Reprioritise reproductive health issues
IN FEBRUARY 1997, the South African government put itself at the forefront of reproductive rights when Parliament passed the landmark Choice on Termination of Pregnancy Act.
It is one of the five African countries with progressive abortion laws.
The hallmark of the the act was the unwavering clarity on the provision of termination of pregnancies at a time when many countries internationally were straying from the subject. The legislation is credited for advancing sexual and reproductive health rights, ultimately reducing maternal deaths by 91% in the country between 1994 and 2001.
The law was reformist in its recognition that the right to terminate was essentially a woman’s choice alone and this choice was fundamental to her physical, psychological and social health. To this end, the South African government agreed that universal access to reproductive health services include family planning and contraception, termination of pregnancy, as well as sexual education and counselling services.
This approach is one that regards being healthy as holistic and integrated. It has been more than two decades that South African women have lived under this progressive legislation.
However, the reality on the ground is a stark reminder of how putting policies in place does not automatically translate to their effective implementation. For example, the gap clearly seen in the lack of implementation of the act.
A 2013, National Department of Health audit recorded a total of 3 880 public health facilities in South Africa. Responding to an Amnesty International request for information in 2016, the department revealed there were only 505 facilities countrywide designated for termination of pregnancy, but only 264 provide the service. These are the statistics in a country where 83% of the population depends on the public health system.
Stigma around termination of pregnancy and unregulated refusal by health-care providers to provide safe procedures are a major contributor to the shortage of health facilities providing services, even within the 264 facilities that are legally allowed to provide pregnancy terminations.
This refusal by health-care providers is referred to as conscientious objection. While the act does not directly address this, the basis of the practice is understood to stem from the right to freedom of conscience.
Health-care providers who object to providing termination of pregnancy services should refer the patients to another service provider. However, these referrals are often not provided. In a 2017 report, “Barriers to safe and legal abortion in South Africa”, Amnesty International mentioned that the lack of clear policy guidelines in health-care provision creates a vacuum that is exploited by healthcare workers to conscientiously object in an “ad hoc, unregulated” manner.
It must be acknowledged that the public health sector is also a challenging space for some pregnancy termination service providers to work in.
Many doctors and nurses have reported that they are often rejected and isolated by their colleagues who raise the moral argument against termination, regardless of its provision within the confines of the law.
The culture of shaming and fear within the termination provisioning is what fuels the secrecy and taboo-like nature around reproductive health care.The secrecy and stigma create access barriers to safe care, and therefore leads many women and young girls in need of these services to find other means – unsafe abortions – that often cost them their health and their lives.
It is because of these whisperings in the community and hushed voices in hospital corridors that thousands of South African women are unaware of their right to a legal, safe termination.
They would rather call that number on the pole or go to uMaDlamini who gives you imbiza – a concoction of traditional medicines. Owing to the cultural barriers of accessing safe abortions, many become desperate and undergo illegal terminations even at 28 weeks of pregnancy, which is illegal by law, but can be done because illegal termination
The secrecy and stigma create access barriers to safe care, and therefore leads many in need of these services to find other means
services are unregulated.
Illegal terminations are thriving, whether in urban Gauteng or rural Eastern Cape. Go to any city centre, poles on street corners are laden with posters offering, “quick, pain-free, cheap” terminations. For every legal termination of pregnancy procedure that is done in South Africa, two terminations are done illegally.
When a woman is confronted with the decision to terminate, she must have all the information, tools and services at her disposal to help her make a choice.
Having a progressive law is futile if the government is not actively engaged in removing all structural barriers to ensure its full implementation.
We need all designated public health-care facilities, with an adequate number of trained health-care providers, available at all times to provide safe abortions.
All pieces of the puzzle need to be in place so young girls and women get a full range of services when they visit public health facilities.
Pre- and post-counselling abortion services are essential so that women know what to expect as they undergo this process, as the decision can sometimes be a difficult one.
Again, fixing these structural barriers will be fruitless if young girls and women still walk into antagonistic environments in health-care facilities.
We need to take some lessons from South Africa’s successful fight against the government in the late 1990s and early 2000s, specifically in terms of how stigma was dismantled, and use the same process of changing mindsets that was applied in the introduction and distribution of ARVs.
We need youth and womenfriendly clinics to be places of safety rather than spaces of fear and stigma, as is the case right now. This includes the government taking decisive steps towards regulating conscientious objection by health-care workers.
As long as there are no clear lines or an effective referral system, we will be unable to improve access to safe services for all our women and young girls.
Civil society organisations need to be able to challenge the government to do more in the field of reproductive health.
Just like it was stipulated in the actual law, comprehensive reproductive health services, including pregnancy terminations, are critical and a legally safeguarded right.
Now is the time to sound the bells to rejig the focus, and for public education geared towards increasing access to facilities and empowering health-care workers.
It is the time for the government to reprioritise reproductive health, so that when the time comes for women to make that choice to terminate, it is informed, voluntary and empowering.
We need to get to the point where MaDlamini refers the young girl to a designated clinic instead of giving her that imbiza – so that when we trace our steps 20 years from now, the passing of this progressive law that put us on the global map is not in vain and remains a beacon of women’s rights and SRHR.
Tshabalala is the national chairperson of the Treatment Action Campaign (TAC). She is also a social justice activist on health and rights issues affecting women and the poor.
In 2009, she became a member of the TAC Vosloorus branch in the Gauteng province of South Africa, and in 2012, she was elected as the Provincial Chairperson of TAC Gauteng. Her leadership and voice has helped raise awareness at local and international platforms, including the International Aids Society Conference.