Less than a third of the country’s 246 public health facilities designated to perform abortions are actually doing so indicating that the government is faltering on its promise to ensure women access to a no-questions-asked first-trimester abortion.
Five years after the Choice of Termination of Pregnancy Act, women’s advocacy groups say health authorities need to flex more muscle to ensure that women, especially the indigent and the rurally based, are not denied their reproductive rights.
In theory, women are guaranteed equitable access the Act allows them to have a first-trimester abortion, free of charge, at any designated government hospital or clinic. Midwives have also been trained in methods of termination of pregnancy so as to ensure service provision at primary health care level. But the reality is different.
There has been a steady increase in the number of abortions reported at public health facilities from 29 236 in the first year of the Act to 44 558 by January 2000. But according to a research report by the Johannesburg-based Women’s Health Project, access for specific groups of women “continues to be a problem”.
The 1998 South African Demographic and Health Survey found that only 53% of women were aware that abortions up to 12 weeks in pregnancy were legal. A higher proportion of young women between 15 and 19 years of age (60%), those with no formal schooling (68%) and rural women (61%) did not know abortions were legal.
Coupled with this is a still-skewed location of services. Ninety-nine percent of the health facilities designated to perform the procedure are in large towns or cities. Although some clinics in rural areas perform the procedure, they are few.
According to several women interviewed by the Women’s Health Project whose sentiments are echoed by reproductive health research workers judgemental attitudes of government health professionals, especially nurses, intimidate women from going to public facilities for abortions.
A health worker may refuse to perform a termination but is obliged to refer the patient to someone within the facility who can. But women are often given misleading information about their eligibility for an abortion.
This is particularly ascribed to staff at referral centres and on the ward, where women having second-trimester abortions stay overnight. Women are either denied pregnancy test results or a referral letter, or are told that abortion is “immoral and sinful”.
Some women complain they are interrogated about their marital status. “You knew how to open your legs, but now you don’t know how to look after your child,” one woman was told by a nurse at a government clinic in Gauteng. Those who make it that far are sometimes put on waiting lists that exceed their time limit to secure a first-trimester abortion.
There have also been reports of young women being refused abortions and told to obtain parental consent. The burgeoning private health care sector has been making mileage out of the perceived “hostile” environment of public hospitals or clinics.
Marie Stopes, one of the leading private clinics providing abortions, as well as sterilisations, vasectomies, contraceptives and HIV tests, has been doing a roaring trade. Last year a total of 15 484 abortions were performed at its 11 clinics nationwide. Its busiest clinic, in Soweto, saw a total of 3 163 last year.
Unlike the public sector, an abortion at a private clinic does not come cheap. A discreetly placed advert in a daily newspaper states that for R350 a client can receive a pregnancy test, pre- and post-procedure counselling, the procedure itself and a room to recover in at the Marie Stopes Soweto clinic. Some of the other clinics charge up to R850.
For those who cannot afford even the bus fare to the local district hospital, there are the hundreds of backstreet abortionists, whose proof of existence are the bleeding, injured women presenting themselves at government hospitals after botched abortions. An estimated 44 000 women end up in government health facilities yearly with incomplete abortions.
An estimated 400 maternal deaths occur every year from these illegal abortions, whose methods range from anti-ulcer medication to the use of a crochet hook to pull the foetus out.
Botched abortions are a substantial drain on state resources. The consequences of an incomplete abortion are usually a long hospital stay, surgery, anaesthesia, blood transfusions and medication. Women’s organisations say the state can prevent this if it takes firm measures to ensure that the availability or non-availability of abortion in government hospitals is not dependent on the goodwill or religious beliefs of the nurses on duty.
A doctor working with the Reproductive Choices Clinic, who also does termination of pregnancy procedures at Pretoria Academic hospital, says that since antenatal care was made free for all mothers and young children, government hospitals have been buckling under the pressure.
She added that it was “quite common” for a hospital’s management to introduce obstacles, such as blocking access to necessary equipment like sonars, to staff who perform abortions. “Health workers really deserve some empathy, because there is often simply just too many patients and too little staff,” she said.