Breast Awareness Month follows National Woman's Month in August closely, so it would seem that women's health issues are in the spotlight in South Africa – on the calendar, at least.
But sadly, despite important advances in law and policy, significant improvements in many areas of women's health in South Africa remain elusive. The democratic government inherited the pattern of neglect of broader women's reproductive health issues and an extremely fragmented and inequitable health service system. Post-democracy we have faced the advent of a severe HIV epidemic, lack of political will or action in many areas and inadequate implementation of reproductive health policies to lead to successful service delivery.
Much headway is still needed in translating policy into practice in key areas of reproductive health such as contraception, maternal health, termination of pregnancy, cervical cancer, gender-based and sexual violence, HIV/Aids and sexually transmitted infections. For example, despite relatively good contraceptive services in South Africa, there are still serious shortcomings in the delivery of contraceptive services, especially for young people.
The youth often face judgment in attempting to access contraceptive services and young men (in fact, men in general), in their engagement with health services, are rarely encouraged to consider preventing pregnancy as part of their engagement with health services. Sexuality is a shared experience, yet there is very little emphasis placed on educating boys to respect girls in sexual relations, equipping them with knowledge and a sense of joint responsibility.
Our maternal death rate has risen to about 400 per 100 000 live births, partly due to the impact of Aids. However, deficiencies are also apparent in our health system's handling of maternal health. Hypertension during pregnancy is an important cause of poor maternal health, leading to poor quality care in some instances and unnecessary deaths of women during delivery. As a result, we are lagging behind other middle-income countries on maternal health indicators and this is a major concern.
Poor screening acces
Unintended pregnancies occur for several reasons, including inadequacies in our contraceptive service delivery system.
Cervical cancer remains the most common cause of cancer deaths among South African women. It is a result of poor cervical screening access for women, despite our good policies in this regard. Cases of cervical cancer have also increased owing to the impact of HIV and cervical cancer is recognised as an Aids-related illness in women living with HIV.
Much remains to be done and areas such as infertility, the integration of reproductive healthcare into services for women living with HIV and the health needs of older women have received little attention to date.
The women's health research unit, part of the school of public health and family medicine at the University of Cape Town (UCT), became an accredited university research unit in 1996, following research into women's health and urbanisation in Khayelitsha. Its overall aim is to improve the health of women through research that provides new knowledge and informs policy and practice. Our key objectives are to act as a centre for women's health research in South Africa in high-priority areas, conduct health systems research aimed at influencing policy and public health sector service programmes and delivery, develop capacity in the field of women's health, as well as gender and health, and be involved in engaged scholarship in the sexual and reproductive health arena by forming partnerships in the health sciences faculty and, more broadly in UCT, with national, regional and global organisations.
In the research field the women's health research unit conducted the first randomised controlled equivalence trial, comparing the rates of complications between mid-level providers and doctors performing first-trimester abortions in South Africa and Vietnam. Other significant research includes integrating fertility with HIV care and utilising innovative technology such as cellphones for health messaging.
Courses in women's health were first introduced at UCT more than a decade ago and a module on gender and health is included in the master's in public health. Annual courses focusing on reproductive health are provided for international groups from New York and Stanford universities. By leading the Global Doctors for Choice in Africa we reach out to health professionals in promoting better abortion care on our continent.
The research unit was born at a time of immense excitement and hope in the country, two years after the advent of democracy in 1994. Unique opportunities were created for new laws and policies to be passed, including many in the sphere of women's reproductive health. Before 1994 there were no comprehensive women's reproductive health policies in South Africa.
In keeping with international trends, women's health services then consisted mainly of maternal and child health services, with an emphasis on contraceptive services that were aimed at limiting population growth. Contraceptive provision had racial undertones as the apartheid government sought to control black population growth.
Apart from contraceptive services, primary-level health services, including other reproductive health services, were poorly developed and inaccessible for the vast majority of the population, especially women living in rural areas. Maternal health services were characterised by overcrowding, understaffing and lack of privacy and women frequently experienced access problems. Cervical screening was conducted in an ad hoc manner in public sector services and was rarely available to older women, among whom cervical health problems are more common. The termination of pregnancy was permitted only on extremely restricted grounds, leading to abortion-related morbidity and mortality.
Civil society has played a major role in securing progressive changes in legislation, policy and service delivery in women's reproductive health. The research unit, the gender, health and justice unit and the perinatal mental health unit at UCT are among the researchers, practitioners and activists that have played a major role in securing progressive changes in legislation, policy and service delivery in women's reproductive health. As a result, South African reproductive health policies and the laws that underwrite them are among the most progressive and comprehensive in the world in terms of the recognition they give to human rights, including women's and sexual and reproductive rights.
The authors are part of the multidisciplinary team in the women's health research unit, which is involved in research, teaching, technical health service support and advocacy in the areas of women's health and gender and health
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Bhekisisa means "to scrutinise" in Zulu
In South Africa, Zulu patients who would like to be thoroughly assessed by a doctor, would ask the physician to "bhekisisa" them.