Written by Dr Tlaleng Mofokeng: Abortion provider for 11 years, consultant at Nalane for Reproductive Justice and SRHR expert with a focus on policy, health communications and advocacy.
It is 2:14 a.m. on a Friday. I receive an email, with the subject line “Please respond” written in capital letters. I read the body of the email and the contents sound all too familiar. What follows is a scanty account of a missed menstrual period, a vague description of how many cycles have elapsed and no details about use of a contraceptive. My work over the past five years can be characterised as guardian of an electronic hub, as I am inundated on a daily basis with requests for information and details of a health facility where an abortion can be performed. Uncertainty about where and when to present to a health facility to request an abortion, together with an overwhelming desperation for timeous procedures, underpin most communications. These take the form of emails, text messages, other social media messages and calls received from women and people ‘asking for a friend’.
South Africa was, and still is, organised in historically-rooted racist and sexist ways. Under apartheid, the health system represented an extension of the white supremacist, nationalist apartheid regime, which introduced the Sterilisation Act of 1976. This Act, a prime example of the violation of women’s right to autonomy, made abortion available under strict conditions. Because of the apartheid segregation, white women were more likely to be able to access abortion than black women. Many of these legacies and injustices remain.
Following the formal end of apartheid in 1994, the Choice on Termination of Pregnancy Act (CTOP) was enacted in 1997 to redress this inequitable access and affirm a rights-based framework, thereby liberalising the law. The constitutional right to reproductive health and the CTOP Act positions South Africa among the most progressive countries in the world, from a legal standpoint. However, these legal gains are undermined by the regressions in implementation that we have witnessed in the last decade.
Half of the women who seek assistance from me via social media are over 12 weeks gestation and a significant number of those are approximately 20 weeks pregnant. Many have visited at least one, some two, public state-run health facilities before reaching out to me for assistance. The recurring theme with all these stories is that there is a lack of signage in the clinics and hospitals indicating that abortion is one of the services offered. There is no information regarding the steps one should take if one is pregnant and wants to terminate the pregnancy. Even an online search of the national Department of Health yields zero results for ‘abortion’.
When women have enough courage to approach a health worker, they are often met with judgemental and humiliating behaviour. Women are often dismissed from the clinics and hospitals without information that enables care. I receive constant reports not only of medical staff, but also allied security and administrative staff, who publicly embarrass women asking for information. When requesting any abortion-related information, women are immediately denied medical services and told to leave the facility. Many are not given a proper medical consultation with history taking, clinical examination and bedside tests such as confirmation of pregnancy by a urine check. In circumstances where the current facility is unable to offer the service, women should be (but are usually not) provided with a referral letter and alternative facility details.
Those women who do make it to an abortion clinic within the state facilities are confronted with further obstacles and delays to care, including queues that begin at 5 a.m., or having to sleep on the floor outside clinics to compete for less than ten appointments per day. For example, in Hillbrow clinic in Region E/J in Johannesburg, one of the busiest metropolitan cities in the country, women are competing for as few as five places. There is one nurse working at the clinic.
Less than five kilometres away from Hillbrow, the biggest quaternary referral hospital, Charlotte Maxeke Johannesburg Academic Hospital, stopped providing second trimester abortions more than five years ago. On average, they performed approximately 45 terminations a week at that time – 9 per day, 5 days a week. This begs the question, where are the women going for second trimester abortions now? In Gauteng province, including in clinics such as Hillbrow, stock outs of contraceptive pills, injectables and condoms continue to be experienced. Health system leadership is grossly negligent across multiple areas, continuing to demonstrate that the health system is a closed loop for those in their reproductive phase.
The barriers are not always about lack of money. The stigma and obstruction that women face at every encounter with the health system is leading women to be lured to fake abortion clinics, which, in some instances, promise women abortion well into the third trimester. The amount of money women pay to pill sellers is exorbitant, sometimes upward of three thousand rand (approximately US$200) for fake pills, hazardous concoctions and provision of abortion pills. The failures have led to brazenly illegal, unsafe and dangerous street pill sellers, who advertise on street lampposts and now social media, scavenging on desperate women while masquerading as private clinics.
As we strive to undo the legacy of a racist and sexist apartheid regime, we cannot be silent, while the national and provincial departments of health, the custodians of the CTOP Act, continue to disrespect the law, as demonstrated by at least a decade of inequitable implementation. Meanwhile, the people who require abortions continue to face barriers and must exert themselves, impacting on their employment, ability to attend school and activities of daily life. It affects all of society, including middle class women, those with money and living in urban centres, black women in rural and peri-urban areas, undocumented migrant women, people of gender and sexual minorities, unemployed people, those with different bodily abilities, those without job security and those unable to take time off for the many visits currently required to receive information and if lucky, the actual abortion procedure.
The right to autonomy, dignity, and respect for vulnerability are human rights. But where is the political will and stewardship to ensure an effective overhaul of the system? This includes various and diverse considerations, including implementation of the law, clinical and bioethics training for undergraduate and postgraduate medical professionals, timeous registration of generic medications to make abortions more affordable, and procurement systems of reproduce commodities to ensure that stock-outs end.
Clinics and hospitals known to be functioning must offer services effectively. A public health campaign must be immediately implemented, using affirming and non-stigmatising language to provide information. There must be a strategy across municipal authorities, prosecuting authorities, policing, and statutory health licencing bodies, led by the national Department of Health, to deal with criminals who advertise medical procedures, break the by-laws, and contribute to the morbidity and mortality of women.
The national and provincial neglect of care is catastrophic, and it must be recognised that health system failures are a form of structural violence. In South Africa today, for countless women in need of information and safe abortion services, there is no reproductive justice.
Please note that blog posts are not peer-reviewed and do not necessarily reflect the views of RHM as an organisation.