South Africa is one of a handful of African countries with liberal abortion laws. The country passed its landmark Choice of Termination of Pregnancy Act in 1996. Following the Act’s introduction, the number of abortions performed in South Africa substantially increased. Today, tens of thousands of safe, legal abortions are performed each year at a rate comparable to that of most nations that have legalised abortions, shows 2016 research by the US Centres for Disease Control. But the Act didn’t just pave the way for easier access to terminations; it also saved lives.
The legislation is credited with bringing about a 91% reduction in maternal deaths related to unsafe abortions in the country between 1994 and 2001, according to a 2005 scientific letter published in the South African Medical Journal. Shortly after, an amendment to the Act placed the responsibility of ensuring abortion services are available — and tracking which facilities provide them — in the hands of provincial departments of health.
Following the passing of the Act, the national health department designated facilities to provide the service and conducted workshops with healthcare professionals to ensure that they understood their roles and responsibilities regarding the law.
But more than two decades after the legislation was passed, there have been, and will continue to be, many different voices both for and against the legalisation for termination of pregnancy services. Some see abortion as a woman’s right; others view it as an unconscionable act in terms of their faith.
These voices are heard in communities throughout the country as well as among health professions, and they help to shape how termination of pregnancy services are provided on the ground.
One senior hospital manager once recounted his staff’s fear of being labelled “baby killers” by the very community they served should they provide abortions. He said he felt powerless to protect his staff from these insults — or worse.
Meanwhile, many healthcare workers remain morally opposed to providing the service “It’s not everybody who actually agrees to termination of pregnancy, and it’s their right to do that,” said the head of a hospital obstetrics and gynaecology department in a 2014 study published in the journal Reproductive Health.
As part of the study, researchers interviewed almost 50 healthcare workers, managers and policymakers in the Western Cape and found that resistance to providing abortions was not only confined to the doctors and nurses actually charged with terminating pregnancies but also among support staff.
“Some of the pharmacists refuse to dispense misoprostol for the patients, and even some of the ward staff don’t like to serve the women tea,” reported one nurse in the study, describing the reluctance of some pharmacists to fill prescriptions for misoprostol, a drug used in medical abortions.
The study also suggested that some healthcare workers do not know what to do when confronted by conscientious objectors, or people who remain morally opposed to performing abortions.
“I need a doctor who can prescribe misoprostol … but then they say: ‘No, it’s against my religion, and I’m not doing it.’ It’s not my position to say to them: ‘Where is your written excuse?’” said another nurse.
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As a result of these challenges, patients sometimes struggle to find abortion services. We fully understand that pregnant women, often in desperation, then seek the services of “backstreet” abortionists with sometimes fatal consequences.
In April 2014, Health Minister Aaron Motsoaledi — alongside Social Development Minister Bathabile Dlamini and then deputy minister of economic development Hlengiwe Mkhize — released new national guidelines on contraception and family planning.
At the same time, the trio launched a long-acting reversible contraceptive implant that would allow women to prevent pregnancy for up to three years — the latest move to broaden the types of contraception people can choose from within the public health sector.
For a wide range of reasons, it is critically important that we ensure that both women and men have access to contraceptives and family planning services — it is considered a “best buy”, meaning it is a cost-effective service for any country to provide in terms of its impact on individuals, families and society in general.
Abortion services are not a replacement for contraception and even those done by trained health professionals carry some potential risks, including bleeding, infections and damage to the cervix or uterus.
But as we continue to work to increase people’s access to new and varied types of contraception so they can find an option that is right for them, we remain committed to putting safe abortion services within easier reach of women.
We are currently striving to expand access to early, nonsurgical termination of pregnancy services that allow people to terminate pregnancies early and without having to be admitted to hospital. By avoiding a conspicuous absence from home, these types of abortions also afford women greater privacy. We are working to put safe, legal services within women’s reach but, as we do so, communities must be at the forefront of outing illegal providers and assisting law enforcement agencies to act against them.
And to safeguard people’s legal right to abortions, we have drafted improved guidelines for conscientious objectors. These guidelines, which have yet to be published, seek to ensure that health facilities can respect workers’ decisions to recuse themselves from providing nonemergency abortion services but ensure that this does not compromise patient care.
When healthcare workers believe that their religious or moral beliefs may affect the advice or treatment they offer people who seek abortions, draft guidelines state that they must explain this to patients in a way that does not stigmatise them.
Health workers must also make arrangements to ensure a patient can be seen by someone who will provide the service.
Additionally, the national health department will be introducing a specially tailored package of contraception for new mothers as well as people who have undergone an abortion. This includes offering women immediate access to long-acting but easily reversible contraceptives.
But a woman’s first step toward exercising her right to an abortion is being able to find basic information on where to get one. Until now, that has been very difficult to track.
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To bridge this information gap, the national health department will be working with provincial departments to establish reliable reporting systems to ensure that the public has access to a list of health facilities that provide termination of pregnancy services.
More than 20 years after the passage of South Africa’s landmark legislation on abortion, we have come a long way but challenges remain. And although the debate about abortion is likely to continue to rage in our communities, we must continue to ensure that the provision of the full range of contraceptive and family planning services is based on a human rights approach.
Strengthening access to contraceptives and family planning services for all is critical to improve our health outcomes and for the general development of our country.
Yogan Pillay is the deputy director general for HIV, tuberculosis and mother and child health at the national health department. You can follow him on Twitter @ygpillay. Manala Makua is the national department of health’s director for women’s health and reproductive health and genetics.
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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.