Barriers to efficient reproductive healthcare in Malta: the ectopic pregnancy case
In November 2020, Sarah’s experience of needing treatment for an ectopic pregnancy was shared on the storytelling platform Break the Taboo Malta. An ectopic pregnancy is not viable, and if left untreated can be fatal. There are two ways for doctors to intervene to treat an ectopic pregnancy – the surgical method of removing the fallopian tube, and the medical method of administering methotrexate medication. Methotrexate has been in use in Malta for the treatment of ectopic pregnancies since 2018, and Sarah was a good candidate for this treatment. However, prescribing methotrexate for ectopic pregnancies is not a simple process in Malta. Sarah recounts significant barriers hindering doctors from administering the treatment. She was told that a protocol was in place, which included the need to present her case to a board for approval. This whole process took two and a half days. In the meantime, ‘the embryo was growing and so with every hour that passed [Sarah’s] fallopian tube was more at risk of scarring and perforating (bursting), and the treatment itself was becoming less likely to work.’
You may be wondering why you are reading about ectopic pregnancy on Abortion Rights’ website. The reality is that Malta has a total ban on abortion; a ban that has an effect on all aspects of reproductive health and on anyone who is pregnant. There is no exception in the law to ‘save the woman’s life.’ In fact, both the pregnant person and whoever assists in terminating the pregnancy risk up to 3 years imprisonment. The penalties for healthcare professionals are harsher. Medical professionals deal with serious complications that risk the pregnant person’s life by applying the ‘principle of double effect,’ a Catholic ethical principle and effectively a loophole. However, it is unclear whether this principle applies to the administration of methotrexate, which ends the pregnancy ‘directly.’ The law itself makes no mention of this ethical principle and condemns all forms of induced miscarriage.
As Sarah’s story spread in the media, people became understandably angry at delays in the provision of essential healthcare. Doctors for Choice Malta made their comments about the case, and Young Progressive Beings gathered in front of parliament for an impromptu protest ‘against the vile misogyny of [Malta’s] institutions.’ The Health Ministry responded by denying the existence of a board and claiming that the approval process only takes a few hours. However, information sourced by the media shows that the process for administering methotrexate is more complicated than what was indicated by the ministry. And it does include board approval. Importantly, this board works from Monday to Saturday until 2:30pm, meaning that if the request comes in after 2:30pm on a Saturday, the patient would have to wait until Monday for the case to be reviewed. This is exactly what happened in Sarah’s case. It is clear that women’s health is subject to needless bureaucratic delays, which could be attributed (at least in part) to Malta’s total legal ban on abortion. Whilst some have argued that the abortion ban is not the reason for the delay, it certainly has an impact in hindering the ease with which methotrexate is used in practice.
Thankfully, it appears that Sarah’s personal story has helped to instigate change. The chain of events – from Sarah deciding to share her experience publicly, to the media covering the case, and activists raising awareness through the staging of protests and dispelling misinformation – caught the authorities’ attention and led to an investigation of the delay in administering methotrexate. The head of the Department of Obstetrics and Gynaecology at Malta’s general hospital said they will ‘take the opportunity to look into how the system can be improved.’ However, this case and others highlight the fact that Malta’s abortion laws can (and do) affect anyone who is pregnant, irrespective of whether they intend to access an abortion or not. The moment a person becomes pregnant is the moment they are stripped of their bodily autonomy and become vulnerable to the country’s dysfunctional, misogynistic laws and policies. This is all happening in a context where there are multiple barriers to accessing emergency contraception and where oral contraceptive pills were not deemed essential medicines during the COVID-19 pandemic.
It is clear that there is an urgent need for change. As Doctors for Choice Malta have said, ‘healthcare systems cannot be guided by vague, unclear or questionable legal frameworks, as these hinder the work of doctors and put patients’ lives at risk.’ Changes are needed to ensure that women and pregnant people in Malta can access the best possible reproductive healthcare free from bias, moral judgement, unnecessary bureaucracy, and misogyny. Abortion must be decriminalised, and it must be made available and accessible locally. And above all, we must learn to trust and believe women.
EC member Liza Caruana-Finkel is active in Malta’s reproductive rights movement and is currently pursuing a PhD at the University of Liverpool.
Actions to take after reading this blog:
- Spread awareness on Malta’s ban on abortion
 Not her real name.
 See this article for more information on the principle of double effect and its use in the context of Malta.
 Doctors for Choice Malta and Young Progressive Beings are both member organisations of Malta’s pro-choice coalition Voice for Choice.
 E.g. see this case of a woman who was prohibited from travelling following false accusations by her abusive ex-partner.
 See more on the topic of abortion in Malta and the effects on COVID-19 here.
This content was originally published here.