Almost exactly three weeks ago, women attending a Cape Town reproductive clinic found themselves running an unexpected gauntlet. Instead of walking through the doors and waiting in line with their appointment cards, women requiring contraception, advice – and some seeking to terminate a pregnancy – had to make their way through a crowd of angry protesters holding placards and Bibles. At the sight of a nurse appearing from inside the clinic the crowd became more animated. “Murderer!” they shouted in unison.
“It was terrible,” said Brenda Bamuza-Mayundla, one of the nurses on duty at the semiprivate Marie Stopes clinic that day.
The nonprofit organisation provides sexual and reproductive health services, including counselling, contraceptives and abortion – or termination of pregnancy (TOP) – at cheaper rates than the private sector. But on that Saturday morning on January 10, a group of “pro-life” protesters barred the entrance to the organisation’s Cape Town clinic on Bree Street.
“I went to the door to help the women inside because their safety is my concern. The protesters shouted at me and called me a murderer and said that I will rot in hell for what I am doing,” said Bamuza-Mayundla. “They were shouting at our patients and not all of them were coming for an abortion; some were coming for Pap smears and family planning.”
Legalisation of abortion
Abortion in South Africa became legal in 1996 when the Choice on Termination of Pregnancy Act was passed. This Act requires the state to provide an abortion at no charge to any woman who requests one up to the 12th week of her pregnancy, but it may only be performed by accredited nurses or doctors.
Women may also receive an abortion during the 13th to 20th week of pregnancy if they or their baby are at risk, there are socioeconomic reasons for why the woman can’t have the baby or if the woman was impregnated by rape or incest.
These can be “surgical”, when the foetus is physically removed, or “medical”, when drugs are given to induce contractions of the womb to expel the foetus. Late-stage abortions can only be performed by doctors.
Bamuza-Mayundla said incidents of intimidation by pro-life groups are on the rise at Marie Stopes clinics across the country.
She and other health experts have attributed the proliferation of anti-abortion activity to growing stigma caused by a lack of awareness in the public as well as a lack of support from authorities. This, combined with a dwindling number of health workers willing to provide these services, according to Bamuza-Mayundla, means that fewer and fewer government facilities are actually doing these procedures.
Few facilities do abortions
According to a 2011 study published in the South African Medical Journal, only 57% of the government facilities designated to provide TOP services were actually doing these procedures.
The health department’s Yogan Pillay could not confirm whether this is still the case as “it is the responsibility of each province’s health MEC to designate and monitor these services”. This, according to Marie Stopes’s head of communication, Andrea Thompson, is one of the reasons why abortion services are scarce and sporadic across the country.
“TOP clinics tend to be personality-driven, so you usually have a really strong and competent nurse or doctor driving the process but if he or she moves on or can’t make the clinic that week it brings things to a close,” she said.
Bamuza-Mayundla said many health workers don’t want to provide the service because they object to it on religious grounds – or their home communities will judge them for it.
“God is life, I believe that, but I also believe that he will not judge a desperate woman,” she said.
Health worker attitudes
When the TOP legislation was first introduced, the health department hosted national “values clarification” workshops “to prepare nurses to provide these services and to ensure that those who didn’t feel they could do so at least treated women with the necessary respect and were able to refer them to someone else”, said Pillay.
But some providers do not even want to refer patients and do not believe they are legally obliged to.
“Referring makes these doctors and nurses morally complicit in the wrongful act,” said Albu van Eeden from the pro-life organisation Doctors for Life. “We are willing to take this to the Constitutional Court because we believe there is nothing in the legislation forcing health workers to refer patients for abortions.”
“[But] you cannot refuse to refer,” said Pillay. “What’s worse, referring someone to a place [where] they can have a safe abortion, or not referring them and then they have an illegal abortion and die? I can’t see any court, if it has a choice between those two, deciding to outlaw referral.”
Marijke Alblas, a doctor and TOP trainer based in Cape Town, said that a lack of availability of free government services as well as the stigma women face from their communities and from some doctors and nurses “means that some women turn to illegal providers”.
“Backstreet abortions are happening,” Bamuza-Mayundla said. “People have seen a gap in the market and they are using it to their advantage – people providing backstreet abortions get business from desperate women.”
According to the 2012 Saving Mothers report, conducted by the National Committee on Confidential Enquiries into Maternal Deaths, between 2008 and 2010 186 women died of a septic miscarriage in public health facilities – 23% of which were caused by unsafe or illegal abortions.
“When they come they tell us the whole story: how they couldn’t find anyone to do it or were treated badly at facilities. In some cases these women lose their uteruses and in the worst cases, which I have seen, they can even die from infections.”
Arresting illegal providers “tricky”
Another problem with “backstreet” abortions, said Bamuza-Mayundla, is that desperate women are often taken advantage of by predominantly male illegal abortion providers.
“We’ve had cases where women have told us that their abortion pills were inserted vaginally by the abortion provider’s penis: these women have been raped.”
She said that this situation is allowed to proliferate because “they can advertise anywhere. We see them all over the place, and nobody does anything to stop them.”
Pillay said the health department has tried to investigate such providers in the past but “it’s very tricky”. “About a year ago the minister asked us to investigate someone in Tzaneen – but these are criminals, and if they get the slightest hint you aren’t who you say you are they stop answering their phones and disappear.”
Taboo: in need of advocacy
Bamuza-Mayundla said what would solve this problem is “more advocacy or publicity from the pro-choice side”.
“We have these huge billboards encouraging medical male circumcision, and others for HIV. Why can’t we have one explaining TOP too?” she asked.
Pillay said: “Fair comment. It’s a difficult one; we need to think about it. What we don’t want to do is encourage unnecessary abortions. It’s a balance between making these services available, destigmatising them and creating awareness, and at the same time not encouraging people to use it as an alternative to contraception.”
But Bamuza-Mayundla said the women she sees for TOPs are not necessarily there because they did not use contraception.
“Contraception is not 100% effective. People are here for TOPs for many different reasons. As much as your reason may not be valid to me, it’s valid to you.”
“As much as the protesters say I’m evil when I’m killing ‘future doctors and lawyers’, I know I’m protecting these women,” she said.
Alblas, who is 70 years old this year and has been working for decades to provide women with safe abortions, said: “We have good legislation and we were satisfied with it. But on the subject of abortion you can never be silent and sit back because laws can change. These days abortion is more of a taboo than HIV.”