Abortion in Madagascar

In [[Madagascar]], [[abortion]] is illegal in all circumstances. The [[abortion law]] punishes receiving or assisting in an abortion with imprisonment or fines. It is one of the only countries with a total abortion ban. Abortion has been illegal since the French colonial era, influenced by attitudes favoring increased births. In 2017, the government rejected a proposal to legalize therapeutic abortion. A bill allowing abortion in the case of rape was proposed by Member of Parliament [[Masy Goulamaly]] in November 2021 but was withdrawn by the parliament.

Most people in Madagascar oppose legalizing abortion. Churches which oppose abortion influence politicians. International organizations have called for the legalization of abortion. The [[abortion-rights]] group [[Nifin'akanga (group)|Nifin'Akanga]] leads research and protests. Abortions in Madagascar are unsafe and are a major cause of [[maternal death]]. Some abortions are performed clandestinely by medical professionals. Some women [[Self-induced abortion|self-induce]] abortions or seek traditional remedies from traditional midwives. Madagascar has low use of contraception.

== Legislation == Article 317 of the [[penal code of Madagascar]] says women who receive abortions can be punished by 6 months to 2 years of prison or a fine of 2 million [[ariary]]. It sentences people who assist in an abortion to 1-5 years of prison and a fine of 360,000 to 10.8 million ariary (€80 to €2,500 in 2022), or higher for repeat offenders.<ref name="Caramel">{{Cite news |last=Caramel |first=Laurence |date=12 May 2022 |title=A Madagascar, « dans chaque famille, on connaît au moins une femme qui a dû avorter » |trans-title=In Madagascar, "In every family, we know at least one woman who has had an abortion" |url=https://www.lemonde.fr/afrique/article/2022/05/12/madagascar-dans-chaque-famille-on-connait-au-moins-une-femme-qui-a-du-avorter_6125861_3212.html |access-date=2 August 2024 |work=[[Le Monde]] |language=fr}}</ref> As of 2020, Madagascar is one of thirteen countries that completely bans abortion.<ref name="Verneau" /> [[Post-abortion care]] is legal.<ref name="Ravaoarisoa et al" />

According to a 2022 survey by [[Afrobarometer]], 96% of Malagasy people oppose the legalization of on-demand abortion, and 85% in the case of rape. However, 65% approve of abortion if the pregnancy is risky.<ref>{{Cite news |last=Rakotobe |first=Narindra |date=28 October 2022 |title=Grossesse non désirée: 96% des Malgaches contre la légalisation de l'avortement |trans-title=Unwanted pregnancy: 96% of Malagasy people against legalization of abortion |url=https://midi-madagasikara.mg/grossesse-non-desiree-96-des-malgaches-contre-la-legalisation-de-lavortement/ |access-date=2 August 2024 |work=[[Midi Madagasikara]] |language=fr}}</ref> The [[Catholic Church in Madagascar]] and the [[Church of Jesus Christ in Madagascar]] completely [[Christianity and abortion|oppose abortion]].<ref>{{Cite news |last=Rakotobe |first=Narindra |date=1 February 2024 |title=Santé de la reproduction: Plus de 81% des femmes qui avortent affirment leur chrétienneté |trans-title=Reproductive health: More than 81% of women who have abortions affirm their Christianity |url=https://midi-madagasikara.mg/sante-de-la-reproduction-plus-de-81-des-femmes-qui-avortent-affirment-leur-chretiennete/ |access-date=2 August 2024 |work=[[Midi Madagasikara]] |language=fr}}</ref> [[Marie Fabien Raharilamboniaina]], head of the [[Episcopal Conference of Madagascar]], has argued that the life of the infant is sacred.<ref>{{Cite news |last= |date=2 August 2023 |title=Madagascar - IVG: l'Eglise catholique réaffirme le rejet de sa dépénalisation |trans-title=Madagascar - Abortion: the Catholic Church reaffirms its rejection of decriminalization |url=https://www.linfo.re/ocean-indien/madagascar/madagascar-ivg-l-eglise-catholique-reaffirme-le-rejet-de-sa-depenalisation |access-date=2 August 2024 |work=LINFO.re |language=fr}}</ref> The church is influential on the electorate, and politicians fear losing its support.<ref name="RFI" />

== History == Madagascar's law was inherited from the [[French Penal Code of 1810]].<ref name="Verneau" /> On 15 June 1898, Governor-General [[Joseph Gallieni]] issued a decree, summarized as "diverse measures aimed at favoring the growth of the population in [[Malagasy Protectorate|Imerina]]". It criminalized abortion. The government believed that Madagascar had a high abortion rate because a lack of medical facilities caused women to fear pregnancy. Gallieni believed the ban would reduce maternal deaths during childbirth.<ref>{{Cite journal |last=Cook Andersen |first=Margaret |date=1 June 2010 |title=Creating French Settlements Overseas: Pronatalism and Colonial Medicine in Madagascar |journal=[[French Historical Studies]] |volume=33 |issue=3 |pages=430, 436 |doi=10.1215/00161071-2010-004}}</ref> During the colonial period, Christian views, such as sexual morals, were associated with social mobility. A 1920 French law banned contraception and abortion, with the intent of increase birth rates. Madagascar retained this law until amending it in December 2017.<ref name="Aasgaard Jansen" />

=== 21st century === Madagascar signed the [[Maputo Protocol]] in 2003, but did not ratify it. The treaty guarantees a right to abortion.<ref name="Caramel" /> In late 2007, multiple [[United Nations agencies]] suggested that the country's abortion ban be lifted. Catholic Church representatives and President [[Marc Ravalomanana]] stated their disapproval.<ref name="Ravaoarisoa et al" /><ref>{{Cite journal |last1=Gastineau |first1=Bénédicte |last2=Rajaonarisoa |first2=Stellina |date=September 2010 |title=Sante De la reproduction et avortement a Antananarivo (Madagascar) Resultats d 'une recherche originale |trans-title=Reproductive Health and Abortion in Antananarivo (Madagascar): Results of an Original Research |journal=[[African Journal of Reproductive Health]] |volume=14 |issue=3 |pages=223–232 |jstor=41329744}}</ref>

Since 1984, [[Republican Party (United States)|Republican]] presidents of the United States implemented the [[Mexico City policy]], which prohibited U.S. federal funding for foreign organizations that advocate for abortion. [[Donald Trump]] reinstated and expanded it in 2017.<ref name="Maistrellis et al">{{Cite journal |last1=Maistrellis |first1=Emily |last2=Juma |first2=Kenneth |last3=Khanal |first3=Aagya |last4=Kimemia |first4=Grace |last5=McGovern |first5=Terry |last6=Midy |first6=Anne-Caroline |last7=Rakotondratsara |first7=Mamy Andrianina |last8=Ratsimbazafy |first8=Marie Rolland |last9=Ravaoarisoa |first9=Lantonirina |last10=Razafimahatratra |first10=Mamy Jean Jacques |last11=Tamang |first11=Anand |last12=Tamang |first12=Jyotsna |last13=Ushie |first13=Boniface Ayanbekongshie |last14=Casey |first14=Sara |date=19 July 2022 |title=Beyond abortion: impacts of the expanded global gag rule in Kenya, Madagascar and Nepal |url=https://gh.bmj.com/content/7/7/e008752 |journal=[[BMJ Global Health]] |volume=7 |issue=7 |article-number=e008752|doi=10.1136/bmjgh-2022-008752 |pmid=35853673 |pmc=9301792 }}</ref> Madagascar was strongly impacted by the policy as it had few foreign donors.<ref name="Bearak & Morello" /> At the time, the [[United States Agency for International Development]] (USAID) was a major source of funding for [[non-governmental organization]]s (NGOs) that supported the [[Ministry of Health (Madagascar)|Ministry of Health]] (MOH) and supplied contraceptives to health facilities. In 2014, 85% of the country's [[sexual and reproductive health]]care funding came from USAID, followed by 11% from the [[United Nations Population Fund]].<ref name="Ravaoarisoa et al">{{Cite journal |last1=Ravaoarisoa |first1=Lantonirina |last2=Razafimahatratra |first2=Mamy Jean Jacques |last3=Rakotondratsara |first3=Mamy Andrianina |last4=Gaspard |first4=Naomi |last5=Ratsimbazafy |first5=Marie Rolland |last6=Rafamantanantsoa |first6=Jean Florent |last7=Ramanantsoa |first7=Voahanginirina |last8=Schaaf |first8=Marta |last9=Midy |first9=Anne-Caroline |last10=Casey |first10=Sara E. |date=13 November 2020 |title=Slowing progress: the US Global Gag Rule undermines access to contraception in Madagascar |journal=[[Sexual and Reproductive Health Matters]] |volume=28 |issue=3 |pages=39–53 |doi=10.1080/26410397.2020.1838053 |doi-access=free|pmid=33054631 |pmc=7887949 }}</ref> Without training from NGOs, public-sector providers were unable to provide long-acting or permanent contraceptive methods.<ref name="Maistrellis et al" /> Women in Madagascar faced higher fees, stock-outs, and further distances to access contraceptives.<ref name="Casey et al" /> Some had unintended pregnancies. Madagascar's government listed the loss of USAID funding as an obstacle to its family planning commitments.<ref name="Ravaoarisoa et al" />

Two international NGOs, including [[MSI Reproductive Choices]], were major contraception partners of the MOH. Both refused to sign the Mexico City policy because they advocate for the legalization of abortion, though they do not provide illegal abortions.<ref name="Ravaoarisoa et al" /><ref name="Bearak & Morello" /> USAID's funding for MSI in Madagascar was redistributed to organizations such as [[Population Services International]].<ref name="Bearak & Morello">{{Cite news |last1=Bearak |first1=Max |last2=Morello |first2=Carol |date=10 October 2018 |title=How a change in U.S. abortion policy reverberated around the globe |url=https://www.washingtonpost.com/graphics/2018/world/how-a-change-in-us-abortion-policy-reverberated-around-the-globe/ |access-date=16 July 2024 |newspaper=[[The Washington Post]]}}</ref> MSI stopped receiving $3.5 million from USAID, which was nearly half of its budget in Madagascar; it recovered $1 million in 2018.<ref name="Ravaoarisoa et al" /> MSI scaled back on 21 of its 22 contraception clinics, shut down its voucher program that provided free contraceptives,<ref>{{Cite news |last=Burns-Pieper |first=Annie |date=16 September 2017 |title=Trump changes to foreign aid restricting access to family planning services in poorest countries |url=https://www.cbc.ca/news/world/mexico-city-policy-affecting-madagascar-and-zimbabwe-1.4284893 |access-date=16 July 2024 |work=[[CBC News]]}}</ref><ref name="Beaubien">{{Cite news |last=Beaubien |first=Jason |date=14 October 2017 |title=U.S. Slashes Funds For Family Planning In Madagascar |url=https://www.npr.org/sections/goatsandsoda/2017/10/14/555863044/u-s-slashes-funds-for-family-planning-in-madagascar |access-date=16 July 2024 |work=[[NPR]]}}</ref> and ended support to 100 public and 90 private health facilities. It also returned twelve vehicles, which it partly replaced through a donation, which were transferred to a U.S. organization.<ref name="Ravaoarisoa et al" /> In 2021, [[Joe Biden]] reversed the Mexico City Policy.<ref name="Casey et al">{{Cite news |last1=Casey |first1=Sara E. |last2=Maistrellis |first2=Emily A. |last3=McGovern |first3=Terry |date=4 February 2021 |title=US anti-abortion "gag rule" hits women hard: what we found in Kenya and Madagascar |url=https://theconversation.com/us-anti-abortion-gag-rule-hits-women-hard-what-we-found-in-kenya-and-madagascar-154434 |access-date=16 July 2024 |work=[[The Conversation (website)|The Conversation]]}}</ref>

In December 2017, [[Parliament of Madagascar|the parliament]] rejected a proposal to decriminalize therapeutic abortion. The proposal was opposed by politicians and the public.<ref name="AFP" /> The abortion-rights group [[Nifin'Akanga]] led a debate in protest. Participants argued that abortion was a public health issue and chanted "Keep your rosaries off our ovaries!"<ref name="RFI">{{Cite news |last= |date=1 July 2018 |title=Madagascar: la légalisation de l'avortement fait l'objet d'un débat |trans-title=Madagascar: legalization of abortion is the subject of a debate |url=https://www.rfi.fr/fr/afrique/20180701-madagascar-legalisation-avortement-fait-objet-debat |access-date=2 August 2024 |work=[[Radio France Internationale]] |language=fr}}</ref> A committee continued to look into the draft law in 2022.<ref>{{Cite news |last=Tétaud |first=Sarah |date=30 September 2022 |title=À Madagascar, l'avortement reste un crime, même pour raisons médicales |trans-title=In Madagascar, abortion remains a crime, even for medical reasons |url=https://www.rfi.fr/fr/afrique/20220930-%C3%A0-madagascar-l-avortement-reste-un-crime-m%C3%AAme-pour-raisons-m%C3%A9dicales |access-date=2 August 2024 |work=[[Radio France Internationale]] |language=fr}}</ref> The [[University of Antananarivo]] hosted the country's first event for [[International Safe Abortion Day]] in 2019.<ref>{{Cite news |last= |date=1 October 2019 |title=Pour la première fois, Madagascar célèbre la journée de «l'avortement sécurisé» |trans-title=For the first time, Madagascar celebrates the day of "safe abortion" |url=https://www.rfi.fr/fr/afrique/20190930-madagascar-avortement-journee-evolution |access-date=2 August 2024 |work=[[Radio France Internationale]] |language=fr}}</ref> In December 2019, a visiting delegation from the [[African Union]] advocated for Madagascar to ratify the Maputo Protocol.<ref name="Ravaoarisoa et al" /> During the [[COVID-19 pandemic]], use of family planning in health centers went down by 40%. This led to an increase in unwanted pregnancies and abortions.<ref name="Verneau">{{Cite news |last=Verneau |first=Laure |date=7 October 2020 |title=A Madagascar, les avortements clandestins se multiplient depuis le confinement |trans-title=In Madagascar, clandestine abortions are multiplying during lockdown |url=https://www.lemonde.fr/afrique/article/2020/10/07/a-madagascar-les-avortements-clandestins-se-multiplient-depuis-le-confinement_6055177_3212.html |access-date=2 August 2024 |work=[[Le Monde]] |language=fr}}</ref> MSI received government permission to use its buses to deliver services to women's homes and take women to health facilities.<ref>{{Cite journal |last1=Banke-Thomas |first1=Aduragbemi |last2=Yaya |first2=Sanni |date=14 December 2021 |title=Looking ahead in the COVID-19 pandemic: emerging lessons learned for sexual and reproductive health services in low- and middle-income countries |journal=[[Reproductive Health (journal)|Reproductive Health]] |volume=18 |issue=1 |page=248 |doi=10.1186/s12978-021-01307-4 |doi-access=free|pmid=34906177 |pmc=8670615 }}</ref> In 2021, a documentary about Nifin'Akanga's research was shown at the {{ill|Institut français de Madagascar|fr}} and broadcast on the radio.<ref>{{Cite news |last=Bezain |first=Laetitia |title=Madagascar: des femmes témoignent des risques de l'avortement clandestin |trans-title=Madagascar: women testify on the risks of clandestine abortion |url=https://www.rfi.fr/fr/afrique/20210206-madagascar-des-femmes-t%C3%A9moignent-des-risques-de-l-avortement-clandestin |access-date=2 August 2024 |work=[[Radio France Internationale]] |language=fr}}</ref> In May 2022, the group led a protest with founding member Mbolatiana Raveloarimisa outside of the [[National Assembly (Madagascar)|National Assembly]].<ref name="Caramel" /> When [[Abortion_in_France#21st century liberalization|France declared a constitutional right to abortion]], Raveloarimisa spoke at the ceremony.<ref>{{Cite news |last=Rakotobe |first=Narindra |title=Constitutionnalisation de l'IVG en France: Nifin'Akanga fait entendre la voix des femmes malgaches |trans-title=Constitutionalization of abortion in France: Nifin'Akanga makes the voice of Malagasy women heard |url=https://midi-madagasikara.mg/constitutionnalisation-de-livg-en-france-nifinakanga-fait-entendre-la-voix-des-femmes-malgaches/ |access-date=2 August 2024 |work=[[Midi Madagasikara]] |language=fr}}</ref>

=== 2021 proposal === On 2 November 2021, independent MP [[Masy Goulamaly]] introduced a bill allowing abortion in the case of rape or incest.<ref name="Caramel" /> She emphasized that her proposal would provide for abortions when medically necessary, not on-demand.<ref>{{Cite news |last=R. |first=Mandimbisoa |date=22 October 2021 |title=Masy Goulamaly défend la propostion de loi sur l'ITG |trans-title=Masy Goulamaly defends proposed law on therapeutic abortion |url=https://www.madagascar-tribune.com/Masy-Goulamaly-defend-la,27120.html |access-date=2 August 2024 |work=[[Madagascar Tribune]]}}</ref> The president of the National Order of Physicians, Eric Andrianasolo, supported legalizing abortions performed to protect health. The deputy of the ruling {{ill|MAPAR|fr|Nous tous, ensemble avec Andry Rajoelina}} coalition, {{ill|Aina Rafenomanantsoa|fr}}, opposed the bill on the grounds of [[fetal rights]].<ref>{{Cite news |last= |date=21 October 2021 |title=Madagascar - Interruption de grossesse: la députée Mapar Aina R. contre le projet de loi |trans-title=Madagascar - Termination of pregnancy: MAPAR deputy Aina R. against the measure |url=https://www.linfo.re/ocean-indien/madagascar/madagascar-interruption-de-grossesse-la-deputee-mapar-aina-r-contre-le-projet-de-loi |access-date=2 August 2024 |work=LINFO.re |language=fr}}</ref> The Catholic Church lobbied against the bill.<ref name="Tétaud" />

The government did not comment on the bill. On 17 May 2022, it was withdrawn without deliberation.<ref>{{Cite news |last=Verneau |first=Laure |date=18 May 2022 |title=Madagascar: l'examen de la loi sur l'interruption de grossesse s'éloigne encore |trans-title=Madagascar: review of the law on termination of pregnancy moves further away again |url=https://www.rfi.fr/fr/afrique/20220518-madagascar-l-examen-de-la-loi-sur-l-interruption-de-grossesse-s-%C3%A9loigne-encore |access-date=2 August 2024 |work=[[Radio France Internationale]] |language=fr}}</ref> Rapporteurs said the bill was "incompatible with Malagasy values". Supporters of the bill on social media said the decision was hypocritical and criticized President of the National Assembly [[Christine Razanamahasoa]] for opposing the bill. Women's rights activist [[Marie Christina Kolo]] said the decision was "insupportable".<ref name="Tétaud">{{Cite news |last=Tétaud |first=Sarah |date=4 June 2022 |title=Madagascar: la loi sur l'interruption thérapeutique de grossesse à nouveau écartée de l'Assemblée |url=https://www.rfi.fr/fr/afrique/20220604-madagascar-la-loi-sur-l-interruption-th%C3%A9rapeutique-de-grossesse-%C3%A0-nouveau-%C3%A9cart%C3%A9e-de-l-assembl%C3%A9e |access-date=2 August 2024 |work=[[Radio France Internationale]] |language=fr}}</ref> ''[[La Première (French TV network)|La Première]]'' reported in 2023 that Goulamaly was proposing an abortion bill every year, though they were always withdrawn.<ref>{{Cite news |last=Minas |first=Bruno |date=6 April 2023 |title=Madagascar: l'avortement est toujours interdit dans tous les cas |trans-title=Madagascar: abortion is always banned under any grounds |url=https://la1ere.francetvinfo.fr/mayotte/madagascar-l-avortement-est-toujours-interdit-dans-tous-les-cas-1382638.html |access-date=2 August 2024 |work=[[La Première (French TV network)|La Première]] |language=fr}}</ref> Razanamahasoa said in March 2024 that she supported wider debate and awareness about abortion. She said the situation in Madagascar was "kind of special" due to the role of Christianity.<ref>{{Cite news |last=Belalahy |first=José |date=9 March 2024 |title=Interruption volontaire de grossesse: Christine Razanamahasoa plaide pour un débat élargi |trans-title=Voluntary termination of pregnancy: Christine Razanamahasoa calles for a wider debate |url=https://midi-madagasikara.mg/christine-razanamahasoa-plaide-pour-un-debat-elargi/ |access-date=2 August 2024 |work=[[Midi Madagasikara]] |language=fr}}</ref> In 2024, the regional director of the [[United Nations Population Fund]], Lydia Zigomo, urged Madagascar to reform its law.<ref>{{Cite news |last=Tétaud |first=Sarah |date=17 March 2024 |title=Santé: à Madagascar, la question de l'interruption volontaire de grossesse avance peu |trans-title=Health: In Madagascar, the question of voluntary termination of pregnancy makes little progress |url=https://www.rfi.fr/fr/afrique/20240317-sant%C3%A9-%C3%A0-madagascar-la-question-de-l-interruption-volontaire-de-grossesse-avance-peu |access-date=2 August 2024 |work=[[Radio France Internationale]] |language=fr}}</ref>

== Prevalence == Between 1990–1994 and 2015–2019, the unintended pregnancy rate in Madagascar decreased 27%, and the share of unintended pregnancies resulting in abortion rose from 43% to 63%.<ref>{{Cite web |author= |date=2022 |title=Madagascar country profile |url=https://www.guttmacher.org/regions/africa/madagascar |access-date=16 July 2024 |website=[[Guttmacher Institute]]}}</ref> Nearly 75,000 illegal abortions are performed per year, according to the [[Center for Reproductive Rights]] in 2022.<ref>{{Cite news |last=Cascais |first=Antonio |date=16 July 2022 |editor-last=Walker |editor-first=Keith |title=Abortion: Is Africa becoming more liberal? |url=https://www.dw.com/en/abortion-is-africa-becoming-more-liberal/a-62481744 |access-date=16 July 2024 |work=[[Deutsche Welle]]}}</ref> A 2016 survey in ten [[districts of Madagascar]] found that 11% of sexually active women had had an abortion in the past ten years.<ref name="Ratovoson et al">{{Cite journal |last1=Ratovoson |first1=Rila |last2=Kunkel |first2=Amber |last3=Rakotovao |first3=Jean Pierre |last4=Pourette |first4=Dolores |last5=Mattern |first5=Chiarella |last6=Andriamiadana |first6=Jocylene |last7=Harimanana |first7=Aina |last8=Piola |first8=Patrice |date=6 May 2020 |title=Frequency, risk factors, and complications of induced abortion in ten districts of Madagascar: results from a cross-sectional household survey |journal=[[BMC Women's Health]] |volume=20 |issue=1 |page=96 |doi=10.1186/s12905-020-00962-2 |doi-access=free|pmid=32375746 |pmc=7203894 }}</ref> In Madagascar, abortion providers are known as "angel makers".<ref name="AFP">{{Cite news |author= |date=9 January 2019 |title=Madagascar's 'angel makers' flourish in ban on abortion |url=https://www.france24.com/en/20190901-madagascar-s-angel-makers-flourish-in-ban-on-abortion |access-date=16 July 2024 |work=[[France 24]] |agency=[[Agence France-Presse]]}}</ref> In 2015, the Ministry of Health estimated that abortion caused 11.8% of [[maternal death]]s.<ref name="Ravaoarisoa et al" /> Unsafe abortions are the second-leading cause of maternal mortality in Madagascar, behind [[postpartum hemorrhage]].<ref name="Bezain">{{Cite news |last=Bezain |first=Laetitia |date=1 October 2021 |title=À Madagascar, les avortements clandestins sont la deuxième cause de décès maternels |trans-title=In Madagascar, clandestine abortions are the second cause of maternal deaths |url=https://www.rfi.fr/fr/afrique/20211001-madagascar-avortements-clandestins-deces-maternels-changer-loi-nifin-akanga |access-date=2 August 2024 |work=[[Radio France Internationale]] |language=fr}}</ref> Three women per day die of induced or [[spontaneous abortion]], according to [[MSI Reproductive Choices]] in 2019.<ref name="Mateso">{{Cite news |last=Mateso |first=Martin |date=9 February 2019 |title=A Madagascar, "trois femmes meurent chaque jour des suites d'un avortement" |trans-title=In Madagascar, "Three women die every day from the effects of an abortion" |url=https://www.francetvinfo.fr/monde/afrique/societe-africaine/a-madagascar-trois-femmes-meurent-chaque-jour-des-suites-d-un-avortement_3600033.html |access-date=2 August 2024 |work=[[France Info]] |language=fr}}</ref>

=== Methods === According to a 2021 study, 52% of abortions are performed outside of medical facilities, and 31% are by people without medical training.<ref name="Bezain" /> Private abortion providers are common, especially in [[Antananarivo]]. The cost of the procedure and transportation make it difficult for women to access these.<ref name="Aasgaard Jansen" /> An abortion from a doctor costs about 50,000 ariary (€10), as of 2020.<ref name="Verneau" /> Common methods performed by trained providers include [[curettage]], insertion of a [[catheter]], and use of [[misoprostol]] alone.<ref name="Ratovoson et al" /> [[Manual vacuum aspiration]] is preferred by many women, who believe it "cleans" the womb similarly to menstruation.<ref name="Aasgaard Jansen" /> ''[[La Gazette de la Grande Ile]]'' has written that, despite the ban, finding an abortion provider is easier than finding a safe childbirth facility.<ref name="Mateso" /> The National Order of Physicians does not perform abortions; its director, Eric Andrianasolo, told [[Radio France Internationale]] in 2018 that the organization instead offers alternatives, saying it was "complicated to speak freely about it".<ref name="RFI" />

[[File:Commelina madagascarica.jpg|thumb|alt=A bush with indigo-colored flowers.|The abortifacent plant ''[[nifin'akanga]]'']] Misoprostol is widely available but not regulated for abortions. Use of misoprostol is not correlated with lower risk of infection.<ref name="Ratovoson et al" /> Doctor's instructions are varied and do not match WHO guidelines and can result in side effects.<ref name="Pourette et al">{{Cite journal |last1=Pourette |first1=Dolorès |last2=Mattern |first2=Chiarella |last3=Ratovoson |first3=Rila |last4=Raharimalala |first4=Patricia |date=11 December 2017 |title=Complications with use of misoprostol for abortion in Madagascar: between ease of access and lack of information |url=https://www.contraceptionjournal.org/article/S0010-7824(17)30531-0/fulltext |journal=[[Contraception (journal)|Contraception]] |volume=97 |issue=2 |pages=116–121 |doi=10.1016/j.contraception.2017.12.005 |doi-access=free|pmid=29242087 |hdl=2078.1/220488 |hdl-access=free }}</ref> [[Black market]] vendors sell adulterated misoprostol pills.<ref name="Aasgaard Jansen" /> Abortions are often [[Self-induced abortion|self-induced]] with abortifacient herbs, {{lang|mg|tambavy}}.<ref name="Aasgaard Jansen" /> Some women induce abortions by taking pills or inserting objects into their uteri. Many women receive abortions from traditional midwives, {{lang|mg|reninjaza}}, who are not medically qualified. Traditional providers charge much lower fees than medical providers.<ref name="Pourette et al" /> Most women in villages consult traditional reproductive health providers, {{lang|fr|matrones}}. They commonly provide clients with {{lang|mg|tambavy}} teas, which may be [[uterotonic]]. {{lang|fr|Matrones}} often deny knowledge of {{lang|mg|tambavy}} that are abortifacient. Abortifacient plants include {{lang|mg|[[Commelina madagascarica|nifin'akanga]]}} and {{lang|mg|ahilava}}.<ref name="Collins et al">{{Cite journal |last1=Collins |first1=Lillian |last2=Mmari |first2=Kristin |last3=Mullany |first3=Luke C. |last4=Gruber |first4=Christian W. |last5=Favero |first5=Rachel |date=1 April 2016 |title=An exploration of village-level uterotonic practices in Fenerive-Est, Madagascar |journal=[[BMC Pregnancy and Childbirth]] |volume=16 |page=69 |doi=10.1186/s12884-016-0858-3 |doi-access=free|pmid=27036886 |pmc=4818420 }}</ref> The former was the basis of the name of the abortion-rights group Nifin'Akanga.<ref name="AFP" />

=== Post-abortion care === In 2016, an estimated 27.7% of abortions resulted in post-abortion care (PAC).<ref name="Ratovoson et al" /> MSI provides PAC in public hospitals to 200,000 women per year. The most common complication is [[organ perforation]].<ref name="AFP" /> Misoprostol was approved for PAC in 2017. It is not approved for use by private-sector health facilities.<ref name="Aasgaard Jansen" /> Approval of the drug was controversial as it can be used to induce abortions. As of 2016, misoprostol was available only at MSI clinics under the name Misoclear.<ref name="Collins et al" />

=== Societal factors === Abortion is a taboo subject in Madagascar. It is considered to violate the concept of [[Spirit (animating force)|life force]], or {{lang|mg|aïna}}.<ref name="Verneau" /> Pregnancies, including unwanted ones, are considered positive signs of a woman's fertility.<ref name="Aasgaard Jansen" /> Contraception is rare. One-fifth of women do not have access to it in Madagascar. Most cannot afford it. Other reasons for the taboo include rumors about negative health effects and pressure from abusive husbands.<ref name="AFP" /> Although Malagasy families historically preferred having many children, many are now having fewer children to focus on finances and completing school. Mobile contraceptive clinics from MSI have been popular in many villages.<ref name="Beaubien" /> Many students have premarital sex, but contraceptive use is low. Many believe the side effects of contraception are more problematic than abortion. Some are discouraged from using birth control by their families.<ref name="Aasgaard Jansen">{{Cite journal |last=Aasgaard Jansen |first=Karine |date=9 July 2020 |title='Cleaning the womb': perspectives on fertility control and menstruation among students in Antananarivo, Madagascar |journal=Culture, Health & Sexuality |volume=23 |issue=9 |pages=1227–1240 |doi=10.1080/13691058.2020.1773539 |doi-access=free|pmid=32643577 |hdl=11250/2764486 |hdl-access=free }}</ref> Women who are more likely to have had abortions are those who are young, have more education, or have ever had [[transactional sex]].<ref name="Ratovoson et al" /> Abortion is more common in urban than rural areas.<ref name="Aasgaard Jansen" />

==References== {{reflist}}

[[Category:Abortion by country|Madagascar]] [[Category:Abortion in Africa|Madagascar]] [[Category:Health in Madagascar]] [[Category:Law of Madagascar]] [[Category:Women's rights in Madagascar]]