Political Priority for Abortion Law Reform in Malawi

Abstract

In July 2015, Malawi’s Special Law Commission on the Review of the Law on Abortion released a draft Termination of Pregnancy bill. If approved by Parliament, it will liberalize Malawi’s strict abortion law, expanding the grounds for safe abortion and representing an important step toward safer abortion in Malawi. Drawing on prospective policy analysis (2013–2017), we identify factors that helped generate political will to address unsafe abortion. Notably, we show that transnational influences and domestic advocacy converged to make unsafe abortion a political issue in Malawi and to make abortion law reform a possibility. Since the 1980s, international actors have promoted global norms and provided financial and technical resources to advance ideas about women’s reproductive health and rights and to support research on unsafe abortion. Meanwhile, domestic coalitions of actors and policy champions have mobilized new national evidence on the magnitude, costs, and public health impacts of unsafe abortion, framing action on unsafe abortion as part of a broader imperative to address Malawi’s high level of maternal mortality. Although these efforts have generated substantial support for abortion law reform, an ongoing backlash from the international anti-choice movement has gained momentum by appealing to religious and nationalist values. Passage of the bill also antagonizes the United States’ development work in Malawi due to US policies prohibiting the funding of safe abortion. This threatens existing political will and renders the outcome of the legal review uncertain.

Introduction

This paper describes how safe abortion became a political priority in Malawi, prompting efforts to reform Malawi’s highly restrictive abortion law. The country’s abortion law, dating from British colonial rule, allows induced abortion only to save a woman’s life.¹ Nevertheless, induced abortions are common. A recent nationally representative survey estimated that there were approximately 141,044 induced abortions in Malawi in 2015.² Despite the legal restrictions, medical professionals in the private sector and traditional healers administer abortions, and many women self-induce, often with unsafe methods.³ An estimated 51,693 abortions result in complications requiring post-abortion care. Unsafe abortion is among the top five direct causes of maternal deaths, contributing to nearly 18% of maternal mortality.⁴ Though women or providers are rarely, if ever, prosecuted for inducing abortions, traditional religious values and societal norms underpin stigmatized and discriminatory attitudes toward those who have abortions.⁵

New evidence on the public health burden of unsafe abortion in Malawi became the basis of a review of abortion law and policy, which resulted in a draft Termination of Pregnancy (ToP) bill, released in July 2015. Currently, the ToP bill awaits debate in Parliament, and if approved, it will expand the grounds for legal abortion to include threats to the woman’s physical or mental health; pregnancy resulting from rape, incest, or defilement; and severe fetal malformation.⁶ Although advocates from national civil society organizations may have hoped for an even more liberal law, this bill represents a significant step forward for Malawi. Its adoption, however, is surrounded by uncertainty due to an opposition based on religious and cultural values, as well as a lack of popular public support for change.

Based on a prospective policy analysis of Malawi’s changing reproductive health policy context since the 1980s, this paper discusses the developments leading to the drafting of the ToP bill and the growth of political will for safe abortion, as well as the factors surrounding current uncertainties in adopting the proposed law. Drawing on Jeremy Shiffman’s framework for analyzing the generation of political priority for different health issues, we emphasize the role of transnational influences, domestic advocacy, and the national political environment.⁷ Here, political priority is “the degree to which international and national political leaders actively give attention to an issue, and back up that attention with the provision of financial, technical, and human resources that are commensurate with the severity of the issue.”⁸ We show that all of the influences outlined by Shiffman as important in generating political priority were present in Malawi. These include international agencies’ efforts to implement global norms in national contexts; forums and major conferences drawing attention to the issue; international agencies’ offers of financial and technical resources to address issues of concern; national actors coalescing as a political force to push the government to act; the presence of respected and capable national champions of the cause; and the availability and strategic deployment of evidence to demonstrate the severity of the problem. Moving beyond the analysis of these factors, we also document the emergent threats to the ToP bill, demonstrating that political and popular support for controversial policy issues such as abortion are very fragile and continually negotiated.

Methodology

The study was conducted between 2013 and 2017 as part of an evaluation of a program to prevent deaths from unwanted pregnancy, funded by the UK Department for International Development. Adopting both retrospective and prospective policy analysis approaches, our aim was to understand the evolving sociopolitical context of reproductive health policy change in Malawi, with a focus on family planning and abortion. We analyzed changing popular and political discourses and sought to describe the history of laws and policies relating to reproductive health, as well as the landscape for policy change, disconnects between policy and practice, and the impact of critical policy events that unfolded during the study period.

We used a combination of qualitative methods. We analyzed a range of policy-related documents, including peer-reviewed journal articles on unsafe abortion in Malawi, laws relating to human rights and access to reproductive health services, relevant Ministry of Health (MoH) policies, strategic planning documents, program and project documents, evaluation reports, technical documents, and studies. To monitor major events and debates related to reproductive health, we tracked local media for relevant coverage.

In addition, we conducted in-depth interviews with 56 national-level stakeholders identified through document review and snowballing methods, in some cases interviewing them more than once. They included national policy makers, MoH officials, parliamentarians, journalists, and representatives of national lawyers’ groups, national health professional associations, civil society and nongovernmental organizations, and religious organizations. Lastly, we interviewed representatives of international nongovernmental organizations and bilateral, multilateral, and private donors funding reproductive health. Interviews were conducted in private and recorded when permitted. We anonymized personal statements since interviews covered highly sensitive issues. We exported our notes, interview transcripts, and electronic literature to Nvivo, which we used to store and analyze data thematically.

We obtained ethical approval for the study from the London School of Hygiene and Tropical Medicine, the College of Medicine in Malawi, and the National Commission for Science and Technology, Malawi.

Political priority for safe abortion in Malawi

Hastings Banda, Malawi’s first president after independence in 1964, initially resisted family planning, rejecting the notion that population growth was a problem and banning family planning entirely in the 1960s on grounds that it was foreign.⁹ In line with global trends in medical care for women and children in developing countries like Malawi, however, maternal health soon became a key health policy priority in the country, with pregnancy care as the focus until the mid-1980s.¹⁰ With the introduction of democracy in the early 1990s, family planning became a political priority in response to rapid population growth. Following the Safe Motherhood Initiative in 1987, the International Conference on Population and Development (ICPD) in 1994, and the Fourth World Conference on Women in 1995, Malawi broadened its reproductive health remit in the early 2000s. The adoption of the Millennium Development Goals in 2000 led to increased national attention to reproductive health, especially maternal mortality, and the government expanded services, such as family planning and post-abortion care.¹¹

Despite adopting these broader policy concepts, abortion care in Malawi remained limited to the treatment of complications of unsafe abortion (in other words, post-abortion care).¹² Post-abortion care had been recommended in the ICPD Programme of Action as a way to address the serious public health problem of unsafe abortion without changing the law. Such care, along with post-abortion family planning, is currently provided for free in Malawi’s public health facilities, but mostly in urban areas. More than 80% of the Malawian population lives in rural areas and is characterized as poor.¹³

Political priority for safe abortion emerged alongside discourses related to family planning as a strategy for controlling population growth and unsafe abortion as a significant contributor to maternal mortality. From the 1980s onward, there were signs of an emerging policy window and enabling environment for addressing safe abortion in Malawi. The pace was slow from the beginning, but events ultimately culminated in the draft bill in 2015. Transnational influences and domestic advocacy work were key factors in this process.

Transnational influence focused on family planning

Malawi is a low-income country that relies heavily on external funding for public services. As much as 40% of the country’s total budget and 70% of its reproductive health funding come from external donors.¹⁴ In addition to supporting government sectors, global health donors are increasingly funding international advocates, organizations, and intergovernmental bodies. These agencies have long encouraged political attention to unsafe abortion through the promotion of global norms related to human rights and women’s access to reproductive health services.

As early as 1977, the United Nations Population Fund, World Bank, and World Health Organization supported a national survey to draw political attention to Malawi’s rapid population growth, which led to the development and implementation of a child spacing policy. Adopted in 1982, the child spacing policy was a precursor to the national population policy.¹⁵ Efforts to develop a population policy started in the late 1980s, when the International Labour Organization and United Nations Population Fund supported the establishment of a national population steering committee, which drafted a population policy in 1993. These agencies’ technical and financial support also helped generate data on population growth and allowed MoH officials to attend international conferences on population health (including the International Safe Motherhood Conference in Nairobi in 1987, the ICPD in 1994, and the Fourth World Conference on Women in Beijing in 1995), study tours to African countries that had national population policies (such as Kenya), and national meetings on these issues.¹⁶ Adopted in 1994, the national population policy served as an entry point for broadening awareness of the concepts of family planning, reproductive health, and women’s rights.

Transnational influence focused on unsafe abortion

Following multiparty elections in 1994, international reproductive health organizations began working in the country. They included Population Services International (1994), Care (1998), Ipas (1999), EngenderHealth, and Jhpiego (1999), in addition to the Family Planning Association of Malawi (registered as a national nongovernmental organization in 1999 and an affiliate of the International Planned Parenthood Federation from 2004 forward). These organizations began to influence the government to liberalize the service delivery environment, including by creating family planning and post-abortion care programs. In 1999, Ipas, a US-based reproductive health and rights organization, provided medical supplies and equipment for manual vacuum aspiration at Queen Elizabeth Hospital in Blantyre.¹⁷ In 2000, Jhpiego and EngenderHealth provided financial and technical resources for piloting and, in 2002, for the scale-up of post-abortion care services, training, the development of standard operating procedures, and participation in policy efforts to incorporate post-abortion care as a component of reproductive health.¹⁸

Ipas became a particularly important actor in the developments leading up to the draft ToP bill. The organization established an office in Malawi in 2008 in response to an invitation from the then minister of health, Marjorie Ngaunje.¹⁹ From 2008, Ipas Malawi worked alongside the MoH’s Reproductive Health Unit to train health professionals in post-abortion care and provide medical supplies and equipment. Along with the Special Programme of Research Development and Research Training in Human Reproduction, based at the World Health Organization, Ipas International provided the MoH with technical and financial support to conduct studies on abortion in 2009. These studies became crucial for building an evidence base on abortion in the country. They included a strategic assessment consisting of a human rights-based review of Malawi’s laws and policies and of international agreements relating to sexual and reproductive health, as well as the production of new data on the epidemiology of unsafe abortion and its costs to the health system.²⁰ Ipas also supported the MoH in disseminating the findings from these studies to a wide range of stakeholders through nationwide workshops.

Meanwhile, Malawi was under growing international pressure to address unsafe abortion to meet its commitments to international and regional agreements, including the Convention on the Elimination of All Forms of Discrimination against Women, the Maputo Plan of Action, and the Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa (Maputo Protocol).²¹ For instance, the United Nations Committee on the Elimination of Discrimination against Women noted its concern regarding Malawi’s high maternal mortality rate, particularly from unsafe abortions, in 2010, a call that was reiterated in 2015, when it urged Malawi to implement laws and policies to expand and secure access to safe and legal abortion.²²

National influences

While international involvement brought policy ideas, research, new practices, and resources that highlighted the issue of unsafe abortion, the domestic political environment was also important in institutionalizing the case for abortion law reform.²³

Policy community cohesion. When the MoH disseminated preliminary findings from the strategic assessment on abortion in 2010, participants at the dissemination workshop, including MoH officials and civil society representatives, developed a set of recommendations, including a recommendation to “review and reform restrictive abortion laws.”²⁴ In an effort to take the recommendations forward, Ipas and Women and Law Southern Africa-Malawi, a regional women’s rights organization, spearheaded the creation of a coalition of actors called the Coalition for Prevention of Unsafe Abortion (COPUA) in 2010. From an initial network of 12 organizations at its inception, this network grew to include more than 60 by 2016. The coalition brings together legal, human rights, and health care professionals; reproductive health organizations; and influential individuals in the community.

In need of skills, resources, and funding, COPUA received a boost when Ipas Malawi became COPUA’s secretariat and national coordinator in 2012.²⁵ With a new major donor grant focused on policy and advocacy work, Ipas led the development of COPUA’s governance structure, funded (or mobilized funding for) activities, provided technical support for advocacy training workshops, provided information on best practices for advocacy strategies, and offered technical and financial support for COPUA’s public campaigns and advocacy activities.²⁶

In 2012, Ipas Malawi’s policy associate (and currently country director), previously a lawyer with the Malawi Human Rights Commission, was appointed head of COPUA. With his connections, he built on his predecessor’s work to strengthen and expand COPUA’s membership and scope of advocacy work. Ipas also mobilized donor funding for COPUA to work with the MoH’s Reproductive Health Unit to strengthen the public health evidence on the burden of unsafe abortion and legal evidence upon which the government could rely to reform the country’s abortion law.²⁷

With this support, COPUA began an advocacy and lobbying campaign for abortion law reform. It organized formal and informal meetings to sensitize key stakeholders—including members of parliament (MP), chiefs, and religious leaders—on the magnitude of unsafe abortion in Malawi, its implications for women’s health, and how it could be addressed through law reform. During these meetings, COPUA secured communiqués from participants supporting policy change on abortion and calling on the government to act. Advocacy work targeting the public took the form of training workshops, debates, social media discussions, radio shows, newspaper articles, TV appearances, concerts, and public rallies.²⁸

In 2013, Ipas Malawi lobbied the Malawi Law Commission to appoint a Special Law Commission on the Review of the Law on Abortion (hereafter Special Law Commission), with commissioners from the Ministries of Health and Justice, religious councils, traditional communities, the Malawi Law Society, and the Malawi College of Medicine who would become involved in developing the ToP bill.²⁹ Throughout the review process, Ipas International funded members of the Special Law Commission to travel to Zambia, Ethiopia, and Mauritius to learn about those countries’ experiences with liberalizing their abortion laws.³⁰ In addition, Ipas Malawi provided information on best practices on abortion and sample laws.³¹ Through COPUA, Ipas Malawi also provided training on reproductive rights, human rights, and abortion for lawyers and judges (some of whom participated in drafting the ToP bill), as well for journalists (who published newspaper articles about unsafe abortion) and local organizations and youth organizations (who helped lobby for law reform).³²

Political entrepreneurship. Ipas Malawi’s country director became a very vocal policy champion who was frequently profiled in the media. Drawing on his extensive network and fundraising ability, he led COPUA’s policy advocacy work in order to generate support on abortion law reform. As the political environment became more open to the idea of abortion law review, he recognized the need for other champions who could advocate policy change and, to this end, mobilized traditional authorities and representatives of medical and legal associations. These new champions provided their expertise and had a powerful impact on the public, such as through media appearances.

Obstetrician-gynecologists also played a leading role in generating and disseminating evidence on unsafe abortion, speaking openly in support of abortion law reform.³³ One such practitioner was Dr. Chisale Mhango, an academic researcher and practicing professional in both the public and private sector.³⁴ As a former director of the MoH Reproductive Health Unit who had participated in the development of the Maputo Plan of Action in 2006, together with the then minister of health, Marjorie Ngaunje, he sparked activity inside the MoH Reproductive Health Unit to follow up on the country’s international and regional commitments. He was also one of the key figures who requested that the Malawi Law Commission review the country’s abortion law in 2008. An emerging group of obstetrician-gynecologists was also involved as co-investigators for the 2009 MoH-commissioned abortion studies and had been guest speakers at COPUA’s workshops and advocacy activities, where they shared personal stories of treating women with complications from unsafe abortion.³⁵ Drawing on their authority as doctors possessing first-hand knowledge of unsafe abortion, they persistently argued that the government must address unsafe abortion as part of its effort to reduce maternal mortality. Some of them became members of COPUA, while others were on the Special Law Commission, or both.

Lawyers in the Malawi Human Rights Commission also publicly called for a review of the country’s abortion law and became involved in COPUA’s advocacy activities and in the bill’s drafting.³⁶ Moreover, certain religious leaders supported the bill, including Prophet Amos Tchuma of the Faith of God Ministries, who was quoted in a 2015 news article expressing shock that “some women use bicycle spokes, cassava sticks and poisonous substances to induce abortions just because we have a restrictive law.”³⁷ In 2016, after a sensitization meeting organized by COPUA, the Malawi Council of Churches expressed optimism that the faith community in Malawi would endorse the safe abortion bill in spite of the opposition that was being expressed.³⁸ The same year, the Obstetrician and Gynaecologist Association of Malawi was formed, and has since been a vocal actor in support of abortion law reform.

Credible indicators and policy alternatives. Even though there existed some epidemiological evidence of the severity of unsafe abortion in Malawi in the early 2000s, these numbers were not national and did not manage to create momentum for law review.³⁹ By contrast, new studies conducted in 2009 and published between 2011 and 2015 were population based and became very important in mobilizing support for abortion law reform, not least because they established a strong link between unsafe abortion and maternal mortality in Malawi.⁴⁰ The studies estimated that despite the strict law, an estimated 70,000 induced abortions occurred in Malawi in 2009, with unsafe abortions accounting for as much as 18% of the country’s immensely high maternal mortality ratio of 846 per 100,000 live births.⁴¹

The growing evidence of the consequences of unsafe abortion opened spaces for new policy discourses on the issue, especially in light of Millennium Development Goal 5 on reducing maternal mortality. This evidence became crucial in the safe abortion campaign’s reframing of unsafe abortion as a public health emergency rather than simply an issue of morality or rights. They used this framing strategically to raise awareness among the general population and key policy actors and to generate popular support for the abortion law review. With this repositioning of unsafe abortion, some actors started to put forward arguments that post-abortion care alone was not sufficient to address unsafe abortion.⁴² This, too, opened the door for proposals to reform the abortion law. The review by the Special Law Commission and the draft bill followed directly from these calls and strongly referred to this new evidence base.⁴³

National political environment. COPUA and its allies worked concertedly to generate political momentum for safe abortion, such as by lobbying MPs and other state institutions. At the 2014 Pan African Parliament Conference, the deputy chair of the Women’s Caucus and deputy secretary-general of the ruling party in Malawi declared that Malawi was committed to reforming its abortion law and that they supported legal reform for abortion.⁴⁴ The same year, Malawi’s government expressed its commitment to review its restrictive abortion law in its reports to three human rights bodies: the African Commission on Human and Peoples’ Rights, the Universal Periodic Review at the United Nations Human Rights Council, and the United Nations Human Rights Committee.⁴⁵ This willingness to be held accountable for its commitments regarding maternal and reproductive health marked a departure from its position in a 2010 report to the Universal Periodic Review, in which the government rejected calls from both local and international organizations to reform its abortion law.⁴⁶

Nevertheless, political support at the domestic level proved to be vulnerable. COPUA’s targeted lobbying helped secure support to pass the ToP bill among a majority of MPs prior to the 2014 general election. But after only 53 of 193 MPs were reelected in the 2014 general election, COPUA had to start afresh to lobby new MPs.⁴⁷ Even though all political parties officially supported the Special Law Commission’s recommendations in a communiqué published in the media in August 2015, COPUA has, until now, been unable to secure support from the majority of MPs.⁴⁸ It has, however, managed to generate popular support among medical professional, lawyers, journalists, and civil society organizations. These actors form a large part of COPUA’s membership and continue to work collaboratively to increase support among the general public, religious leaders, and MPs. COPUA’s recent advocacy work has focused on MPs and religious leaders, which has led to a wavering support for abortion law reform among some leaders within the Malawi Council of Churches and among traditional leaders.⁴⁹

Uncertainties surrounding the ToP bill’s adoption

Although targeted lobbying generated both political priority for and popular awareness of safe abortion in Malawi, ambivalence toward legal reform is present throughout society, even among the commissioners involved in drafting the bill. There is also religiously based opposition in the country, mainly from the Catholic and Evangelical congregations, as well as some Muslim leaders. As religious leaders expressed in an article in one of Malawi’s main national newspapers, “After a critical reflection on these matters, we came to a conclusion that it was in fact the abortion bill that needed aborting.”⁵⁰

Passage of the bill requires support from MPs and key politicians, who at the constituency level must consider the views of traditional and religious leaders. Thus, support for legal reform remains fragile, and there is now more open resistance to law reform than was evident prior to the ToP bill’s publication. The Catholic Church is one of the biggest civil society organizations in Malawi and has actively opposed modern contraceptives and abortion for a long time. This opposition has intensified with introduction of the bill, and the Catholic hierarchy—as well as the Muslim Association of Malawi and the Evangelical Association of Malawi—has published articles opposing change and campaigning against it.⁵¹

This national religious opposition has been compounded by an international anti-choice movement that claims that the bill represents international sexual and reproductive health and rights organizations’ efforts to “deconstruct” African culture and pan-African values as part of Western “cultural imperialism.”⁵² These groups build on Banda’s discourse of family planning as un-Malawian and argue that both family planning and abortion services are the result of donors taking advantage of the country’s developmental vulnerability.⁵³

In recent years, international anti-choice organizations have supported national anti-abortion activists in hosting meetings to counter the pro-choice influence and have used religious radio stations to reach out to the public.⁵⁴ They have also organized workshops and trainings for religious leaders, traditional leaders, and MPs, and have encouraged them to publicly oppose the bill.⁵⁵ Their activities reached a high point in December 2016, when the Catholic Church, in collaboration with the Evangelical Association of Malawi, organized demonstrations in Malawi’s main urban centers, where protestors opposed both the ToP bill and homosexuality.

In response to this increased opposition following the launch of the ToP bill, COPUA intensified its advocacy activities before MPs, religious leaders, and traditional leaders. For example, between 2016 and 2017, it conducted countrywide meetings with MPs and traditional leaders. In addition, through the Malawi Council of Churches, it organized meetings with church leaders to teach them about the content of the ToP bill and explain that it is not about abortion on demand. Based on this, they encouraged them to support the law review and the passage of the bill.⁵⁶

Even though the bill seeks to liberalize Malawi’s current abortion law, some of those who support legal reform argue that it falls short of what they had hoped and worked for. In September 2016, the bill was criticized as inadequate by COPUA’s chairperson, who argued that it has failed to provide enough grounds on which women and girls can seek safe abortion services. This will force women and girls to continue to use unsafe abortion methods, the very thing the bill is fighting against.⁵⁷

External factors also represent a major challenge for the enactment of the bill. Both national and international civil society groups have lobbied for a long time for the bill to be presented to Parliament during the autumn of 2017. However, according to a representative of a national nongovernmental organization, the bill might not be presented to Parliament this year due to US President Trump’s decision to reinstate and extend the Mexico City policy. This policy bans US funding for foreign nongovernmental organizations advocating for or providing abortion services.⁵⁸ With the United States Agency for International Development being one of Malawi’s biggest bilateral donors toward health services and general budget support, the government might not be willing to risk antagonizing it.

Conclusion

In this paper, we have described how transnational influences and domestic advocacy work were both influential in generating political priority for ensuring safe abortion in Malawi. Political priority for unsafe abortion emerged as an evolving international response to reproductive health and rights, driven first by data on rapid population growth and then by the linkage between maternal mortality and unsafe abortion. Following the introduction of multiparty democracy, which allowed more actors to be involved in policymaking and service provision, international and national actors provided technical and financial support for the generation of evidence on the impact and cost of unsafe abortion and politically supported the need to reform Malawi’s strict abortion law. This stands in contrast to the anti-choice movement, which increased its activities in Malawi after the ToP bill was introduced in 2015 and based its opposition primarily on a rejection of abortion law reform as a form of “cultural imperialism.”⁵⁹

As the ToP bill awaits parliamentary debate, it is uncertain if or when it will be passed into law in light of political threats from the international anti-choice movement, which has strengthened opposition activities in the country among religious leaders, MPs, and traditional leaders. The government also needs to play its cards carefully given that passage of the law may threaten its development relationship with the United States Agency for International Development. Our observations on the uncertainties surrounding the bill’s future highlight that in addition to the emphasis on the facilitators of political priority in Shiffman’s framework, attention to the factors that threaten or inhibit such progress is necessary. In this regard, it is important to consider how political priority can be maintained past the agenda-setting and policy-adoption stage to ensure that policy translates into practice.

For example, although many African countries, such as Mozambique, have expanded the legal grounds for abortion in recent years, their abortion policy environments remain restrictive due to entrenched discriminatory cultural and religious values and norms for reproductive health.⁶⁰ In Malawi, the increasing force of the anti-choice movement highlights that even if the bill is passed, changing the law alone will not guarantee a conducive environment for safe abortion. Experiences from other countries, such as Zambia, show that access to safe abortion services is sometimes poor despite liberal reproductive health laws and policies.⁶¹ Addressing the myriad factors hindering access to safe abortion care therefore requires a multipronged strategy. Continued policy-implementation and value-clarification activities are useful for addressing barriers to access that stem from misinformation, the stigmatization of women and providers, and negative attitudes and obstructionist behaviors.⁶² Continued advocacy is also necessary to obtain political commitment in the form of technical support and financial resources that ensure the rollout of required infrastructure, processes, and systems for the provision of safe abortion for all who need it. Given Malawi’s reliance on external funding and expertise, policy changes and the implementation of safe abortion services will depend on continued external support for policy advocacy and the implementation of associated changes in practice. In addition, considering Malawi’s significant health systems challenges, even if the ToP bill is enacted, access to safe abortion will require a significant strengthening of the health care system (especially at the primary health care level), the development of standards of comprehensive abortion care, and the availability of resources for health care services.