Two-thirds of sexually active women in South Africa are using contraception to prevent unplanned pregnancy, yet almost 90 000 abortions were performed in government clinics and hospitals in the 2012-2013 financial year – almost 20 000 more than the previous year – according to the national health department.
But reproductive health organisations warn that this does not necessarily mean that more abortions are taking place in the country.
Marie Stopes South Africa, a nongovernmental organisation that offers reproductive health services at reduced rates, has experienced "a slight decline in women seeking abortions", says the organisation's Andrea Thompson.
"We have provided 1% fewer abortion services since January this year compared to the same period last year."
Similarly, private sexual health practitioner Elna McIntosh says her Johannesburg-based Disa sexual and reproductive health clinic has seen a decline in the number of women seeking a termination of pregnancy.
Thompson says that, "as very limited data is available on the illegal or 'backstreet' market, where many [abortions] take place", the uptake of abortions in the public sector "could potentially point to increased awareness of the need for safe services, and thus more women seeking services in a designated facility".
Reasons for abortionsMcIntosh says there are many reasons why women have abortions, despite the wide range of contraceptive services that are available.
Sometimes couples experience contraception failure or use unreliable contraceptive methods such as the "withdrawal method", where the man pulls his penis out of the vagina before reaching his orgasm during sexual intercourse.
"Also, often unintended pregnancies are a result of infidelity."
According to Thompson, limited access to reliable contraceptive services is a major cause of unintended pregnancy.
"Women who live a significant distance from their local clinic and have work or study obligations may struggle to return for repeat prescriptions or dosages.
"With short-acting contraceptive methods such as the injection or pill, human error accounts for most cases of contraceptive failure – when either repeat use is not adhered to or the method itself is not used effectively. Condoms not being used according to the strict instructions on the packet is another common problem."
Myths about the impact of contraceptives also result in unintended pregnancies. "One of the biggest concerns women have about using hormonal contraceptives like the pill and injection is that these will cause weight gain," says Howard Manyonga of the Women's Reproductive Health and HIV Research Initiative, affiliated to the University of the Witwatersrand.
"One of the side effects of both the pill and the injection is an increase in appetite. Although there is some degree of weight gain, it is quite difficult to untangle what you can attribute to the injection and what was bound to happen naturally," says Manyonga.
Pushback from partnersAccording to Thompson, "the central challenge we see women face around contraception is pushback from partners. A great many of the abortion clients we see are survivors of gender-based violence, a struggle that keeps many women from accessing the contraception they may well wish for."
Manyonga says the government's new contraception and fertility planning policy, which was launched earlier this year, is a significant improvement on the previous 2001 policy.
It recognises "power imbalances that make it difficult for some women to negotiate condom use and seeks to make contraceptive services available that will not fuel women's vulnerability to HIV infection".
"There have also been some additions to the contraceptives available for free in government facilities in South Africa, most notably the contraceptive implant – a small matchstick-sized silicone rod that releases a long-acting low dose of hormone to prevent pregnancy for three years – along with changes to recommendations around efficacy of certain methods for women on antiretroviral therapy," says Thompson.
Unplanned pregnancy and HIV The policy further focuses on dual protection from unplanned pregnancy and HIV infection.
According to the 2011 Antenatal HIV Prevalence Survey, almost 30% of pregnant women in South Africa are HIV positive.
Only condoms protect against both pregnancy and HIV. The health department distributed about half a billion male condoms and 12-million female condoms in the past financial year, according to deputy director general Yogan Pillay. That works out to about 23 condoms per sexually active male between the ages of 15 and 49 a year.
Yet, despite the wide availability of condoms, the South African National HIV Prevalence, Incidence and Behaviour Survey released earlier this year shows that condom use is declining, particularly among sexually active people aged 15 to 49.
The survey reports that more than half of the people who took part in the study did not use condoms with their last sexual partner. The survey further shows that South Africa had 400 000 new HIV infections in 2012 – the highest in the world.
"Condoms are probably around 80% effective against pregnancy when used correctly and consistently. The problem is that many people will use them at the beginning of a relationship and then stop using condoms as the relationship develops," says Manyonga.
When a woman is taking an oral or injectable contraceptive, he says, it often leads to the discontinuation of condom use, which exposes both partners to sexually transmitted infections and HIV.
Hormone contraceptivesHormone contraceptives (especially the progestogen injections) have also been linked to an increased risk of HIV infection, progression and transmission.
But the World Health Organisation issued a directive in 2012 saying that studies in this regard are inconclusive and showed no "clear causal link" between the injection and HIV infection.
Consistency of use is also a problem with pregnancy prevention methods such as the pill and the progestogen injectable contraceptive. The latter accounts for almost half of contraceptive use nationally.
"If the contraceptive pill is used perfectly, as prescribed, it is more than 99% effective against pregnancy. But the effectiveness drops significantly in typical use because sometimes people forget to take the pill, or they get diarrhoea or are put on medication that interacts badly with the pill," says Manyonga.
The injectable contraceptive must be administered every two or three months, depending on the type.
If a follow-up injection is not administered at the correct time, there is a risk of unplanned pregnancy.
Long-acting methods"Most contraceptive failure relates to human error, which is why we advocate long-acting methods like the intrauterine device and implant that last between three and five years … these are most effective in avoiding unplanned pregnancy as they involve minimal intervention from the individual once they are in place," says Thompson.
The intrauterine device, which is inserted into the uterus and protects against pregnancy for up to five years, can also be used as emergency contraception.
"It used to be much more common in the past, but because of the amount of attention given to HIV prevention, the device kind of fell off the radar for a while. But now in the new policy we're really promoting widening the choice for patients to include the devices," says Manyonga.
Condoms are still the only contraceptive methods that can protect against both pregnancy and sexually transmitted infections.
"Thus we always recommend that they [contraceptive methods mentioned above] be used along with a condom," says Thompson.
Different contraceptive pills are available, depending on your health and menstrual cycle.
Sources: Marie Stopes South Africa, department of health
Birth control hits the spot
Human rights must be central to contraception policy
Motsoaledi launches new contraceptive implant
The right choice of contraceptive is crucial. Science can help you to choose one that's right for you.
In the Free State, access to health services can depend on who you know, as the tragic case of one woman illustrates.
Where traditional beliefs are more real than textbooks, treating illness is a balancing act for sangomas and medical doctors alike.
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.