Malawi: Doctors use the best of what they have maternal deaths. The Law Commission, after conducting nationwide consultations, has proposed that abortion remain illegal but that the exceptions under which it may be legally provided should be expanded to include the following grounds: (a) when the continued pregnancy will endanger the life of the pregnant woman; (b) when termination is necessary to prevent injury to the physical or mental health of the pregnant woman; (c) when there is a severe malformation of the foetus, which will affect its viability or compatibility with life; and (d) when the pregnancy is a result of rape, incest, or defilement. While termination to save a woman’s life may be conducted at any gestational age, if termination is carried out because of incest or rape it must be conducted before 16 weeks’ gestation. This is not science-based determination; rather, it reminds us that before abortion was coded in the legislature in Englandiii to be dealt with in state courts, it was dealt with in the ecclesiastical courts, where abortion procured after quickening was punished by death. Before quickening, the punishment was less severe—penance for 40 days, for example. This thinking originated from Aristotle, who taught that the soul entered the body at 40 days for males and 90 days for females, and quickening was evidence of the presence of a soul. The Law Commission further proposed that the law be removed from the Penal Code and be made to stand alone as the Termination of Pregnancy Bill. This would coincide with a clarification of terminology wherein termination carried out before foetal viability would be called “abortion”, while “preterm delivery” would be the designation used for termination after viability. In cases of the latter, both the mothers and the babies are saved, while in cases of the former, the foetuses are sacrificed for the mothers’ lives. Those who are opposed to the new bill on the grounds of foetal rights are effectively saying that even the law that is currently in place should be scrapped in that it sacrifices foetuses to save pregnant women. Most obstetricians, on the other hand, say that it is not enough to reduce abortion deaths; abortion deaths should be totally eliminated. They quote the typical case of a couple who presented to request an abortion at Bwaila Hospital in Lilongwe. After screening the female spouse, they told the couple that they did not qualify for safe abortion, based on the stipulations of the current law. A week later the husband brought his wife back to Bwaila after procuring unsafe abortion elsewhere. She died after a lot of resources were spent trying to save her. The only way to eliminate such deaths and save the MOH more than US$1 million annually, is to legalise abortion on demand, as is the case in Mozambique and South Africa. The proposed bill further outlines where abortion shall be provided and who shall provide it. It also provides for conscientious objection. Any service provider who could not provide the service on this ground is, however, required to find and make necessary arrangements to refer the patient to another willing provider without delay. Every health facility is to have a complaints board, where clients may lodge complaints if they feel that they have been unfairly denied service. Chisale Mhango

BACKGROUND:The ETATMBA (Enhancing Training And Technology for Mothers and Babies in Africa) project-trained associate clinicians (ACs/clinical officers) as advanced clinical leaders in emergency obstetric and neonatal care. This trial aimed to evaluate the impact of training on obstetric health outcomes in Malawi. METHOD:A cluster randomised controlled trial with 14 districts of Malawi (8 intervention, 6 control) as units of randomisation. Intervention districts housed the 46 ACs who received the training programme. The primary outcome was district (health facility-based) perinatal mortality rates. Secondary outcomes included maternal mortality ratios, neonatal mortality rate, obstetric and birth variables. The study period was 2011-2013. Mortality rates/ratios were examined using an interrupted time series (ITS) to identify trends over time. RESULTS:The ITS reveals an improving trend in perinatal mortality across both groups, but better in the control group (intervention, effect -3.58, SE 2.65, CI (-9.85 to 2.69), p=0.20; control, effect -17.79, SE 6.83, CI (-33.95 to -1.64), p=0.03). Maternal mortality ratios are seen to have improved in intervention districts while worsening in the control districts (intervention, effect -38.11, SE 50.30, CI (-157.06 to 80.84), p=0.47; control, effect 11.55, SE 87.72, CI (-195.87 to 218.98), p=0.90). There was a 31% drop in neonatal mortality rate in intervention districts while in control districts, the rate rises by 2%. There are no significant differences in the other secondary outcomes. CONCLUSIONS:This is one of the first randomised studies looking at the effect of structured training on health outcomes in this setting. Notwithstanding a number of limitations, this study suggests that up-skilling this cadre is possible, and could impact positively on health outcomes. TRIAL REGISTRATION NUMBER:ISRCTN63294155; Results.

BACKGROUND:Health systems could obtain substantial cost savings by providing safe abortion care rather than providing expensive treatment for complications of unsafely performed abortions. This study estimates current health system costs of treating unsafe abortion complications and compares these findings with newly-projected costs for providing safe abortion in Malawi.METHODS:We conducted in-depth surveys of medications, supplies, and time spent by clinical personnel dedicated to postabortion care (PAC) for three treatment categories (simple, severe non-surgical, and severe surgical complications) and three uterine evacuation (UE) procedure types (manual vacuum aspiration (MVA), dilation and curettage (D&C) and misoprostol-alone) at 15 purposively-selected public health facilities. Per-case treatment costs were calculated and applied to national, annual PAC caseload data.RESULTS:The median cost per D&C case ($63) was 29% higher than MVA treatment ($49). Costs to treat severe non-surgical complications ($63) were almost five times higher than those of a simple PAC case ($13). Severe surgical complications were especially costly to treat at $128. PAC treatment in public facilities cost an estimated $314,000 annually. Transition to safe, legal abortion would yield an estimated cost reduction of 20%-30%.CONCLUSIONS:The method of UE and severity of complications have a large impact on overall costs. With a liberalized abortion law and implementation of induced abortion services with WHO-recommended UE methods, current PAC costs to the health system could markedly decrease.

This study aimed to evaluate the feasibility of conducting a randomized controlled trial of postpartum intrauterine device insertion and to demonstrate that the postpartum intrauterine device is acceptable to women. Women attending prenatal care at a maternity hospital in Lilongwe, Malawi were recruited into a trial comparing immediate (10 minutes to 48 hours) to 6 week postpartum insertion. Feasibility of recruiting and consenting 140 women and randomizing 70% of them was evaluated. Satisfaction with the intrauterine device was also assessed. One hundred fifteen women consented and 49 (61%) were randomized. Twenty-six women were assigned to immediate insertion, and 23 to insertion at 6 weeks postpartum. Thirty (24%) women received the device as part of the study protocol, and 28 (93%) had the device in place at 12 weeks postpartum. The intrauterine device is acceptable to some postpartum women in Malawi, but conducting a randomized clinical trial may not be feasible.

Background Millennium Development Goal 5 (MDG 5) targets a 75% reduction in maternal mortality from 1990 to 2015, yet accurate information on trends in maternal mortality and what drives them is sparse. We aimed to fill this gap for Malawi, a country in sub-Saharan Africa with high maternal mortality. Methods We reviewed the literature for population-based studies that provide estimates of the maternal mortality ratio (MMR) in Malawi, and for studies that list and justify variables potentially associated with trends in MMR. We used all population-based estimates of MMR representative of the whole of Malawi to construct a best-fit trend-line for the range of years with available data, calculated the proportion attributable to HIV and qualitatively analysed trends and evidence related to other covariates to logically assess likely candidate drivers of the observed trend in MMR. Results 14 suitable estimates of MMR were found, covering the years 1977–2010. The resulting best-fit line predicted MMR in Malawi to have increased from 317 maternal deaths/100 000 live-births in 1980 to 748 in 1990, before peaking at 971 in 1999, and falling to 846 in 2005 and 484 in 2010. Concurrent deteriorations and improvements in HIV and health system investment and provisions are the most plausible explanations for the trend. Female literacy and education, family planning and poverty reduction could play more of a role if thresholds are passed in the coming years. Conclusions The decrease in MMR in Malawi is encouraging as it appears that recent efforts to control HIV and improve the health system are bearing fruit. Sustained efforts to prevent and treat maternal complications are required if Malawi is to attain the MDG 5 target and save the lives of more of its mothers in years to come.

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.

Malawian women in all sectors of society are suffering from social implications of unwanted pregnancy and unsafe abortion. Unwanted pregnancies occur among women who have limited access to family planning and safe abortion. A legally restrictive setting for safe abortion services leads many women to unsafe abortion, which has consequences for them and their families. In-depth interviews were conducted with 485 Malawian stakeholders belonging to different political and social structures. Interviewees identified the impact of unwanted pregnancy and unsafe abortion to be the greatest on young women. Premarital and extramarital pregnancies were highly stigmatized; stigma directly related to abortion was also found. Community-level discussions need to focus on reduction of stigma.

Maternal mortality in much of sub-Saharan Africa is very high whereas there has been a steady decline in over the past 60 years in Europe. Perinatal mortality is 12 times higher than maternal mortality accounting for about 7 million neonatal deaths; many of these in sub-Saharan countries. Many of these deaths are preventable. Countries, like Malawi, do not have the resources nor highly trained medical specialists using complex technologies within their healthcare system. Much of the burden falls on healthcare staff other than doctors including non-physician clinicians (NPCs) such as clinical officers, midwives and community health-workers. The aim of this trial is to evaluate a project which is training NPCs as advanced leaders by providing them with skills and knowledge in advanced neonatal and obstetric care. Training that will hopefully be cascaded to their colleagues (other NPCs, midwives, nurses).

As part of efforts to achieve Millennium Development Goal 5 – to reduce maternal mortality by 75% and achieve universal access to reproductive health by 2015 – the Malawi Ministry of Health conducted a strategic assessment of unsafe abortion in Malawi. This paper describes the findings of the assessment, including a human rights-based review of Malawi's laws, policies and international agreements relating to sexual and reproductive health and data from 485 in-depth interviews about sexual and reproductive health, maternal mortality and unsafe abortion, conducted with Malawians from all parts of the country and social strata. Consensus recommendations to address the issue of unsafe abortion were developed by a broad base of local and international stakeholders during a national dissemination meeting. Malawi's restrictive abortion law, inaccessibility of safe abortion services, particularly for poor and young women, and lack of adequate family planning, youth-friendly and post-abortion care services were the most important barriers. The consensus reached was that to make abortion safe in Malawi, there were four areas for urgent action – abortion law reform; sexuality education and family planning; adolescent sexual and reproductive health services; and post-abortion care services.

BACKGROUND:Malawi adopted syndromic management of sexually transmitted infections in 1993. Based on clinical efficacy and cost, gentamicin 240 mg intramuscularly, and doxycycline 100 mg twice daily x 7 days was selected as the first line regimen to treat urethritis. We sought to establish current laboratory-based Neisseria gonorrhoeae antibiotic susceptibility patterns for Malawi and describe the pattern of susceptibility since syndromic management began.METHODS:Between May 15 and August 10, 2007, 126 men with urethritis attending the STD clinic at Kamuzu Central Hospital in Lilongwe had history, genital exam, and urethral swabs taken. All were treated with gentamicin and doxycycline in accordance with Malawi guidelines. Gonorrhea was diagnosed by Gram stain and culture. Antimicrobial susceptibility patterns in gonococcal isolates were determined by disk diffusion and E-test minimum inhibitory concentration (MIC) determination and agar dilution MIC determination.RESULTS:One hundred six isolates were cultured, and MICs were determined for 100. High levels of resistance to tetracycline and penicillin were observed, but isolates were uniformly susceptible to both gentamicin and ciprofloxacin. Susceptibility patterns identified by the agar dilution MIC and E-test MIC agreed.CONCLUSIONS:The most recent study continues the trend of high susceptibility of gonococcal isolates to gentamicin in Malawi after 14 years of use and suggests agar dilution MICs may be substituted with the simpler E-test methods in future susceptibility testing. However because of the lack of susceptibility criteria for aminoglycosides for N. gonorrhoeae and the difficulty obtaining clinical/in vitro correlates in this setting, caution should be exercised in using these data for modifying treatment regimens.