RESEARCH ARTICLE
Incidence of induced abortion in Malawi, 2015 Chelsea B. Polis1*, Chisale Mhango2, Jesse Philbin1, Wanangwa Chimwaza2, Effie Chipeta2, Ausbert Msusa2 1 Guttmacher Institute, New York, New York, United States of America, 2 Centre for Reproductive Health, College of Medicine, University of Malawi, Blantyre, Malawi * [email protected]
Abstract a1111111111 a1111111111 a1111111111 a1111111111 a1111111111
OPEN ACCESS Citation: Polis CB, Mhango C, Philbin J, Chimwaza W, Chipeta E, Msusa A (2017) Incidence of induced abortion in Malawi, 2015. PLoS ONE 12(4): e0173639. https://doi.org/10.1371/journal. pone.0173639 Editor: Angel M. Foster, University of Ottawa, CANADA Received: December 16, 2016 Accepted: February 23, 2017 Published: April 3, 2017 Copyright: © 2017 Polis et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: The Malawi 2010 Demographic and Health Survey Births and Individual data files are available here: http:// dhsprogram.com/data/dataset/Malawi_StandardDHS_2010.cfm. The datasets collected by the authors and used in this paper are publicly available on figshare.com. The Health Facilities Survey can be accessed under DOI 10.6084/m9. figshare.4711273, and the Knowledgeable Informant Survey can be accessed under DOI 10. 6084/m9.figshare.4711279.
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
PLOS ONE | https://doi.org/10.1371/journal.pone.0173639 April 3, 2017
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Incidence of induced abortion in Malawi, 2015
Funding: This study was funded by the UK Government (https://www.gov.uk/government/ organisations/department-for-internationaldevelopment) under grant number 20317740053169, the Norwegian Agency for Development Cooperation (https://www.norad.no/en/front/) under grant number 1300340, and the Dutch Ministry of Foreign Affairs (https://www. government.nl/ministries/ministry-of-foreignaffairs) under grant number 24590. The funders had no role in study design, data collection, analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist.
pregnancies in Malawi are unintended. Our findings should inform ongoing efforts to reduce maternal morbidity and mortality and to improve public health in Malawi.
Introduction About 56 million women worldwide are estimated to have an induced abortion each year [1]. Contrary to popular belief, regions with restrictive abortion laws do not have lower abortion rates than those with liberal laws [1], but women in restrictive settings are more likely to experience morbidity and mortality stemming from unsafe abortion [2–4]. In addition to serious health risks, unsafe abortion poses high financial costs and service burdens on families and on the national health system [5;6]. In Africa, more than one in every seven pregnancies (15%) end in an induced abortion [1], and the majority of women of childbearing age in Africa live in countries with restrictive abortion laws [7]. Africa accounts for about 15% of all abortions in the world [1], but contributes 65% of all estimated abortion deaths in the world [2]. While the maternal mortality ratio (MMR) in developed countries in 2015 averaged 12 maternal deaths per 100,000 live births, the MMR averaged 239 in developing regions, and more than double this (546) in sub-Saharan Africa [8]. Malawi has one of the highest MMRs in the world, even higher than in the rest of Africa, at 574 maternal deaths per 100,000 live births in 2014 [9]. The probability that a 15 year old Malawian girl will eventually die from maternal mortality is 1 in 29 [8]. Due to its persistently high MMR, Malawi failed to meet the Millennium Development Goal to reduce the MMR by 75% between 1990 and 2015. According to a review of largely hospital-based studies, abortions are estimated to contribute between 6–18% of maternal deaths in Malawi [10]. Medication abortion (use of either mifepristone plus misoprostol or misoprostol alone to induce an abortion), could significantly reduce maternal mortality in low-resource settings [11;12]. However, while misoprostol is registered in Malawi for prevention and treatment of post-partum hemorrhage and for post-abortion care, it is not believed to be widely used for induced abortion. Abortion is only legal in Malawi if performed to save a woman’s life, and attempts to procure an abortion are punishable by 7–14 years imprisonment [13]. The majority of terminations in Malawi are performed under unsafe conditions [14], and the stigmatized nature of the procedure often leads to delays or avoidance in seeking medical care for complications [15]. Among women who do reach a facility for post-abortion care (PAC), more than one in four have severe or moderate morbidity, and there were an estimated 387 deaths per 100,000 PAC complications in 2009 [16]. Malawians are currently debating whether to liberalize the abortion law by providing more exceptions under which an abortion could be legally obtained. A Special Commission was established to investigate the issue, conduct national consultations, and make recommendations in a draft bill for Parliament to consider [17]. As part of this process, policymakers need reliable, up-to-date evidence on the magnitude and impact of abortion in Malawi. A 2009 study estimated a total of 67,300 induced abortions (range 48,600–86,000) in Malawi that year, equivalent to a rate of 23 abortions per 1,000 women aged 15–44 [18]. Between 2010 and 2015, the contraceptive prevalence rate in Malawi increased from 46% to 59% [19]. During this same period, the percent of adolescents aged 15–19 who had begun childbearing rose slightly from 25.6% to 29%.[19] Changes such as these could impact the abortion rate, rendering the 2009 estimates potentially outdated. We undertook a study to determine current estimates of induced abortion in Malawi.
PLOS ONE | https://doi.org/10.1371/journal.pone.0173639 April 3, 2017
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Incidence of induced abortion in Malawi, 2015
Methods Overview We used an indirect estimation approach called the Abortion Incidence Complications Method (AICM) [20], which has been used in over 20 countries, including Malawi in 2009 [18]. It requires two surveys: a Health Facilities Survey (HFS) conducted in facilities with the potential to treat abortion complications, and a Knowledgeable Informants Survey (KIS), conducted among individuals knowledgeable about abortion in the country. Women undergoing induced abortion have three potential outcomes: experiencing no complications, experiencing complications but not obtaining treatment in a health facility, or experiencing complications and obtaining treatment in a health facility. Data from the HFS is used to estimate the latter. KIS respondents estimate the distribution of abortions by provider type, the probability of experiencing complications by provider type, and the probability of obtaining PAC in a facility. Given differentials in women’s access to abortion and to PAC, these probabilities are estimated separately for four sub-groups: rural poor and non-poor women, and urban poor and non-poor women. This information is used to calculate a multiplier which represents, for each induced abortion complication treated, how many induced abortions occurred for which treatment was either not required or not obtained. Applying the multiplier (calculated from the KIS) to the estimated number of induced abortions with treated complications (calculated from the HFS) yields an estimate of all induced abortions in the country. Fieldwork occurred during October-December 2015, led by the Centre for Reproductive Health at the College of Medicine, University of Malawi, with technical support from the Guttmacher Institute. Twelve interviewers with previous experience administering surveys related to reproductive health conducted HFS and KIS interviews, supervised by three MPH-level interviewers who also administered several KIS interviews. All of these interviewers were in turn supervised by a Project Coordinator. A week-long training for all interviewers, supervisors, and study staff was held in Blantyre just prior to fieldwork initiation. We pilot tested questionnaires in a small number of interviews with respondents outside of our sample. Ethical approval to conduct the study was obtained from Guttmacher’s Institutional Review Board and the Research and Ethics Committee of the College of Medicine. We also obtained a letter of support from the Malawi Ministry of Health, Department of Planning and Policy Development. Respondents in both surveys provided written informed consent, and interviews were conducted in English or Chichewa (the vernacular of Malawi), according to the respondent’s preference. We did not provide incentives for participation in either survey.
HFS sampling and fieldwork We obtained a list of 977 facilities from the 2013–14 Malawi Service Provision Assessment [21], which represented 92% of all known health facilities in the country (Table 1). We excluded 49 facilities too specialized to provide PAC (e.g., dental offices, prison clinics, podiatry clinics), plus 47 dispensaries and 20 health posts, since PAC services are not offered at this level of health care facility in Malawi. Among 861 remaining facilities, we selected a nationally representative sample using stratified random sampling by facility level (central hospital, district hospital, rural/community hospital, other hospital, health centre, clinic, maternity unit), administrative zone of the Ministry of Health (North, Central-East, Central-West, Southeast, and Southwest) and ownership type (government, non-governmental organization [NGO], or private). We included all hospitals and maternity units, and randomly sampled 40% of health centers and 12% of clinics, for a total of 334 sampled facilities.
PLOS ONE | https://doi.org/10.1371/journal.pone.0173639 April 3, 2017
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Incidence of induced abortion in Malawi, 2015
Table 1. Number of facilities sampled, Health Facilities Survey, Malawi 2015. Facility type
# facilities in 2013–4 MSPA
# facilities possibly providing PAC
% of facilities sampled
# facilities sampled*
Central hospital
4
4
100%
4
District hospital
24
24
100%
24
Rural/community hospital
41
41
100%
41
Other hospital
47
40
100%
40
Health centre
473
467
40%
187
Clinics
34
317
281
12%
Maternity unit
4
4
100%
4
Dispensaries
47
0
n/a
n/a
20
0
n/a
977
861
Health Posts TOTAL
n/a 334
* To determine the number of health centers and clinics to be sampled within each geographical zone, we determined the proportion of all health centers and clinics represented in each geographical zone. We then applied the relevant proportion to the total number of health centers (187) or clinics (34) we planned to sample. To determine the number of health centers and clinics to be sampled within each geographical zone and by ownership, we determined the proportion of health centers and clinics within each geographical zone that were within each ownership category (public, NGO, and private). We then applied the relevant proportion for each type of health facility (health centre or clinic) and zone to the total number of health centers or clinics that we planned to sample in each geographical zone. https://doi.org/10.1371/journal.pone.0173639.t001
To minimize refusals, the Malawian Ministry of Health sent letters introducing the study and noting an upcoming interview request to the 334 sampled facilities in advance of data collection. Interviewers used a standardized questionnaire to conduct a face-to-face interview with a senior staff member knowledgeable about the facility’s provision of abortion services; generally a nurse-midwife (68%) or other clinician (27%).
KIS sampling and fieldwork In consultation with zonal officers and reproductive health experts in Malawi, we developed a purposive sample of 125 potential knowledgeable informants; 25 per zone, representing 27 of Malawi’s 28 districts (the small Lake Malawi island district of Likoma was excluded due to accessibility issues). Trained interviewers successfully interviewed all 125 invited respondents, who held a range of professions, including formal sector medical providers (45%), community health workers (19%), NGO employees (11%), village health committee members (6%), traditional birth attendants (5%), or other professions (14%). Respondents were balanced by gender (52% male and 48% female). Almost half (46%) worked in the public sector, with 29% in NGOs, 12% in the private sector, 5% affiliated with a Christian Health Association of Malawi (CHAM) facility, and 8% in other sectors (for example, a traditional leader or member of a community health committee). The 2009 Malawi AICM [18] noted concern about potential underrepresentation of informants familiar with the situation of abortion in rural areas, and recommended that future studies identify informants with recent rural experience. Thus, we paid particular attention to this factor. While 16% of our respondents worked in urban areas, 42% worked in rural areas and another 42% worked in both urban and rural areas. Interviewers determined that the respondent knew about abortion in rural areas very well or moderately well in 91% of interviews. In 10 of 125 KIS interviews, interviewers noted concern about respondent uncertainty in responses to key questions. We excluded these 10 respondents from analysis, after confirming that they were similar to the remaining sample of KIS respondents in terms of location, gender, age, or years in profession.
PLOS ONE | https://doi.org/10.1371/journal.pone.0173639 April 3, 2017
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Incidence of induced abortion in Malawi, 2015
Table 2. Facilities sampled, interviewed, and providing PAC, with estimated national PAC caseloads, Health Facilities Survey, Malawi 2015. Facility type
# sampled facilities completing interviews
# facilities sampled*
% sampled facilities completing interviews
# interviewed facilities providing PAC
% interviewed facilities providing PAC
Estimated annual PAC caseload (weighted) **
% of caseload by facility type
Central hospital
4
4
100%
4
100%
4,398
6%
District hospital
24
24
100%
23
96%
25,674
35%
Rural/ community hospital
41
39
95%
39
100%
7,494
10%
Other hospital
40
28
70%
22
79%
5,114
7%
Health centre
187
174
93%
103
60%
16,520
22%
34
21
62%
10
50%
15,038
20%
4
4
100%
1
25%
90
Incidence of induced abortion in Malawi, 2015 Chelsea B. Polis1*, Chisale Mhango2, Jesse Philbin1, Wanangwa Chimwaza2, Effie Chipeta2, Ausbert Msusa2 1 Guttmacher Institute, New York, New York, United States of America, 2 Centre for Reproductive Health, College of Medicine, University of Malawi, Blantyre, Malawi * [email protected]
Abstract a1111111111 a1111111111 a1111111111 a1111111111 a1111111111
OPEN ACCESS Citation: Polis CB, Mhango C, Philbin J, Chimwaza W, Chipeta E, Msusa A (2017) Incidence of induced abortion in Malawi, 2015. PLoS ONE 12(4): e0173639. https://doi.org/10.1371/journal. pone.0173639 Editor: Angel M. Foster, University of Ottawa, CANADA Received: December 16, 2016 Accepted: February 23, 2017 Published: April 3, 2017 Copyright: © 2017 Polis et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: The Malawi 2010 Demographic and Health Survey Births and Individual data files are available here: http:// dhsprogram.com/data/dataset/Malawi_StandardDHS_2010.cfm. The datasets collected by the authors and used in this paper are publicly available on figshare.com. The Health Facilities Survey can be accessed under DOI 10.6084/m9. figshare.4711273, and the Knowledgeable Informant Survey can be accessed under DOI 10. 6084/m9.figshare.4711279.
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
PLOS ONE | https://doi.org/10.1371/journal.pone.0173639 April 3, 2017
1 / 16
Incidence of induced abortion in Malawi, 2015
Funding: This study was funded by the UK Government (https://www.gov.uk/government/ organisations/department-for-internationaldevelopment) under grant number 20317740053169, the Norwegian Agency for Development Cooperation (https://www.norad.no/en/front/) under grant number 1300340, and the Dutch Ministry of Foreign Affairs (https://www. government.nl/ministries/ministry-of-foreignaffairs) under grant number 24590. The funders had no role in study design, data collection, analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist.
pregnancies in Malawi are unintended. Our findings should inform ongoing efforts to reduce maternal morbidity and mortality and to improve public health in Malawi.
Introduction About 56 million women worldwide are estimated to have an induced abortion each year [1]. Contrary to popular belief, regions with restrictive abortion laws do not have lower abortion rates than those with liberal laws [1], but women in restrictive settings are more likely to experience morbidity and mortality stemming from unsafe abortion [2–4]. In addition to serious health risks, unsafe abortion poses high financial costs and service burdens on families and on the national health system [5;6]. In Africa, more than one in every seven pregnancies (15%) end in an induced abortion [1], and the majority of women of childbearing age in Africa live in countries with restrictive abortion laws [7]. Africa accounts for about 15% of all abortions in the world [1], but contributes 65% of all estimated abortion deaths in the world [2]. While the maternal mortality ratio (MMR) in developed countries in 2015 averaged 12 maternal deaths per 100,000 live births, the MMR averaged 239 in developing regions, and more than double this (546) in sub-Saharan Africa [8]. Malawi has one of the highest MMRs in the world, even higher than in the rest of Africa, at 574 maternal deaths per 100,000 live births in 2014 [9]. The probability that a 15 year old Malawian girl will eventually die from maternal mortality is 1 in 29 [8]. Due to its persistently high MMR, Malawi failed to meet the Millennium Development Goal to reduce the MMR by 75% between 1990 and 2015. According to a review of largely hospital-based studies, abortions are estimated to contribute between 6–18% of maternal deaths in Malawi [10]. Medication abortion (use of either mifepristone plus misoprostol or misoprostol alone to induce an abortion), could significantly reduce maternal mortality in low-resource settings [11;12]. However, while misoprostol is registered in Malawi for prevention and treatment of post-partum hemorrhage and for post-abortion care, it is not believed to be widely used for induced abortion. Abortion is only legal in Malawi if performed to save a woman’s life, and attempts to procure an abortion are punishable by 7–14 years imprisonment [13]. The majority of terminations in Malawi are performed under unsafe conditions [14], and the stigmatized nature of the procedure often leads to delays or avoidance in seeking medical care for complications [15]. Among women who do reach a facility for post-abortion care (PAC), more than one in four have severe or moderate morbidity, and there were an estimated 387 deaths per 100,000 PAC complications in 2009 [16]. Malawians are currently debating whether to liberalize the abortion law by providing more exceptions under which an abortion could be legally obtained. A Special Commission was established to investigate the issue, conduct national consultations, and make recommendations in a draft bill for Parliament to consider [17]. As part of this process, policymakers need reliable, up-to-date evidence on the magnitude and impact of abortion in Malawi. A 2009 study estimated a total of 67,300 induced abortions (range 48,600–86,000) in Malawi that year, equivalent to a rate of 23 abortions per 1,000 women aged 15–44 [18]. Between 2010 and 2015, the contraceptive prevalence rate in Malawi increased from 46% to 59% [19]. During this same period, the percent of adolescents aged 15–19 who had begun childbearing rose slightly from 25.6% to 29%.[19] Changes such as these could impact the abortion rate, rendering the 2009 estimates potentially outdated. We undertook a study to determine current estimates of induced abortion in Malawi.
PLOS ONE | https://doi.org/10.1371/journal.pone.0173639 April 3, 2017
2 / 16
Incidence of induced abortion in Malawi, 2015
Methods Overview We used an indirect estimation approach called the Abortion Incidence Complications Method (AICM) [20], which has been used in over 20 countries, including Malawi in 2009 [18]. It requires two surveys: a Health Facilities Survey (HFS) conducted in facilities with the potential to treat abortion complications, and a Knowledgeable Informants Survey (KIS), conducted among individuals knowledgeable about abortion in the country. Women undergoing induced abortion have three potential outcomes: experiencing no complications, experiencing complications but not obtaining treatment in a health facility, or experiencing complications and obtaining treatment in a health facility. Data from the HFS is used to estimate the latter. KIS respondents estimate the distribution of abortions by provider type, the probability of experiencing complications by provider type, and the probability of obtaining PAC in a facility. Given differentials in women’s access to abortion and to PAC, these probabilities are estimated separately for four sub-groups: rural poor and non-poor women, and urban poor and non-poor women. This information is used to calculate a multiplier which represents, for each induced abortion complication treated, how many induced abortions occurred for which treatment was either not required or not obtained. Applying the multiplier (calculated from the KIS) to the estimated number of induced abortions with treated complications (calculated from the HFS) yields an estimate of all induced abortions in the country. Fieldwork occurred during October-December 2015, led by the Centre for Reproductive Health at the College of Medicine, University of Malawi, with technical support from the Guttmacher Institute. Twelve interviewers with previous experience administering surveys related to reproductive health conducted HFS and KIS interviews, supervised by three MPH-level interviewers who also administered several KIS interviews. All of these interviewers were in turn supervised by a Project Coordinator. A week-long training for all interviewers, supervisors, and study staff was held in Blantyre just prior to fieldwork initiation. We pilot tested questionnaires in a small number of interviews with respondents outside of our sample. Ethical approval to conduct the study was obtained from Guttmacher’s Institutional Review Board and the Research and Ethics Committee of the College of Medicine. We also obtained a letter of support from the Malawi Ministry of Health, Department of Planning and Policy Development. Respondents in both surveys provided written informed consent, and interviews were conducted in English or Chichewa (the vernacular of Malawi), according to the respondent’s preference. We did not provide incentives for participation in either survey.
HFS sampling and fieldwork We obtained a list of 977 facilities from the 2013–14 Malawi Service Provision Assessment [21], which represented 92% of all known health facilities in the country (Table 1). We excluded 49 facilities too specialized to provide PAC (e.g., dental offices, prison clinics, podiatry clinics), plus 47 dispensaries and 20 health posts, since PAC services are not offered at this level of health care facility in Malawi. Among 861 remaining facilities, we selected a nationally representative sample using stratified random sampling by facility level (central hospital, district hospital, rural/community hospital, other hospital, health centre, clinic, maternity unit), administrative zone of the Ministry of Health (North, Central-East, Central-West, Southeast, and Southwest) and ownership type (government, non-governmental organization [NGO], or private). We included all hospitals and maternity units, and randomly sampled 40% of health centers and 12% of clinics, for a total of 334 sampled facilities.
PLOS ONE | https://doi.org/10.1371/journal.pone.0173639 April 3, 2017
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Incidence of induced abortion in Malawi, 2015
Table 1. Number of facilities sampled, Health Facilities Survey, Malawi 2015. Facility type
# facilities in 2013–4 MSPA
# facilities possibly providing PAC
% of facilities sampled
# facilities sampled*
Central hospital
4
4
100%
4
District hospital
24
24
100%
24
Rural/community hospital
41
41
100%
41
Other hospital
47
40
100%
40
Health centre
473
467
40%
187
Clinics
34
317
281
12%
Maternity unit
4
4
100%
4
Dispensaries
47
0
n/a
n/a
20
0
n/a
977
861
Health Posts TOTAL
n/a 334
* To determine the number of health centers and clinics to be sampled within each geographical zone, we determined the proportion of all health centers and clinics represented in each geographical zone. We then applied the relevant proportion to the total number of health centers (187) or clinics (34) we planned to sample. To determine the number of health centers and clinics to be sampled within each geographical zone and by ownership, we determined the proportion of health centers and clinics within each geographical zone that were within each ownership category (public, NGO, and private). We then applied the relevant proportion for each type of health facility (health centre or clinic) and zone to the total number of health centers or clinics that we planned to sample in each geographical zone. https://doi.org/10.1371/journal.pone.0173639.t001
To minimize refusals, the Malawian Ministry of Health sent letters introducing the study and noting an upcoming interview request to the 334 sampled facilities in advance of data collection. Interviewers used a standardized questionnaire to conduct a face-to-face interview with a senior staff member knowledgeable about the facility’s provision of abortion services; generally a nurse-midwife (68%) or other clinician (27%).
KIS sampling and fieldwork In consultation with zonal officers and reproductive health experts in Malawi, we developed a purposive sample of 125 potential knowledgeable informants; 25 per zone, representing 27 of Malawi’s 28 districts (the small Lake Malawi island district of Likoma was excluded due to accessibility issues). Trained interviewers successfully interviewed all 125 invited respondents, who held a range of professions, including formal sector medical providers (45%), community health workers (19%), NGO employees (11%), village health committee members (6%), traditional birth attendants (5%), or other professions (14%). Respondents were balanced by gender (52% male and 48% female). Almost half (46%) worked in the public sector, with 29% in NGOs, 12% in the private sector, 5% affiliated with a Christian Health Association of Malawi (CHAM) facility, and 8% in other sectors (for example, a traditional leader or member of a community health committee). The 2009 Malawi AICM [18] noted concern about potential underrepresentation of informants familiar with the situation of abortion in rural areas, and recommended that future studies identify informants with recent rural experience. Thus, we paid particular attention to this factor. While 16% of our respondents worked in urban areas, 42% worked in rural areas and another 42% worked in both urban and rural areas. Interviewers determined that the respondent knew about abortion in rural areas very well or moderately well in 91% of interviews. In 10 of 125 KIS interviews, interviewers noted concern about respondent uncertainty in responses to key questions. We excluded these 10 respondents from analysis, after confirming that they were similar to the remaining sample of KIS respondents in terms of location, gender, age, or years in profession.
PLOS ONE | https://doi.org/10.1371/journal.pone.0173639 April 3, 2017
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Incidence of induced abortion in Malawi, 2015
Table 2. Facilities sampled, interviewed, and providing PAC, with estimated national PAC caseloads, Health Facilities Survey, Malawi 2015. Facility type
# sampled facilities completing interviews
# facilities sampled*
% sampled facilities completing interviews
# interviewed facilities providing PAC
% interviewed facilities providing PAC
Estimated annual PAC caseload (weighted) **
% of caseload by facility type
Central hospital
4
4
100%
4
100%
4,398
6%
District hospital
24
24
100%
23
96%
25,674
35%
Rural/ community hospital
41
39
95%
39
100%
7,494
10%
Other hospital
40
28
70%
22
79%
5,114
7%
Health centre
187
174
93%
103
60%
16,520
22%
34
21
62%
10
50%
15,038
20%
4
4
100%
1
25%
90
