How we found the country’s ‘missing’ abortion providers – and mapped contraception services too.
Bhekisisa has created #SizaMap, South Africa’s first searchable map of free abortion providers. Please note that this map is based on facilities’ self reporting so it’s best to call ahead and confirm services are offered. Spot an error? Let us knowhere. For more information on how we constructed the map and its limitations, click here.
On the side of a pale dustbin next to a McDonald’s in Melville, Johannesburg, a white piece of paper emblazoned with blue and red letters is pasted over a rainbow Universal Paints ad. It says: “30 minutes abortion. Women’s Clinic, Sonar pill. [Cell phone number].”
Not far from there, another placard on a dilapidated green and grey dustbin proclaims: “Expert: Quick, safe and pain-free abortion”, along with contact details.
You find them on highway bridges, the walls of government buildings, even right next to the health department in Pretoria: posters and stickers advertising illegal abortions. But the procedures they offer are neither quick nor safe. And definitely not pain-free. As well as being against the law, they’re dangerous to the point of sometimes being life-threatening.
The World Health Organisation says up to 13% of deaths among pregnant women can be attributed to unsafe abortions.
And there are many such abortions happening. A 2017 study published in The Lancet journal found that each year almost half of the 55.7-million abortions that take place worldwide are unsafe. Most – 97% – take place in Africa, Asia and Latin America.
Why then, in a country in which abortion became legal more than 20 years ago, and whose government clinics terminate pregnancies for free, are such illegal and hazardous services still available in South Africa?
A 2005 International Journal of Obstetrics & Gynecology study revealed that just more than half of a sample of about 50 women in South Africa, who had had illegal abortions, did so because they “did not know about the law”. Fifteen percent knew about their legal rights, but “did not know about a legal facility”.
Over the past five years, Bhekisisa journalists have interviewed many women who simply didn’t know where to go for safe abortions. But, after almost a year’s work, the centre is now able to launch #SizaMap – South Africa’s first online, searchable map of designated safe, legal abortion services that have been telephonically verified.
Between 2007 and 2008, six out of 10 pregnancies in the country were unplanned, according to a study published in the BMC Public Health journal in 2010.
A legal abortion in South Africa can only be performed by a midwife, a registered nurse trained for the procedure, a general practitioner or a gynaecologist.
Abortions are mostly only legal up to 20 weeks of pregnancy.
In February, the national department of health gave Bhekisisa a list of 450 clinics designated to provide abortion services. But the department admitted that the list was outdated.
A few months prior to Bhekisisa’s request, Amnesty International researcher Louise Carmody requested similar information and was told in writing by Health Minister Aaron Motsoaledi’s office that “505 facilities are designed to provide termination of pregnancy services”.
Because Carmody was never provided with a list of facilities, Bhekisisa worked with the list it received from the department.
To construct an up-to-date list of where abortions were actually being offered, Bhekisisa reporters worked with provincial health departments to verify the information.
During this process, Bhekisisa also learnt that, except in the cases of the Western Cape and Free State, the names of such facilities are not available on the provincial and national health department websites. A health department official told Bhekisisa that seekers of abortion services would have to phone district health offices to obtain the names of clinics they could go to.
At the end of February, the list that incorporated the information provided by provincial health department representatives showed that 246 facilities provided abortions.
But when Bhekisisa launched #SizaMap in March, activists and officials called the centre, complaining that the information provided by provinces was outdated and that abortion services at some facilities on #SizaMap were not operating.
Bhekisisa then set out on a cross-country telephonic expedition.
With the help of a handful of #SizaMap consultants and a master’s of public health student, Bhekisisa contacted each of the 246 facilities listed on the original map to verify the provincial departments’ information
This time, in addition to information on the type of abortion provided, each facility was asked on which days they offered the service and whether other family planning services are also available.
#SizaMap consultants called health facilities, introducing themselves as patients seeking abortions, so they could also record the attitudes of health workers (see “Stigma still endangers women seeking an abortion”).
When the telephonic survey was completed, we realised that even fewer facilities offered termination of pregnancy services than previously reported.
Of the 236 facilities that could be reached by phone by the end of September, 197 provided abortions — 156 offered first trimester (during the first 12 weeks of pregnancy) abortions, three conducted second trimester (during week 13 and 20 of pregnancy) abortions only, and 38 facilities offered both first and second trimester abortions.
But it should be noted that telephonic surveys are vulnerable to bias, meaning that those surveyed may be tempted to responded positively so that answers reflect better on themselves, services or their places of work. Because of this, #SizaMap may overstate the number of functioning abortion providers. Also, this type of mapping does not measure the quality or consistency of care provided. People using the map should call facilities before seeking services because these may change depending on the availability of trained health professionals at the facility.
South Africa has a total of 5 048 public health facilities where abortions could potentially be offered. This excludes mobile clinics and specialist hospitals for tuberculosis or psychiatric treatment.
Second trimester termination of pregnancies, also known as surgical abortions, can only be performed at one of the country’s 332 non-specialist hospitals, according to the health department’s deputy director general for maternal health, Yogan Pillay.
South Africa’s Choice on Termination of Pregnancy Act of 1996 had a drastic effect on abortion-related deaths relatively soon after abortions became legal: between 1994 and 2001 maternal deaths because of unsafe abortions decreased by 91%, according to a scientific letter in a 2005 edition of the South African Medical Journal.
But Pillay warns that it will continue to be difficult to provide an exact number for abortion facilities. “At some facilities, termination of pregnancy services stop when the only midwife or nurse providing the service moves on to work elsewhere,” he says.
“That makes it challenging to provide an accurate list of services at a given time, because services can change monthly, depending on whether someone resigned, and if a replacement for that person, who is willing to provide abortions, has been found.”
Bhekisisa would like to thank #SizaMap consultants Tuyeimo Haidula, Keshie Nafte and Susan Saburi for their work on the map.