Why is there such great demand for illegal abortions?

Abortion was legalised in South Africa in 1996, cutting maternal mortality by over 90%. The Guttmacher Institute named the Choice on Termination of Pregnancy (CTOP) Act “one of the most liberal abortion acts in the world.”

In a study published earlier this year, Associate Professor Jane Harries, Director of the Women’s Health Research Unit at the University of Cape Town, wrote, “The CTOP Act was groundbreaking for women’s rights and health in South Africa, with the country having taken the lead in Africa and elsewhere in abortion reform and rights.”

Illegal abortions are openly advertised and easy to access. Women present at hospital with complications resulting from unsafe abortions. An estimated half of abortions in South Africa are performed illegally. This figure is shockingly high given it is among the very few countries in Africa where abortion on demand is legal. So why this disjuncture between law and practice?

It can be attributed to three factors: confusion about the legality of abortion; stigma pushing procedures underground; and poor service provision.

Knowledge of legality

Ten years after the CTOP Act was passed, a 2006 study found that 32% of women were not aware that abortion was legal.

Andy Gray, Senior lecturer in Pharmacology at the University of KwaZulu Natal, says that the high rate of illegal abortions taking place in South Africa was unsurprising given the wealth of advertising from backstreet abortionists compared to the dearth of information on safe and legal termination. He says, “There needs to be a clear message about legality” and advocates posters in clinics and education at school.

Stigma

When a woman chooses abortion, she faces stigma both from workers at health facilities and from people in her community. Stigma surrounding abortion can lead to a lack of consultation within families and the community.

Andrea Thompson from Marie Stopes, an organisation that offers a range of reproductive health services including abortion, says that it is often women who feel they have no one to talk to who choose illegal abortions. “When you are in a desperate situation, you make a desperate decision. Abortion needs to be something that can be talked about. The more it is stigmatised, the more the problem perpetuates because it perpetuates in the dark.”

Abortion is an extremely emotive issue that sees people divided into two main camps of thought. The first is ‘pro-life’, the notion that an embryo represents life, and should not be terminated regardless of its levels of consciousness. The second is ‘pro-choice’, which believes in the individual liberty of a woman and her right to control her fertility.

Andy Gray says the pro-life message is dominant within the conservative profession of nursing, and that women presenting for termination may be chastised by nurses who disagree with their decision. Pro-choice healthcare providers can also be victims of harassment. He has heard of anti-abortion nurses spitting on those recruited to perform terminations. “Abortion has never been popular politically” says Gray. This has created a stumbling block for policy roll-out. “The Department of Health has neglected the service and this may reflect ambivalence on their part.”

Jane Harries told me this stigmatisation has led to professionals performing terminations in isolated areas of hospitals and not receiving adequate support from their colleagues.

Poor service provision

A worrying 50% of designated facilities do not provide termination of pregnancy. This is because the staff in those facilities are untrained or unwilling to perform the procedure or even counsel the women.

According to the constitution, healthcare providers have the right to conscientiously object to performing termination of pregnancy. However, they are legally obliged to refer patients to another provider and assist in emergency situations resulting from termination procedures. But problems arise when widespread conscientious objection means that there are no available care providers at a facility.

Harries says, “Healthcare professionals are not actually formally registering as conscientious objectors.” This means that if there is a gap in the service, it is not identified and therefore not filled. While the guidelines call for written confirmation of conscientious objection, this has not been implemented. She advocates a formalised, confidential record-keeping system that would allow district departments to evenly distribute doctors and nurses with different beliefs on abortion.

Thompson says that workshops explaining the reasons for the CTOP Act have helped. She says, “Once people realise they are not being forced to perform termination of pregnancy, uptake grows.” The workshops were run by the non-government organisation Ipas, but have not been sustained.

Thompson also explained that by law, only practitioners of abortions can conscientiously object. But when it is the managers at a healthcare facility who object, those working lower in the hierarchy are often assumed to hold the same view and feel powerless to voice dissent.

Even if healthcare professionals are pro-choice, there is poor access to training. Training for termination of pregnancy services is not an obligatory part of medical education but has to be elected. Thompson said that in a climate of stigma and poor access, “You have to be very passionate and pro-choice to push for training.”

This issue has arisen because of a tension in the constitution, the right to religious autonomy and the protection of a woman’s right to terminate an unintended pregnancy. The practical solution is to balance healthcare professionals of different religious and ethical beliefs to ensure that women’s rights are always protected. Women need to know their rights and be able to access what is legally available to them. As Thompson says, “People have to be respectfully demanding what they are entitled to.”

Also see: Behind the abortion adverts.