Many women and girls, deprived of access to safe and legal abortion facilities, are forced to turn to backstreet providers, and the results are often devastating.

A 19-year-old Johannesburg student, deprived of both private healthcare and the basic information about how to access abortion services at public health facilities, died last year after complications arising from an unsafe abortion.

This was only one of the chilling stories in Barriers to Safe and Legal Abortion in South Africa, a report published on 1 February, just days before the 20-year anniversary of the Choice on Termination of Pregnancy Act (CTOPA). Amnesty International and UCT’s Women’s Health Research Unit (WHRU) produced the report together.

On its own, the CTOPA is a useful piece of legislation, according to the report. But many women and girls, especially in poor, marginalised communities, are falling through the cracks and becoming victims of unsafe, backstreet abortion providers.

“An expert review of maternal deaths in South Africa has indicated growing concern that the lives of pregnant women and girls are put at unnecessary risk due to barriers to abortion services, which are legal and available,” says the report.

Inequality and stigma

Pregnant woman living in rural areas (as 43.6% of the South African population do) and relying on the public health system (as nearly 83% of South Africans do) have to try their luck at being seen to by one of only 12% of the country’s doctors and 19% of its nurses – the rest are employed by the private sector.

They might need to travel as much as 100 km, by taxi and on foot, to the nearest hospital or public healthcare facility, just to book an appointment. But sometimes the rosters are full and the journey is futile. Some women spend up to R3 000 travelling back and forth to secure and attend an appointment, by which time they might have been with child for as much as 20 weeks.

It gets worse.

Of the 3 880 recorded public health facilities in SA, only 264 provide for terminations of pregnancy. Compounding the problem, a 2013 audit found that nearly 50% of the clinics and 20% of the community health centres reported no access to doctors, despite laws permitting all general practitioners to perform the surgery.

It’s not rare for health practitioners’ own beliefs to block a woman’s right to an abortion. Health workers often refuse to perform abortions and, because of a misunderstanding of their right to conscientiously object to performing the procedure, sometimes even refuse to refer patients to clinics and doctors who could treat them.

Health workers themselves don’t escape the stigma of performing abortions.

“They [colleagues] make it difficult for you,” said a hospital manager, as quoted in the report. “They spread the word in the community ... and also isolate you in the hospital where you’re supposed to work hand in hand, and you can become extremely unhappy. And you’d often find midwives who would often not be practicing doing abortions because they fear the victimisation, being stigmatised, being isolated from their peers.”

Lack of info negating good laws

Widespread lack of knowledge about how and where to access safe and legal abortions is another major barrier.

“Ensuring access to information on how and where to access lawful abortion services is a critical part of protecting access to sexual and reproductive rights and ensuring that women and girls are empowered to make decisions regarding their own health and lives,” the report notes.

Communities must be educated about which public health facilities provide safe abortion services and at which gestational ages and under what conditions, it says. Under the Maputo Protocol, it’s the state’s responsibility to provide this information, especially to women in rural areas.

The compounding failure of the state to regulate conscientious objection; inequality of access to services for women and girls from poor and marginalised communities; and a dearth of available information on sexual and reproductive rights, including how and where to access legal abortion services, means that the aforementioned 19-year-old student is not alone.

CTOPA is one of the “most progressive legislative frameworks worldwide”, the report says. But it is being implemented poorly, which is compromising South African women’s rights and health.

Associate Professor Jane Harries, director of the WHRU, said that continued efforts needed to be made by government and all those involved in sexual and reproductive healthcare services to continue to provide safe and quality abortion care services.

“We hope that government and all other stakeholders will engage with this report based on evidence based research,” said Harries.

Story Yusuf Omar. Photo Thom Pierce for Amnesty International.