Strengthening the provision of second-trimester abortions in South Africa – it’s time to act

Despite abortion having been legalised in South Africa for the past two decades women still get judged and are ostracised when they seek abortion services.

As we celebrate 21 years of the CTOPA, access to safe, second-trimester abortions remains a challenge for many South African women.

What makes our Choice on Termination of Pregnancy Act (CTOPA) stand out amongst other global laws on abortion is its truly progressive nature. The Act enables women, who choose to terminate their pregnancies, to do so legally and safely. According to the law, they have a right to safe abortion care upon request up to the 12th week of pregnancy and services can be provided by a registered midwife or a medical doctor with appropriate training. For the second trimester, which is from the 13th week, up to and including the 20th week of pregnancy, the woman’s request can only be attended to by a medical doctor who makes an opinion based on conditions. The conditions include substantial risk that the foetus may suffer abnormality and risk of injury to her physical and mental health, which takes into account rape, incest and substantial impact on a woman’s socio-economic status. Given the high rate of rape in South Africa, the importance of the provision of this law cannot be understated.

Despite this legislation in place, the realities on the ground are different. There are several barriers to the full and effective implementation of this law.

Many women are not aware of their legally safeguarded rights. This, at times, results in delays in them accessing safe services. The stigma around abortion continues to persist as the subject of abortion remains largely taboo in our communities.  This further adds to the hesitancy among women, as they mentally battle how they will surmount opinions from those close to them and from the health facility they will approach.

Many a times, women go to clinics on time, well within their gestation limits, and still do not get the services they need. A report by Amnesty International released in 2017 says only 264 out of the 3880 public health facilities in the country provide second-trimester abortion services. According to findings shared during a meeting looking at strengthening second trimester TOP services in 2017, in KwaZulu Natal only 16 of the 42 active sites provide such services. In the Free State, only one facility provides such services, while no second-trimester abortion services are provided by any public facility in the Northern Cape.  So where can a woman in the Northern Cape, the Free State or the Eastern Cape access safe second trimester abortion care?

If services are not available at primary care facilities, women are supposed to be referred to appropriate designated district or regional health facilities. However, this does not always happen.  And even if it does happen, there are other hurdles that women have to deal with such as transport cost implications, taking days off work and long waiting lists at facilities. By the time, a woman is finally able to get her appointment, the pregnancy is already advanced.  Unfortunately for some women, it may even be way past the legal limit for an abortion.

Many women who need second-trimester abortions get turned away at the public health facilities. A research conducted in Cape Town in 2016, found that 20% of women who were turned away were in their second-trimester of pregnancy. According to a qualitative study conducted in 2009, nurses blamed a complex booking system, under-resourced and over-burdened facilities as well as the shortage of willing and appropriately trained providers. As a result, the number of second-trimester abortions that could be performed in those designated facilities was restricted.

But then it is no secret that many doctors shy away from performing abortions. On the other hand, the law prescribes that second trimester abortions can only be conducted by medical doctors. A number of health professionals cite conscientious objection as a basis of their refusal to perform second-trimester abortions.  Some public health facilities are run by managers who are anti-choice, who use their positions to hinder abortion care, some even dissuade willing providers from helping women who need the service.

Such barriers leave women with no option but to seek help from unsafe and clandestine providers.  If you need any proof, go to any city centre and you will see posters everywhere. Search abortion services on the internet, and you will see how illegal abortion providers are quickly filling the gap and are publicly advertising to provide abortions of up to 28 weeks. Abortions advertised as safe are performed using various unorthodox methods – including using the wrong or poor-quality medication – by untrained providers who operate from facilities not accredited by the Department of Health.

The backstreet methods in most cases lead to serious complications. Women are known to end up with severe bleeding, uterine perforation, tearing of the cervix, severe damage to the genitals and abdomen, internal infection of the abdomen and blood poisoning. Furthermore consequential prolonged absences from work worsen women’s economic conditions.  And, sadly for some women, this can result in ectopic pregnancy, miscarriage or premature delivery in subsequent pregnancies and infertility or even death. Government’s failure to provide women with safe abortion care is an indication that it does not value women’s lives.

The National Department of Health’s abortion guidelines were scheduled to be released in March this year. Now more than ever, the department needs to fast track them. We also need to invest in awareness campaigns informing women about their rights and empowering them in making timely decisions in seeking and demanding quality reproductive health and rights services.

More funding should be allocated to improving delivering a comprehensive reproductive health services inclusive of quality abortion care. Infrastructure and service delivery across all provinces, and the Department of Health should ensure that the mandated public health facilities are adequately staffed with trained and willing abortion service providers.  

Collaborations with the NGOs supporting the public sector in providing client-centred, supportive abortion care services should be highly considered for the areas where services are not available. Lessons can be drawn from the success in KwaZulu Natal, where government facilities outsource abortion services to three service providers: Marie Stopes, Rose clinic and Khululeka clinic. They are currently expanding this initiative to include private general practitioners.

It has been 21 years since our landmark legislation was enacted, and it is therefore only fair for women to demand the rights that the law provides for them. Women in our country need to be empowered to able to own their bodies, make their own choices about their bodies and be reassured that there is a health system that is ready and equipped to cater for their needs.

Daphney Nozizwe Conco is a public health specialist and a Senior Lecturer at the School of Public Health, University of the Witwatersrand in Johannesburg, South Africa. She also serves as the Treasurer of the Public Health Association of South Africa (PHASA) and as a Board Member of the Rural Health Advocacy Project (RHAP)