As we celebrate 21 years of the Choice on Termination of Pregnancy Act (CTOPA), access to safe, second-trimester abortions remains a challenge for many South African women.
What makes our CTOPA stand out among 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 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 the woman's physical or mental health, which takes into account rape, incest and any substantial impact on her 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 safe-guarded rights. This can result 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.
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Often, women go to clinics on time but don't get the services they need. A 2017 Amnesty International report 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 termination of pregnancy (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.
If services are not available at primary care facilities, women are supposed to be referred to appropriate district or regional health facilities. However, this does not always happen.
Many women who need second-trimester abortions get turned away at public health facilities. Research conducted in Cape Town in 2016 found that 20 percent 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.
It's no secret that many doctors shy away from performing abortions. Some public health facilities are run by managers who are anti-choice, who use their positions to hinder abortion care, and some even dissuade willing providers from helping women in need.
Such barriers leave women with no option but to seek help from unsafe and clandestine providers.
The backstreet methods can lead to serious complications: severe bleeding, uterine perforation, tearing of the cervix, severe damage to the genitals and abdomen, internal infection of the abdomen and blood poisoning, while 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. The government’s failure to provide women with safe abortion care is an indication that it does not value women’s lives.
The 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 to make timely decisions in seeking quality reproductive health and rights services.
* Daphney Nozizwe Conco is a public health specialist and a senior lecturer at the School of Public Health, Wits University. She is treasurer of the Public Health Association of South Africa and is on the Rural Health Advocacy Project board.