The sugarcane industry is the third largest user of pesticides in Malawi. Our aim with this study was to document pesticide use and handling practices that influence pesticide exposure among sugarcane farmers in Malawi. A semi-structured questionnaire was administered to 55 purposively selected sugarcane farmers and 7 key informants representing 1474 farmers in Nkhata Bay, Nkhotakota and Chikwawa Districts in Malawi. Our results indicate that herbicides and insecticides were widely used. Fifteen moderately and one extremely hazardous pesticide, based on World Health Organization (WHO) classification, were in use. Several of these pesticides: ametryn, acetochlor, monosodium methylarsonate and profenofos are not approved in the European Union because of their toxicity to terrestrial and aquatic life, and/or persistence in water and soil. Farmers (95%) knew that pesticides could enter the human body through the skin, nose (53%) and mouth (42%). They knew that pesticide runoff (80%) and leaching (100%) lead to contamination of water wells. However, this knowledge was not enough to motivate them to take precautionary measures to reduce pesticide exposure. Farmers (78%) had experienced skin irritation, 67% had headache, coughing and running nose during pesticide handling. Measures are in place to reduce pesticide exposure in the large estates and farms operated by farmer associations. Smallholder farmers acting independently do not have the resources and capacity to minimize their exposure to pesticides. There is need to put in place pesticide residue monitoring programs and farmer education on commercial sugarcane production and safe pesticide use as ways of reducing pesticide exposure.