Stakeholder engagement in post abortion care service provision in humanitarian emergencies: A case of public health and education in Malawi

• In Event: Challenges, crisis contexts, and complexities in education

Proposal

Malawi has one of the highest maternal mortality ratios in the world, with unsafe abortions being among the main factors contributing to maternal mortality (Polis et al., 2017). For adolescent girls, teen pregnancy is among the top factors contributing to school dropout, especially those impacted by humanitarian crises—with some girls dying due to complications in childbirth (Eaton, 2021; Worku et al., 2021). Most recent data from the World Health Organization (WHO) indicated 381 deaths per 100,000 live births as the maternal mortality rate in Malawi (WHO, 2023). Women living and experiencing harmful environmental conditions such as natural disasters, including floods, cyclones, etc., are particularly vulnerable to unintended pregnancies and unsafe abortions (Dias-Amaral and Sakellariou, 2021; Pabalan, 2020). In Malawi, floods and cyclones are the major climate-induced disruptors that have internally displaced communities, with women bearing the brunt of these crises (IOM, 2023; UN Women, 2019).

The Malawi Constitution requires protecting women’s rights to life and health, including providing comprehensive sexual reproductive education and health care (Gallagher et al., 2019). These constitutionally mandated services also include Post-Abortion Care (PAC) and abortion care within the legal requirements (Malawi Ministry of Health, 2020). Despite numerous programs such as comprehensive abortion care and other initiatives provided in both stable and humanitarian emergencies, the delivery of these sexual reproductive health services in humanitarian crises poses unique challenges (Endler et al., 2020), including limiting learners’ access to education when there is little to no support. However, some scholars (Brown & Donini, 2014) have emphasized that the focus on stakeholder involvement and engagement in humanitarian action has generally remained rhetorical, not implemented as routine procedures or producing meaningful outcomes. There is a need to examine why there is a gap between stakeholders engaging in providing PAC services to reduce maternal mortality from unsafe abortions, which largely impact school-aged girls.
This study seeks to explore and gain insights into the challenges faced by various stakeholders in Malawi, including the Ministry of Health, district hospitals, non-governmental organizations, and the affected community leaders, in their concerted efforts to collaborate and provide post-abortion care (PAC) services for Malawian women and girls in humanitarian settings. The research design utilized a qualitative approach with a thematic analysis (Saldana, 2021; Bhattacharya, 2017; Creswell, 2008) to investigate the experiences and challenges faced by stakeholders in providing PAC during humanitarian emergencies in Malawi. The study aims to identify challenges and facilitators experienced by these stakeholders as well as investigate strategies local and international stakeholders use to address the sociocultural factors that impact PAC delivery in humanitarian emergencies. The study also explores the extent of stakeholders’ involvement in decision-making regarding PAC provision.

For this study, I conducted one-on-one semi-structured interviews with 10 healthcare professionals and organization representatives who work in humanitarian emergencies and have post-abortion care knowledge. To be part of this study, participants were required to have at least two years of healthcare experience in Malawi and experience in humanitarian emergencies. Some of the selected participants worked with government hospitals and international organizations. Data collection was conducted via Zoom and telephone in the Spring of 2024. The methodology highlighted the integration of digital tools in research, reflecting broader trends in leveraging technology for effective communication and collaboration. For data analysis, I used Saldana’s (2021) approach to thematic analysis to identify themes and categories from participant narratives.

The findings of the study indicate significant challenges arising from inadequate support from both local and international organizations, particularly in securing enough funding and partnerships to support post-abortion care services in healthcare centers. The results also highlight the presence of communication disparities and challenges that limit effective engagement, affecting the delivery of timely and comprehensive PAC services in humanitarian emergencies, which subsequently shapes the experiences of schoolgirls affected by this phenomenon. The study also shows the persistence of a culture of shame and silence that discourages people from seeking care is exacerbated by societal stigma, which becomes a significant barrier to using PAC services in communities. People are hesitant to disclose their abortion events and seek the necessary medical care out of fear of societal judgment and criticism. These challenges also lead to girls missing school, thus the humanitarian crisis together with societal stigma perpetuates the systematic pushout of girls from school. The improvement of post-abortion care (PAC) services has been supported by a variety of strategies that focus on mobilizing resources, building capacity, and raising community awareness.

Furthermore, the study highlights the presence of communication disparities and challenges that limit effective engagement, affecting the delivery of comprehensive PAC services in humanitarian emergencies. Other humanitarian organizations follow their own goals or have different priorities that do not benefit the affected women in humanitarian emergencies. The study also shows both the absence and limited consideration of community input in the decision-making process, indicating a significant gap in community inclusivity and representation within the healthcare governance structure. Stakeholders can improve the provision of important health services and educational development by utilizing their combined knowledge and resources to create interventions that are comprehensive, culturally sensitive, and adaptable through collaborative efforts with the community.

The significance of the study lies in its contribution to understanding public health issues, education and humanitarian response, particularly how health challenges like ineffective engagement among stakeholders in healthcare and inadequate post-abortion care impact health and educational outcomes for women and girls in crisis settings. This research underscores the need for integrated strategies that address both health and education needs. The use of digital methods, such as Zoom and telephone, for qualitative interviews (Archibald et al., 2019) demonstrates how technology can not only overcome geographical barriers but also enable inclusive research and broader participation from diverse voices.

Author

• Alinafe Chinkondenji, Oklahoma State University