Healthcare providers’ and policy-level stakeholders’ experiences on provision of post-abortion care and disclosure of abortion outside Malawi’s legal framework - a qualitative study

Abstract Background Maternal deaths due to unsafe abortion remain a major public health challenge in sub-Saharan Africa. Malawi’s legal framework permits abortion only when the pregnancy poses a threat to the mother’s life, but a significant number of induced abortions are performed outside this legal framework and outside health facilities and/or by untrained healthcare providers. Although post-abortion care (PAC) is available to all women, regardless of whether the abortion was spontaneous or induced, legal, social and provider-related factors may influence women’s disclosure of unsafe abortions. To improve the provision of post-abortion care, it is essential to understand healthcare providers’ and policy stakeholders’ experiences with women’s disclosure of unsafe abortions. Methods We conducted 16 in-depth interviews with healthcare providers and policy-level stakeholders serving patients needing post-abortion care. Semi-structured interview guides were used, and snowball sampling was used to identify participants. Interviews were audio-recorded and later transcribed. Data were coded in NVivo 12 using a deductive approach, and illustrative quotes were identified during analysis. Results Healthcare providers and policy-level stakeholders described five interrelated factors that shaped women’s disclosure of unsafe abortion: (1) legal frameworks on abortion and fear of prosecution; (2) healthcare providers’ attitudes and perceptions, which were often less favorable toward women presenting with septic or induced abortion; (3) community-level stigma toward women known to have had an abortion; (4) religious beliefs particularly within Christian health facilities where abortion was seen as sinful; and (5) limited community awareness that PAC services were available. Overall, legal frameworks surrounding abortion in Malawi were perceived as a major barrier to disclosure and, subsequently, to women seeking post-abortion care. Conclusion PAC provision in Malawi is shaped by an interplay of legal frameworks, health system capacity, and provider-patient dynamics. Addressing these issues will support timely disclosure of unsafe abortion. Timely disclosure, knowledge of and access to post- abortion care are key to minimising complications related to abortion. While abortion remains restricted by legal frameworks in Malawi, hospitals should be made more patient-centred in their delivery of post-abortion care.