Ayanda Masondo died on 19 March 2012. She was 20 years old. A student at the University of Johannesburg, Masondo’s body was found leaning against the door in her room at the Benjemijn hostel. The cause of her death was complications from an illegal abortion.
Sadly, Masondo’s fate is all too common. Illegal abortions kill dozens of South African women every year.
According to the Saving Mothers report, published earlier this year by the National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD), 4 867 maternal deaths were recorded between 2008 and 2010. 186 of those women died of a septic miscarriage in public healthcare facilities, 23 percent of which were the direct result of an unsafe abortion.
Although there is limited formal data on the subject, the number of deaths caused by unsafe abortion is likely far higher than recorded since the NCCEMD only took into account cases in public health facilities.
Alongside death (mortality), illegal abortions result in serious illness (morbidity). Immediate complications from unsafe abortions include severe bleeding, uterine perforation, tearing of the cervix, severe damage to the genitals and abdomen, internal infection of the abdomen and blood poisoning. Medium-term complications range from reproductive tract infections and pelvic inflammatory disease to chronic pain. Long term complications include increased risk of infertility and ectopic pregnancy, miscarriage or premature delivery in subsequent pregnancies. Unfortunately, data on the number of women who experience morbidity due to illegal abortion is also not available.
However, the media has reported on how easily accessible illegal and unsafe abortion is in South Africa.
Impact of legalising abortion in South Africa
Since the legalisation of abortion in 1996, the number of unsafe abortion-related deaths has decreased by as much as 90 percent . Nevertheless, there are still serious challenges nationwide on the implementation of the Choice on Termination of Pregnancy Act. Most notably, the Act has had no impact on decreasing the rate of illegal abortions taking place in South Africa.
Lack of data
Unfortunately, the very nature of illegal abortion provision makes it difficult to collect figures on providers’ activities or confirm trends, though increased advertising seems to support that the number of unsafe providers is increasing.
Very limited data is collected on the number of women who die or experience serious illness due to illegal abortion outside of health facilities, apart from sporadic cases, like Masondo’s, that receive media coverage.
What is clear is that the number of women who seek an abortion in a formal health facility is nearly equal to those who seek them elsewhere. A study published by the South African Medical Research Council in 2010 reports that 49 percent of abortions undergone by young people between the ages of 13 and 19 took place outside a hospital or clinic and were therefore likely to be unsafe.
Why do women seek abortions from illegal providers?
Women in South Africa seek abortions outside hospitals and clinics for various reasons.
A qualitative study by the World Health Organisation on abortion services in the Western Cape showed that, "Providers’ reluctance to be involved in different aspects of abortion provision led to complex and fragmented levels of service provision in many healthcare facilities.”
A study in 2005 looked at women’s reasons for going to illegal providers, which included: not knowing where to access safe abortions, stigma from their communities, judgemental staff and concerns over confidentiality and cost.
Anecdotal evidence from Marie Stopes clients supports these claims, suggesting that although public health facilities are legally required to provide abortion on request, public-sector nurses frequently chastise clients, particularly younger women, for being sexually active, for being ‘irresponsible’, and for choosing to terminate the pregnancy rather than give birth. Clients have also reported being turned away from public hospitals because the facility has reached its weekly abortion quotas or does not provide the service at all.
Street marketing also plays a role in promoting illegal providers. Women see walls and lamp posts plastered with advertisements claiming to offer 'safe', 'painfree', 'quick', and 'cheap' abortions. The proliferation of this advertising, and the fact that it is posted in public spaces such as taxi ranks and shopping centres make many women believe they are accessing a legitimate service.
Right to safe abortion
The Choice on Termination of Pregnancy Act is clear on the right of every woman, regardless of her age, to a safe abortion. Yet, at least 30 percent of South African women believe that abortion is still illegal, which is a major hindrance to women seeking safe abortions.
Similarly worrying, of those who do know that abortion is legal 48 percent do not know of the time limitations involved. The consequence is that women may seek medical abortion beyond nine weeks gestation or a surgical and/or medical abortion beyond 20 weeks gestation – both of which are illegal and unsafe.
Putting an end to illegal abortion
Illegal abortion providers prey on women’s lack of knowledge for their financial gain. There is a vital need for a two-pronged approach to end illegal abortion. First, the public need to be fully informed on who is a legitimate, safe abortion provider. Second, implementation of the Choice on Termination of Pregnancy Act needs to be assessed on a national level.
Steps must be taken to end the needless mortality and morbidity that result from unsafe abortion.
As a first step, Marie Stopes, endorsed by three organisations (Sex Worker Education and Advocacy Task Force, Wish Associates and Ipas) began a flyer distribution campaign. 500 000 flyers, warning of the danger of illegal abortion providers, are being handed out in 33 districts across the country. They serve to remind women that they are legally entitled to access abortion in South Africa, according to the Choice on Termination of Pregnancy Act and to advise them against visiting unsafe, illegal abortion providers and to opt for a legal provider instead.
The circulation of this factsheet builds on the success of the flyer campaign, and is aimed at forming an action-group to address illegal and unsafe abortion. A stakeholder meeting, that will bring together safe providers, women’s rights groups, government, health activists and law enforcement is being organised for August 2012 - interested parties are encouraged to contact Marie Stopes.
The action-group will urgently address:
1. Regulation of abortion advertising
There is a need to eliminate advertising by illegal abortion providers. It is recommended that policy-makers, law-enforcement agencies and safe service providers devise a communication and law-enforcement strategy that would protect the public from illegal abortion advertising.
2. Access to safe abortion services
While 52 percent of public facilities designated to provide abortion are functioning, it is unclear what happens to women who access the non-functional facilities. It needs to be clearly communicated to staff who conscientiously object to providing abortion that they are legally obliged to ensure that the client has access to a facility where she can access safe abortion, in line with Regulations 6 and 10(1)(c) of the Act.
3. Strategic implementation of the Act
There is currently no implementation strategy around regulation 10(1) (a), (b) and (d) in the Act. The action-group will strategise around a feasible and cost-effective strategy to enforce these regulations.
This factsheet was prepared by Sarah Osman and Andrea Thompson.
a cross-sectional study. Reproductive Health, 3-7.