People tell Noluthando Baloyi (not her real name) that she’s headed for hell in all kinds of ways.
She works as a data collector and spends hours making undercover calls to public health facilities pretending that she wants to get an abortion.
“You don’t have to abort the baby. I can just pray for you,” the person on the other end of the phone would say.
Or: “Please don’t do this.”
If Baloyi is lucky, the health worker on the phone would skip such comments and direct her to an adoption agency.
Baloyi and seven other mappers make these calls because the health department doesn’t have an updated list of abortion facilities, so people don’t know where to go. It means women often end up using illegal services, which are unsafe to use.
The data collector has become used to the reactions is surprised that these are the responses from facilities that are supposed to offer legal abortions.
It’s a legal right that became reality in South Africa 23 years ago with the passing of the Choice of Termination of Pregnancy Act. And safe, legal abortions prevent a lot of women from dying, studies have shown.
All women in South Africa who are pregnant for 12 weeks or less can request an abortion for any reason and those with pregnancies of 13 weeks and more can end these under certain circumstances.
State clinics and hospitals provide abortions for free and in the private sector terminations are, like other services, available at a fee.
Baloyi works for the TRIAD Trust, a health nonprofit that is mapping South Africa’s HIV treatment and reproductive health services for a project called Where to Care. Reproductive and sexual health services are all the procedures and treatments that go into making sure a person’s reproductive system is healthy. They include, for instance, screening and treatment for sexually transmitted infections and infertility, and pregnancy services (although these aren’t tracked on the Where to Care map).
Baloyi and her team have spent the past two years trying to figure out which public and private clinics and hospitals in South Africa offer abortion, contraceptives, services for survivors of abuse and voluntary male medical circumcision.
They call the facilities every three to six months to keep the list updated because the availability of abortion services can change overnight when staff members at small clinics move on to other employment.
The TRIAD trust has partnered with Bhekisisa after it created a similar map in 2017, but with less rigid methodology and limited resources to keep it updated. Bhekisisa funds three members of the Where to Care mapping team.
But, after more than 23 000 calls, only facilities in six of the country’s nine provinces have been mapped. Three quarters of the calls to clinics have gone unanswered, even after as many as 50 attempts, which means it’s taking ages to work through provinces.
Rape crisis centres and shelters for survivors of abuse are the only services that the team has been able to track right across the country.
Baloyi is using a pseudonym to protect her future job prospects, because abortion stigma is real.
And if she and her team get alienating responses when they ask clinics if abortion services are available, people who actually need the service almost certainly get such reactions as well, increasing their chances of turning to illegal, unsafe facilities.
Why all the fuss about telephone numbers?
Baloyi and her six colleagues have made about 23 600 calls to facilities since they started working for the Where to Care project in 2020.
The data collection process is meticulous.
Their job — to call clinics and find out which services they offer and when — may sound simple, but it isn’t. The “call the clinics” bit is a nightmare.
When they can find such contact details, the Where to Care team works from lists of telephone numbers provided by provincial health departments, either online or by request. But the lists contain many numbers that are no longer working.
In such cases, the TRIAD Trust uses the district manager contacts it has built up in provinces over the years. These managers are often the ones in charge of communicating messages from the national health department to facilities, and they usually have more updated phone details — but not always.
On a good day, the team might get the cell phone number of the person who heads up one or two clinics or community health centres, but that’s it.
Sometimes, TRIAD gets in touch with other nonprofits supporting the health sector, asking to use their lists of phone numbers, but most of those organisations battle with the same dearth of details.
In the end, few of the phone number hunting exercises bear fruit.
But let’s say they do find a number to call. What happens then?
How the Where to Care project works
Baloyi and her team tell the person who picks up the phone about the Where to Care project and how it works. Then, they find out which reproductive health services are provided, whether it’s care for survivors of domestic violence, contraception services or a termination.
It can take a few tries before somebody answers the phone for this round of calls. But once they do, it means that, at the very least, the team has confirmed that they’ve got the correct number for the facility and can make it available to the public on their map.
The next time that facility is contacted, the mappers pretend to be someone who wants to get an abortion.
This is where responses — that can block someone’s access to a legal service — come in.
All in all, 76% of the calls Baloyi and the team have made went unanswered (this figure includes repeat calls to clinics).
Almost 800 of the numbers called (most obtained from provincial health department lists) were incorrect. So TRIAD’s data collectors got through to somebody, but were then told they’d got the wrong number. This figure includes all the times the mappers found a new number for a clinic that was also wrong.
The chances of getting through to someone by phone varies widely.
For example, the mappers have been calling Nagina Clinic near Pinetown in KwaZulu-Natal since July 2020, but they only managed to get the information they needed in the last of 53 calls they made over a year and a half.
For other facilities such as Nhlungwana clinic, also in KwaZulu-Natal, mappers made only one call to complete the whole data-capturing process.
Abortion services finally get a training manual
For all legal health services in South Africa, the national health department publishes a book of clinical guidelines, which sets the standard of care in the country.
These guidelines are updated with the latest evidence, or include treatment rules for new diseases such as Covid-19.
But for the termination of pregnancies a “how to” document was only issued at the end of 2019 — 23 years after the service had been legalised.
For the years in between, doctors only had the Choice of Termination of Pregnancy Act to guide them. As a result, abortion care would often differ between provinces, or even from one facility to the next in the same area.
The missing guidelines didn’t just affect the combination of procedures and medicines patients received, it also created a gap for doctors who refuse to perform terminations to go unregulated and become “a law unto themselves”, doctors told Bhekisisa.
Doctors’ constitutional rights allow them to legally refuse to perform abortions if they have conscientious objections, but only if they also refer the person to a willing health worker. The new rulebook gives clear steps for doctors and nurses to follow, should they hold a moral objection to providing this service.
For instance, facilities are now also directed to keep a record of all the people who weren’t helped, which health worker refused care and what was done to refer the patient to a facility where they could undergo an abortion.
Will training for doctors help?
The new abortion rules have been worked into a training programme run by an advocacy non-profit organisation, Ipas. They’re helping the government to get facilities up to speed, but there is also an online course.
Doctors, nurses and midwives must now complete this curriculum before they can terminate pregnancies, says Makgoale Magwentshu, an Ipas doctor who heads up the training project.
Magwentshu, or “Dr M” as most people call her, says Ipas presents the first module of the course to everybody who works at a facility that provides abortion.
It includes an exercise called “values clarification” in which Magwentshu explains, along with patients’ rights, how easy it is for someone to have an unplanned pregnancy.
The sessions also teach people about the effect that harsh treatment may have on a person who requests an abortion. They also get the opportunity to think about their values, and to resolve any conflicts in their behaviour.
People seeking abortions have long reported that non-medical staff such as security guards also block access to terminations by telling them no such service is available.
That’s why Ipas includes all staff on site in its workshops, says Magwentshu.
“Everyone who you might encounter when you come through the gate [or who might answer the phone]: the security guard, the cleaner, pharmacists, and all the healthcare and administrative staff.”
The organisation has trained 139 people in the Northern Cape, Free State and Gauteng since early 2020.
Research has found that such sessions often improve staff’s abortion knowledge to such an extent that it led unwilling staff to support abortions services.
But for the Where to Care data collectors, such progress has done little to make their jobs easier.
Some clinics haven’t answered their phones in years, says Baloyi.
“These are supposed to be the places you call for a medical emergency, but no matter what time of day you call nobody picks up.”
Trust has also been a barrier to the project.
Baloyi explains: “Just getting [facilities] to trust that we are authentic and we’re just trying to help the health system, is a challenge.”
Requests for the health department to send out a circular informing clinics about the Where to Care project have been unsuccessful.
The health department didn’t respond to requests for comment.
The phantom list and why it matters
Why is a regularly updated map such as Where to Care useful — and essential?
Because access to safe abortions stop women from dying. South Africa’s Choice on Termination of Pregnancy Act of 1996 had a dramatic 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.
And research shows that sufficient information about where to get an abortion is still one of the main hindrances to safe terminations in South Africa.
The new rulebook says everyone is entitled to information about abortion services and in its most recent submission to the Partnership for Maternal, Child and Newborn Health, the health department has commited to improve young women and girls’ knowledge of their reproductive rights by 2022.
But unanswered telephones may be standing in the way of a map that will make access to such information possible in all nine provinces, says the TRIAD Trust’s executive director, Brooke Wurst. “It’s impossible to know whether the numbers we have are outdated or whether they’re just not answered.”
And the less new information the mappers can collect, the less useful the tool becomes.
Abortion services are fragile, and often depend on a single health worker willing to perform abortions at a facility. In those cases, the service disappears when they move on to other employment.
The Where to Care project can do the heavy lifting to help find out when services change, Wurst says. It already allows people to see when services disappear without having to wait in line to find out, having to spend money on transport to get to the clinics.
But if the mappers’ experience is any indication of how difficult it is to get in touch with clinics (when they know the phones are working), Wurst says, it reflects a dire situation for patients, whether they’re calling about a termination, contraception or HIV treatment.
Says Wurst: “The reality is, [the lack of information] is deadly.” – Additional reporting by Dylan Bush.
Bhekisisa’s work on the Where To Care map is funded by the Hivos Southern Africa Hub as part of the Regional Sexual and Reproductive Health and Rights Fund. Read more about how the Centre is involved here.