Despite international calls to recognise unsafe abortion as a serious health problem in developing countries, very little quantitative and qualitative information exists on national levels of abortion activity, major health-related sequelae of unsafe abortion or the quality of routine medical care provided to post abortion patients in countries where induced abortion is legally restricted(Huntington et al, 1998).

All this despite the fact that regardless of the legal status, accessibility or safety of induced abortion, information about it is essential if health planners are to ensure that women's reproductive health is protected. To make matters worse, reliable information on abortion is extremely difficult to obtain in many parts of the developing world(Bretto et al, 1992). Although the problem is most severe where the procedure is highly restricted by law, there are a number of reasons why the procedure is often underreported, even in countries where abortion is legally permitted under broad conditions. This is because health providers may not report all of the procedures they perform, an official system for recording abortions may not exist or may be incomplete, and women may not always acknowledge an abortion.

In spite of these draw backs we believe that defining the magnitude of a health care problem is a first essential step in determining how resources should be allocated to combat the problem. In this spirit we undertook this study to find the scope and magnitude of clandestine abortions in Thyolo, one of Malawi's 24 districts.

We note that although complications of abortions are a major cause of morbidity and mortality much of the literature and research has concentrated on the health implications of these abortions. While such data are necessary to continuously highlight the need to liberalise restrictive laws on induced abortion, rough estimates of financial implications of treating complication of clandestine abortions will no doubt provide additional data /information which may be needed for decisions to be made on liberalising abortion laws. This is especially more so now that economic crises in third world countries have caused a sustained reduction in health care expenditures (Konje et al 1992)

Therefore, besides studying the prevalence of abortions, our other main objective was also to crudely estimate the economic implications of managing complications of abortions and we hope that this information can be used as one of the tools in our call for provisions of limited abortion services in the country.

This document research demonstrates that hospital-based studies can provide a practical alternative to community-based research. We hope that this article will stimulate research on this topic in other settings and other districts, so that eventually we can come up with national abortion figures for Malawi and thus start to "nurture the development of comprehensive reproductive health care services identified in the Cairo Programme of Action" (UN 1994).

To this end the regional health officer must work closely with district health officers to strengthen the districts capacity to monitor management, progress and outcomes of abortions. To strengthen the weak health information systems (HIS) in districts like Thyolo, this must also involve ensuring that the statistical infrastructures in key district sites are adequate to mount periodic surveys and analyse the data, and that there is capacity to conduct participatory studies and hear the voices of the women of reproductive age. Knowledge about what leads to unwanted pregnancies and the subsequent induced abortions has to inform, first and foremost, a district's policies and programs. This is why it is essential that there exist in each district the capacity to monitor prevalence, causes and health outcome of abortions and comprehensively analyse the local impact of national policies, such as restrictive abortion laws.

Within the district, the DHO and the Matron should continue to work in a number of district health centres and at the main hospital to strengthen in-district capacity to assess what works and what does not, based on evidence. For example, the widespread use of dilatation and curettage and general Anaesthesia in the treatment of incomplete abortion in Thyolo suggests that improvements in the quality of care are needed. The sustained use of vacuum aspiration under local Anaesthetics in central hospitals and some Private clinics in the country indicate that changes in case management procedures are feasible.

We observed widespread use of antibiotics in the treatment of incomplete abortions in the district hospital. Normally when patients finally come to the hospital they have already been bleeding for a day or so at home. In some cases the delay is due to problems in sending out an Ambulance to collect the patient from the referring health centre. Clinicians therefore tend to cover these cases with antibiotics. In addition, the substandard of aseptic procedures in most public-sector hospitals contribute to this over reliance on antibiotics. While clinical protocols to safeguard against hospital-acquired infections exist in government health institutions, they are not rigorously observed. The lack of basic supplies, such as disinfectant solutions, is often cited as a reason for lax aseptic procedures, yet the supply systems for the governmental hospitals work mostly on a "pull" system: If enough disinfectants are not ordered by a facility, then supplies will run out (i.e., quotas are not commonly given, and only ordered supplies are distributed, in order to avoid oversupply and wastage of materials and medications).

There is therefore a significant role for health education for women of reproductive age especially antenatal women about seeking medical help earlier when they are having per vaginal blood loss. There is need too for more liaison and co-operation between the transport department and referring health centres so that women with complications of abortions are ferried to the hospital as soon as possible.

Enforcement of aseptic procedures deserves increased effort, particularly as world wide attention is drawn to the emergence of resistant strains of bacterial infections. As there was a wide variation of antibiotics prescribed for abortions, because prescription is the prerogative of the clinician, there is room here for standardisation through say a clinic audit so that a protocol of antibiotics for well defined cases of abortions is arrived at, based on local knowledge of bacterial sensitivities and prevalence, and implemented.

We noted that treatment for complications of abortion consumes substantial resources not only within the Thyolo district health care system drug budget but probably also in hospitality expenses and health workers time expended before, during and after theatre procedures.