Termination of pregnancy, or abortion, is available on request from most clinics. But many of them can’t cope with the numbers. Lizeka Mda spent a day at the Soweto clinic
It is not quite 8am but the clinic is buzzing. Women have been streaming in from the moment the gates opened at 7.30am. Many walk in alone. Abortion is clearly a solitary pursuit at the only clinic in Soweto, and the central Witwatersrand region of Gauteng, to offer the service.
All the women look anxious, some, like the schoolgirl in a uniform, look embarrassed.
“I’ve come to clean,” says one to Sister V, who is in charge of the unit.
“Clean what?”
“My womb.”
“We don’t clean wombs here.”
“Eh … I missed my period for two months. I thought you could check and see if I’m pregnant.”
“You have to go to the other side for a pregnancy test.”
“I thought you could just clean out my womb …”
“Why don’t you say what you are here for?”
“I want an abortion.”
“Okay, wait in that room.”
Surely she does not have to be so brutal? Sister V is adamant that the staff cannot assume that every woman who walks through the door wants an abortion and that she will not put words in their mouths. That’s because in the past she has unwittingly offended people who were genuinely lost by mentioning that this is the wing that does termination of pregnancies. A mother who had brought her daughter for a pregnancy test even reported her.
Ever since then, the nurses are relentless in getting the women to talk. And many of them do not readily say the “a word”. All of them whisper. One says she has come for “topping”, obviously alluding to the fact that the termination of pregnancy is referred to as Top, particularly by health workers.
The clinic started terminating pregnancies on March 17 this year, and had terminated 1145 by the end of October. “It has been a madhouse here,” says the lone doctor who does abortions at the clinic.
The majority of the women come from Soweto, but some come from as far afield as KwaZulu-Natal and the Eastern Cape. No one is turned away, even if they come from Maputo or Gaborone. As this is a free service – these women are pregnant, after all – there is no mechanism built in to bill women who come from outside South Africa.
“They give local addresses anyway,” shrugs Sister G.
The national department of health does not even know that it is extending a free service to foreign women. Dr Eddie Mhlanga, the director of child and maternal health, thinks “women from neighbouring and foreign countries pay for the service as they would pay for any other operative procedure”.
Research conducted by the reproductive health research unit at Chris Hani Baragwanath Hospital last year put the cost of abortion at between R171 during the first 12 weeks at a primary health care facility, and R1 307 in the second trimester at a tertiary institution.
The Soweto clinic gets about 15 requests a day but on some days this number doubles. Those who have come to request an abortion wait together in a room the size of a single ward for the doctor to examine them.
The unit has a space problem. The few women who have come with friends or partners are quickly separated from their friends, who are sent out to the waiting area near the general wing. There is no privacy at all here, and the staff see that as a problem
“You need someone to hold your hand during the operation,” says Sister G. “And lately more and more men come in with their wives or girlfriends. Some are clearly disappointed that they cannot stay and offer support to their partners. From our point of view it would be better if the men could be present throughout, even for the counselling, because they are as ignorant about contraception and the choices available as the women.”
Indeed, the overwhelming majority of women who come in for abortions have not used any form of contraception whatsoever.
Sister G says very few people are aware of emergency contraception like the morning- after pill, available from local clinics.
“Instead of getting rid of the possibility of pregnancy after unprotected sex, many women wait anxiously for their period to come, exposing themselves to something as drastic as a surgical operation.”
The doctor arrives at about 9am and starts with the surgical operations. He comes through after 11am and the first woman is called in.
He works very fast, much faster than the clerk who takes the women’s details and books them for the abortion. “My patients are under a lot of stress,” says Doctor D. “I work quickly so I don’t add to their stress.”
Of the 15 women, three who have had caesarean sections are referred to Chris Hani Baragwanath Hospital where they can have abortions. Two women are referred to the ante-natal section of the clinic. One is 24 weeks pregnant, and the other 30 weeks pregnant. They are too late for legal abortions. They are going to have babies.
Only 10 are booked for abortions. The length of their pregnancies vary from eight to 11 weeks. The clinic does terminations on women who are up to 12 weeks pregnant.
While the Act makes provision for abortion up to 20 weeks, from the 13th, up to and including the 20th week, abortion is not automatic. This clinic refers the women with advanced pregnancies to the hospital as well, where a termination will be performed if the pregnancy poses a health risk to the woman; if the foetus is in risk of abnormality; if the pregnancy resulted from rape or incest; or if the continued pregnancy would significantly affect the social or economic circumstances of the woman.
The Gauteng Department of Health says the terminations performed at the province’s institutions amount to 53% of total requests received. Some women change their minds. Others might try another institution with a shorter waiting period or seek terminations at private clinics.
At the Soweto clinic the waiting period is approximately two weeks. There are only nine beds in the two recovery wards, and that is what determines how many abortions the doctor performs each day. Today though, he tells the clerk to start booking 13 a day. His target is 15 per day. They will “make a plan” about the beds.
Ideally, the time that women should be counselled is after the pregnancy is confirmed. According to the Act “the state will promote the provision of non-mandatory and non-directive counselling before and after the termination of pregnancy”.
This abortion centre is short-staffed, with only five staff members – who all volunteered to work in the unit. Pre- termination counselling is squeezed in only on the return visit.
Even then there is no privacy. All nine women are counselled together. Sister V talks about adoption and fostering as alternatives to termination. To blank faces. Obviously these minds are made up. She goes on to explain the abortion procedure. That tablets will be inserted in the vagina to dilate the cervix. That a couple of hours later they may bleed, and that this may be accompanied by pain, for which they can take the painkillers that are supplied. She also talks about the contraception methods available for use after the termination.
Before the pills are administered she gives them a consent form to sign. Then the women go home, to return the following day for the surgical treatment that evacuates the womb.
It is 12 o’clock now. In the recovery room all nine beds are occupied by women who have just had the surgical procedure.
Sharon is a 24-year-old student nurse from Eersterus in Pretoria. She says she is feeling dizzy and that she found the suction painful. But perhaps that’s because she has a growth in her uterus. She chose to come here because of the risk of being recognised in Pretoria hospitals. She was 11 weeks pregnant.
Ever since she had her appendix removed two years ago, she has had recurring infections. It was the antibiotic she was taking for the infection that rendered the contraceptive pill ineffectual. She knew she was at risk of pregnancy – she is a nurse, after all. But her fianc, the father of her 17-month-old son, refuses to wear a condom, and she does not insist. In fact, he was against the termination but she convinced him that her studies come first. She is going to opt for the injection before she goes home.
Dudu, who is 18, was eight weeks pregnant. She is in the middle of matric exams and plans to study physiotherapy next year. “The stress makes me study harder,” she says.
Her father has no idea what is going on. Nor does her 24-year-old boyfriend, whom she has been sleeping with for three years without using any contraception. “His mother died recently,” she says. “I think this would have disturbed him.” She is also going to have an injection.
A 28-year-old and a 35-year-old, both unemployed, say they want sterilisation because with three and five children respectively they do not want any more. They will be referred to their local clinics because sterilisation is not performed at this unit.
Before the women leave, they are advised again on the likely complications and offered contraceptive pills or an injection. Not all accept them, and they are within their rights.
“Some cite religious beliefs,” says Sister V. “Others say contraception makes them fat.”
Yet this does not make condoms any more acceptable. Sister G says a lot of the women she sees at the clinic, not just in the abortion unit, have sexually transmitted diseases. They come back for treatment over and over again because they do not take the advice to bring their partners for treatment as well.
All of this adds to the frustration of the staff who terminate pregnancies as they feel rather helpless in the face of the Act. They can give “information” but not offer “advice”. The unit has no family- planning component, yet the nurses have to deal with the results of the general population’s ignorance, and obstinacy, about contraception. They can only refer women to their local clinics for family planning. There is no regular check-up several weeks after a termination – as there is after a birth – so the nurses just hope for the best.
Often the worst happens, as Doreen Senokoanyane, deputy director for reproductive health in Gauteng, admits. “There is very little doubt that our family-planning services still need to be made more accessible – in every sense of `access’ – to prevent unwanted pregnancies.”
In the meantime, the department has to meet a huge demand for abortions, and this demand continues to outstrip the capacity.
The inadequacy of the system is further emphasised by the presence of a handful of women who have come back for repeat abortions at the clinic. One had categorically refused contraception both times. The nurses, who are directed by the Act that termination of pregnancy is not a form of contraception, have misgivings about this. But the same Act is clear that any woman who requests an abortion within 12 weeks has a right to have it performed – no questions asked.
And for women who have made this choice, the staff at the Soweto clinic are as welcoming, friendly and supportive as they can be.