With the collapse of apartheid and the advent of democracy in the early 1990s, “sweeping changes to South African laws” were made, explains Rebecca Hodes, a medical historian at the University of Cape Town.
“In 1996, the Abortion and Sterilisation Act of 1974, which barred legal access to abortion except within narrow structures, was replaced by the Choice on Termination of Pregnancy Act.”
This Act, which came into effect in 1997, gives women the right to an abortion on request during the first 12 weeks of pregnancy, the right to an abortion at 13-20 weeks if the health of the women or foetus is at risk or if the pregnancy is the result of rape or incest, and after 20 weeks if the health of the woman or foetus is at stake.
Yet Hodes, who has studied the history of abortion in South Africa, says research has shown “consistently that, while laws and policies regarding women’s health have changed in post-apartheid South Africa, the practice of healthcare workers and the experiences of patients hold many similarities with apartheid health practices”.
“South Africa’s culture of illegal abortion is partly the legacy of apartheid reproductive policies, in which access to legal abortion was severely proscribed,” she says. “The result was that many thousands of women resorted to illegal abortion to end their unwanted pregnancies. Despite changes in the law, this remains the reality today.”
The director of the Women’s Health Research Unit at the University of Cape Town, Jane Harries, says that women who are ill-treated when seeking health services in the public sector have the right to lodge formal complaints.
“I think people should be doing that, because [patients] are badly treated but people don’t [complain]. I think they’re sometimes just so relieved to be helped that they never do [complain],” she says.
Women who receive suboptimal health services when seeking abortions are often afraid of being victimised if they speak out.
Hodes says patients in this situation have little recourse and often turn to “illegal abortion through ‘lamppost’ providers”, referring to unlicensed abortion providers who advertise their services on the street or lampposts across the country.
An unsafe or illegal abortion, according to the World Health Organisation, is a termination of pregnancy conducted in “unhygienic conditions, or by a health practitioner outside official or adequate health facilities”.
The dangers of unsafe abortions include the lack of “immediate intervention if severe bleeding or other emergency develops during the procedure” and “failure to provide post-abortion check-up and care”.
The World Health Organisation estimates that one in five pregnancies globally end in induced abortion, and 21.6-million of the 43.8-million abortions that occurred in 2008 were unsafe. Almost all of unsafe abortions happen in developing countries; more unsafe abortions are conducted in these countries than safe abortions. Research shows that prior to the introduction of the Choice on Termination of Pregnancy Act, complications from unsafe abortions were a leading cause of maternal deaths in South Africa.
120 000 to 250 000 a year
According to the United States National Institutes of Health, “unsafe abortion is a significant contributor to worldwide maternal mortality; however, abortion law and policy liberalisation could lead to drops in unsafe abortion and related deaths”. The report found that the same is true for South Africa, where estimates for unsafe abortions between 1975 and 1996 ranged from 120 000 to 250 000 per year.
The unavailability of legal abortion during those years, says Hodes, led to a large number of women seeking “abortion in the informal health sector, resulting in high levels of mortality and morbidity from septic abortions”.
According to the National Institutes of Health, “the abortion law of 1996 was the first step towards significant reductions in unsafe abortions. In 1994, complications from unsafe abortion led to 32.69 deaths per 1 000 abortions. By 1998, only 0.80 deaths per 1 000 were reported.”
The report further states that there was a 91% decrease in deaths related to unsafe abortions between 1998 and 2001 in South Africa. But national health spokesperson Joe Maila says the department does not have an estimate of the number of unsafe abortions provided in South Africa.
“However we believe that the number could be very high, given the seriousness of the adverts we see all over in the country promising ‘safe, painless and quick’ abortions, and the number of women who come to our facilities with pregnancy-related complications as a result of unsafe backstreet abortions,” he says.
But the abortion laws did little to improve the overall number of South African women who die during pregnancy, childbirth or shortly thereafter. Even the reported uptake of safe, legal abortions, with more than 90 000 abortions performed in government clinics and hospitals between April 2013 and March 2014 – almost 20 000 more than the previous year – has not translated into a decrease in maternal mortality.
Six times the target
The United Nations estimates that maternal deaths in South Africa have increased from 250 deaths per 100 000 live births in 1990 to a peak of 360 deaths per 100 000 live births in 2005.
The latest government estimates of 269 deaths per 100 000 live births is not only higher than the 1990 figures, it is also more than six times the target South Africa is supposed to achieve by 2015. “We are not able to provide the exact percentage [of maternal deaths due to unsafe abortions] at this stage, but I can confirm that indeed, unsafe backstreet abortions contribute to maternal mortality, as some women die of septic miscarriage as a direct result of unsafe abortion,” says Maila.
Despite legislation legalising abortion, obstacles to accessing safe legal abortions remain.
“The barriers include a shortage of trained legal abortion providers – particularly second trimester abortion providers. Those are abortions provided when the pregnancy is greater than 12 weeks, so between 12-20 weeks, which can only be performed by a doctor,” says Harries.
The stigma of abortion is as much an obstacle to women accessing the services as it is to the doctors and nurses who provide the services.
“Many healthcare providers that are providing the services don’t always feel fully supported by the people they work with. They are ostracised, isolated and stigmatised themselves because they are providing the service.”
Harries says that health professionals who are working under these conditions often experience burnout and frustration.
“The women [who seek abortions] on the one hand are on the receiving end of not always getting the most optimal treatment, but equally some of those healthcare providers that have opted to provide those services aren’t fully supported by their colleagues, peers and management,” says Harries.