SPECIAL REPORT

Abortion Reform in South Africa: A Case Study of the 1996 Choice on Termination of Pregnancy Act By Sally Guttmacher, Farzana Kapadia, Jim Te Water Naude and Helen de Pinho

n December 11, 1996, South Africa population was stagnating, and that the threat to a woman’s mental well-being. enacted the Choice on Termination black and colored populations were be- Physicians who performed be- Oof Pregnancy Act, which gives coming a burden upon the country’s re- yond this criterion took personal and pro- women of any age or marital status access sources. The views of the government were fessional risks, since many were prosecut- to services upon request during epitomized when the Minister of Bantu Ad- ed or fined. In addition, financially secure the first 12 weeks of pregnancy, and in cer- ministration and Development, M.C. Botha, upper- and middle-class white women tain cases, extends access to the first 20 asked the white citizens of South Africa to could fly to England to terminate an un- weeks of pregnancy. This act replaced a sacrifice by having “...enough children to wanted pregnancy if they could not procure 1975 law that severely curtailed access to ensure [South Africa’s] continued existence adequate services privately in South Africa. abortion services by requiring a physi- as a Christian and Western country on the In contrast, the relatively low-paying cian’s, and in some cases a magistrate’s, ap- continent of Africa.”1 and insecure jobs available to black and proval for abortion procedures. The law’s While most religious groups in South colored women limited their ability to seek passage was a crucial advance for women, Africa opposed legalization of abortion, the termination of an unwanted pregnancy. as it represented the recognition of repro- Dutch Reformed Church, the official Besides the difficulty of financing a safe ductive rights by South Africa’s first de- church of South Africa, not only opposed abortion, finding a trained doctor willing mocratically elected parliament. the new law but propagated the belief that to perform an abortion was more difficult This article examines the policies that the white population must grow to main- for women of color.4 have regulated accessibility of abortion and tain its supremacy.2 In addition, govern- Under these constraints, clandestine abor- assesses their impact on reproductive health. ment tax incentives were used to encour- tions often became the only option. Poor We also describe the newly enacted legisla- age white women to procreate. By contrast, women who could not afford a doctor’s fee tion, and examine some of the difficulties contraception was promoted for black and often sought the aid of less-skilled midwives, that will need to be overcome to ensure that colored women as a measure to stymie the lay practitioners or nonregistered doctors women derive full benefit from the law. growth of the black population. Thus, fam- who had not completed their medical train- ily planning became associated with the ing. Many of these practitioners offered their The Apartheid Era racist policies of the apartheid government. services without adequate technical knowl- Family Planning and Abortion Furthermore, by limiting black and col- edge or access to proper facilities and clean During apartheid, the Afrikaner-dominat- ored women’s ability to get schooling or instruments.5 Women who did not want a ed National Party government advanced hold jobs, apartheid policies granted “backstreet” abortion, or could not afford separate population policies for white, black greater employment and educational op- one, would often try to terminate their own and colored (those of mixed black, Malay portunities to white women. However, pregnancies, endangering their lives by at- and white background) South Africans, fu- many white women who took advantage tempting abortions using dangerous meth- eled by fear of unsustainable population of the opportunity to seek employment at ods such as knitting needles or detergent. growth. This fear took on racist overtones a managerial or professional level found manifested in propaganda suggesting that the notion of a smaller nuclear family The 1975 Abortion and Sterilization Act the black population was growing too more desirable for their lifestyle, leading Seeking protection from the technically il- quickly while the growth rate of the white to greater demand for contraceptive ser- legal abortions they were providing, the vices and, when an unwanted pregnancy medical establishment pressured for ex- * The Abortion Reform Action Group was the primary occurred, for abortion services.3 pansion of the circumstances for legal abor- grassroots lobby fighting for changes in South African Since pregnancies could not be termi- tions, as did women’s organizations such abortion legislation for more than 20 years. Formed large- ly by middle- and upper-class white women, the group nated upon request, white women had sev- as the Abortion Reform Action group began lobbying in the early 1970s to protest against the eral options when an unwanted pregnan- (ARAG).* Together, they created momen- conservative abortion policies of the government. Al- cy occurred. Many procured abortions from though progressive in its concern for improving women’s their private practitioners, who would per- Sally Guttmacher is associate professor and Farzana Ka- health, the organization seemed to echo the sentiments form a in the office. padia is assistant research scientist at the Department of of the National Party government by advocating two- Health Studies at the School of Education at New York child families as the only reasonable measure to facili- Prior to 1975, this could be justified by com- University; Jim Te Water Naude is registrar and Helen tate sustainable development of South African land and mon law, which permitted the termination de Pinho is senior researcher at the Department of Com- resources. (Source: reference 1.) of a pregnancy if the pregnancy posed a munity Health, University of Cape Town, South Africa.

Volume 24, Number 4, December 1998 191 Abortion Reform in South Africa tum for abortion reform in South Africa. experiences for fear of negative social, per- necology and obstetrics caseload of pub- However, this call for reform coincided sonal and legal consequences. lic-sector hospitals in South Africa.12 The with the prevalent fear among parliament However, women continued seeking consequences of an incomplete abortion ministers of a stagnating white population. terminations of pregnancies despite the are usually a longer hospital stay and more The pronatalist attitude of the govern- possibilities of serious health risks. Ad- extensive use of surgery, anesthesia, blood ment toward the white population was missions to gynecologic wards increased transfusions and medications, as com- formalized by an all-male, all-white com- substantially due to women presenting pared with those associated with an un- mittee appointed in 1973 to draft legisla- with incomplete and septic abortions.7 complicated first-trimester abortion. The tion regulating the availability of abortion Maternal morbidity and mortality result- need for immediate medical treatment services. By 1975, the committee present- ing from septic abortions also increased.8 often results in a major drain on limited ob- ed, and parliament subsequently passed, Moreover, the 1,000 or so legal abortions stetric and gynecologic hospital re- the Abortion and Sterilization Act. performed in South Africa annually rep- sources.13 Moreover, although the long- In an attempt to appease its more pro- resented a tiny fraction of all abortions car- term psychosocial effects of incomplete gressive constituents, the South African ried out. Estimates of the number of clan- abortions cannot be measured in monetary parliament framed the 1975 Abortion Act destine abortions were dramatically larger, terms, they place a heavy burden on the in such a manner that it seemed to grant ranging from 120,000 to 250,000 per year lives of women and their families. greater freedom to women seeking abor- between 1975 and 1996.9 The estimated cost of treating women tions. However, by narrowly specifying the In an attempt to understand the epi- for incomplete abortions in South Africa conditions under which abortions could be demiology of induced abortions and their in 1994 was 18.7 million Rand (approxi- obtained, the new law actually made it impact on maternal morbidity and mortal- mately US $4.4 million). Since only more difficult to procure abortions. Under ity, researchers from the Medical Research 10–50% of women who have induced the 1975 Abortion and Sterilization Act, Council of South Africa began, in 1993, to abortions present for some form of med- abortions could be performed legally only monitor complications of unsafe abortions. ical treatment, the estimated cost of treat- when a pregnancy could seriously threat- According to adjusted estimates from that ing these women underestimates the ac- en a woman’s life or her physical or men- study, approximately 45,000 women were tual cost if all women with a complication tal health; could cause severe handicap to admitted to hospitals for spontaneous abor- from a clandestine abortion were to pre- the child; or was the result of rape (which tions or complications of induced abortions sent. Moreover, data from the Medical Re- had to be proved), incest or other unlaw- in 1994. Of these, more than 12,000 had search Council indicate that procedures ful intercourse, such as with a woman with moderate-to-severe complications resulting for managing incomplete induced abor- a permanent mental handicap.6 from clandestine abortions, and more than tions are not cost-effective, and are not safe Thus, it appeared that women could seek 400 died from septic abortions.10 or widely accessible outside the major hos- abortions for a greater number of reasons, These data probably underestimate the pital centers.14 and that doctors performing abortions total number of unsafe abortions. Some would no longer suffer prosecution. How- women who resorted to clandestine abor- Regional Variation ever, to qualify for an abortion under these tion may have been unable or unwilling The incidence of complications related to circumstances, women had to receive ap- to seek hospitalization, especially if they incomplete or septic abortions varied re- proval from two independent physicians, did not experience any complications. gionally. For example, in the Western Cape, neither of whom could perform the actual Furthermore, women who died prior to 14.3% of hospital admissions for incom- procedure. In some cases, the approval of reaching a hospital, or poorer women with plete abortions were for severe complica- either a psychiatrist or a magistrate was also little access to health services of any kind, tions and 3.8% were for moderate com- necessary before permission was granted. were unlikely to be accounted for. plications; in comparison, in Gauteng Approved abortions had to be performed A closer inspection of the Medical Re- province, 20.6% were for severe compli- in state hospitals, and records of all legal search Council data shows that women cations and 22.7% were for moderate com- abortions conducted were stringently kept. under the age of 20 were three times more plications.15 This disparity is no doubt due likely to present at a hospital with incom- to a variety of factors, including differences Impact of the 1975 Act plete abortions than were older women. in the availability of skilled “backstreet” Not surprisingly, as a health policy, the Women from this age-group were also at practitioners and variations in women’s 1975 Abortion and Sterilization Act failed greater risk of medical injury during clan- ability to pay for such services. In addition, to increase access to safe abortion services destine abortions, perhaps because of the because of the lack of adequate health care (as its parliamentary advocates had claimed common use of objects such as catheters or facilities in rural areas, admissions to urban it would) and failed to improve the repro- sticks inserted into the vagina, uterus or facilities in Gauteng were bolstered by ductive health of South African women. cervix to induce an abortion.11 women from surrounding provinces that Data on abortion following passage of the have a larger rural population. Some hos- 1975 abortion act are limited, due to the lack Methods and Costs of Termination pitals in nearby provinces also lacked ad- of a comprehensive surveillance system to In public-sector hospitals, incomplete equate facilities to treat women with com- monitor abortions performed outside the abortions were managed primarily by plications from induced abortions. medical system. The extent of health prob- uterine evacuation with sharp curettage, lems arising from clandestine abortions was performed under general anesthesia in op- The Transition To Democracy also difficult to estimate, since women were erating rooms. , al- Struggle for Reform seldom willing to voluntarily discuss their though a simpler procedure, was prac- Access to legal abortion was an integral ticed at only a few of the larger hospitals.* part of a national health program drafted *Training programs are in place to increase the use of this Women presenting with incomplete by African National Congress (ANC) lead- new technique in South Africa. abortions constituted almost 50% of the gy- ers during the 1994 elections. The ANC’s

192 International Family Planning Perspectives Reconstruction and Development Pro- speculation that had the ANC allowed an and providers’ beliefs and attitudes re- gramme outlined new national goals stat- open vote, the 1996 Act might not have garding abortion. Under the new act, ing that “every woman must have the passed by such a wide margin. health care workers are not mandated to right to choose whether or not to have an perform abortions, or even to refer women early termination of pregnancy according The 1996 Act to other providers. Their only obligation to her own beliefs.”16 After the ANC’s The Choice on Termination of Pregnancy is to inform women of their rights under electoral victory, the new government Act, which came into effect on February 1, the new law. Thus, lack of cooperation by began to prepare a new for 1997, permits abortions to be performed health care workers claiming conscien- consideration by the nation’s parliament. upon the woman’s request through the first tious objection due to moral or religious The call to replace the 1975 Abortion and trimester of pregnancy, without any need conflicts is emerging as a major obstacle Sterilization Act aroused passionate de- for the approval of doctors, psychiatrists for women seeking abortion services. bates between antiabortion and prochoice or magistrates.18 Minors are counseled to As a way of dealing with the antago- advocates. Opponents to change ranged notify their parent or guardian of their de- nism of some health care professionals, the from religious organizations representing cision but are not required to receive con- education of providers about their re- the Christian and Muslim churches to pro- sent for the procedure. Victims of rape or sponsibilities under the new law has be- fessional groups such as Doctors for Life. incest are not required to provide any doc- come a pressing issue. The Planned Par- Prior to the parliamentary vote on the 1996 umentation in order to obtain an abortion. enthood Association of South Africa has Termination of Pregnancy Act, almost two Women between 13 and 20 weeks of ges- been conducting values-clarification dozen antiabortion groups united under tation can obtain an abortion if a medical workshops in hospitals that provide abor- the National Alliance for Life and held practitioner believes that the pregnancy tion services. The main goal of these work- demonstrations. Groups such as The threatens the mental or physical health of shops is to facilitate the implementation Women’s Health Project, the Reproductive the woman or fetus, if the pregnancy re- and management of abortions in an effi- Rights Alliance, Planned Parenthood of sulted from rape or incest, or if it affects the cacious manner. In addition, the work- South Africa and ARAG supported the woman’s socioeconomic situation. After shops try to gain an understanding of prochoice stance of the ANC, and spoke the 20th week, termination of pregnancy providers’ concerns regarding abortion in support of abortion access as a means is permissible if a doctor or trained midwife and assist providers in relating their val- for creating greater gender equality as well finds that continuation of the pregnancy ues to their clients’ needs. The final aim as furthering women’s rights. would threaten the health of the woman or of the workshops is to develop recom- The debate among prochoice and an- cause severe handicap to the fetus. mendations for incorporating such train- tiabortion advocates was further compli- ing sessions into regular training pro- cated by the historically racist use of pop- The Road Ahead grams for providers.20 ulation control policies under the For the new act to be successful in reduc- Furthermore, many health care work- Nationalist Party government. Even ing morbidity and mortality from unsafe ers require technical training in proce- today, black people in South Africa are di- procedures in South Africa, abortion ser- dures such as manual vacuum aspiration, vided in their views toward abortion. vices will have to be implemented so that which is still a relatively new technology Many blacks oppose abortion for religious they are available and accessible to all in South Africa. Currently, there is con- reasons or view abortion as yet another women. This will involve patient out- siderable variation both in the methods vestige of apartheid policy, designed to reach, provider education, equalization used for first-trimester abortion and in the control the growth of the black and col- and expansion of services throughout the manner in which some of these methods ored population; black public health and country, and continuous monitoring of are applied. Without appropriate training, women’s rights advocates, on the other how these activities are progressing. hospitals will be further delayed before hand, support easier access to abortion •Outreach. First, resources will have to be they can begin to offer abortion services, and contraception.17 expended to inform all women of their which in turn will place a burden on the This struggle was most visibly mani- right to have an abortion without fear of few hospitals that provide comprehensive fested among the rank-and-file members legal prosecution. Despite negative pub- services. Additional funding was recent- of the ANC—many of whom, despite licity that the Choice on Termination of ly made available for training programs commitments to gender equality, are de- Pregnancy Act received within the first few to increase health care providers’ skills vout Christians or Muslims. Prior to the months of passage,19 the demand for safe and technical knowledge. vote in the South African National As- and legal abortion services has increased. •Accessibility and availability. Third, the sembly, many representatives argued that However, there have been no comprehen- availability of abortion services needs to they should be allowed to vote according sive outreach and educational campaigns be expanded by ensuring equality of ac- to their own consciences. While the ANC to inform women of their newly acquired cess to services across provinces. As a re- leadership was divided on this issue, those and to reduce the stig- sult of refusals on the part of some hospi- who supported the prochoice movement ma associated with abortion. Also, while tals to offer abortion services, cooperating dominated seats in the National Assem- the media have aired stories about doctors hospitals are being overloaded, and con- bly and contended that representatives and hospitals refusing to perform or even sequently are finding it difficult to meet the should vote according to their party plat- offer abortion services, there has been rel- demand for abortions. For instance, hos- forms. Meanwhile, opposition-party rep- atively little publicity or educational ma- pitals in the Gauteng, Western Cape and resentatives were allowed to vote in ac- terial concerning the steps that women Free State provinces provide a substantial cordance with their personal beliefs. need to take to gain access to these services. proportion of abortions in the country The legislation was passed 209 to 87, •Provider education. Second, health care (59%, 13% and 9%, respectively); facilities with five abstentions and 99 absentees. workers must be educated to reduce the in KwaZulu/Natal, Northern and North- However, there has been widespread tension arising from conflicts in patients’ west provinces, on the other hand, perform

Volume 24, Number 4, December 1998 193 Abortion Reform in South Africa only 3%, 1% and 1% of abortions. For rural areas and by conflicting cultural atti- 4. Ibid. KwaZulu/Natal, this rate is significantly tudes toward abortion. On the clinical side, 5. Ibid. lower than the anticipated number of abor- evaluations of the effectiveness of various 6. The Abortion and Sterilization Act No.2 of 1975, Sec- tions, since it is one of the most populous abortion methods in the South African con- tion 3, Government Gazette, 478 (1975). 21 provinces in South Africa. text will also need to be conducted. 7. Fawcus S et al., Management of incomplete abortions Thus, women who come to hospitals of- at South African public hospitals, South African Medical fering abortion services are often met with Conclusion Journal, 1997, 87(4):438–442. long waiting lists and an overburdened As in many other countries, abortion is a 8. Shweni PM, Margolis J and Monokoane TS, Abortions: staff reluctant to meet their needs. Due to volatile issue in South Africa. Implemen- the King Edward VIII Hospital experience, O & G Forum, the long wait for services at some hospi- tation of the 1996 Choice on Termination of July 1992, pp. 25–26 tals, women are frequently turned away Pregnancy Act faces many challenges: the 9. Rees H et al., The epidemiology of incomplete abor- for being too advanced in their pregnan- pronatalist views of conservative South tion in South Africa, South African Medical Journal, 1997, cies, despite their having made appoint- Africans; limited access to health care for 87(4):432–437. ments before 12 weeks of gestation.22 medically underserved blacks and coloreds; 10. Ibid. Availability of state-funded abortions and limited access in hospitals, due to staff 11. Ibid. is limited. Such abortions are not available resistance and lack of resources. Despite 12. Shweni PM, Margolis J and Monokoane TS, 1992, op. at many local clinics because of a shortage these setbacks, the Pretoria High Court re- cit. (see reference 8). of trained providers and adequate tech- cently upheld women’s right to abortion. 13. Fawcus S et al., 1997, op. cit. (see reference 7). nology. Currently, state-funded termina- Approximately 30,000 abortions were tions are only available at secondary or performed in the year since implementa- 14. Kay BJ et al., An analysis of the cost of incomplete abortion to the public health sector in South Africa, South tertiary facilities, where the necessary re- tion of the new act, while the number of African Medical Journal, 1997, 87(4):442–448. sources are not as scarce. A woman can get women presenting for treatment of severe 15. Ibid. an appointment at such a facility only after complications resulting from incomplete being referred by a community clinic or abortions decreased significantly.23 In late 16. African National Congress, The Reconstruction and Development Programme: A Policy Framework, Johannes- local day hospital. If it is economically fea- 1997, the first official report of maternal burg, South Africa:Umanyano Publications, 1994. sible, a woman can arrange to have an deaths in South Africa cited only nine abortion at a private freestanding clinic or deaths resulting from septic abortions, com- 17. Kay BJ et al., 1997, op. cit. (see reference 14). with a private doctor, as long as these pared with the Medical Research Council’s 18. Choice on Termination of Pregnancy Bill, Section 2, providers are registered with the state. reports of more than 400 in 1994.24 Gazette, 45 (1997). •Monitoring implementation. Finally, imple- However, despite these advances, ade- 19. Reproductive Rights Alliance, A six month overview mentation of the act will have to be moni- quate social and financial support for the of implementation of the Choice on Termination of Preg- nancy Act, Barometer, 1997, 1(2):1–2. tored and evaluated, as is the case with implementation of this much-needed leg- many other newly developed programs and islation is still necessary to ensure the re- 20. Marais T, Provisional overall results from abortion values clarification workshop pilot study, Health Sys- policies of this transitional society. A qual- productive health of South African women. tems Trust Update, Planned Parenthood Association of ity evaluation requires allocation of re- South Africa (Western Cape), Issue No. 21, Nov. 1996. sources and trained research personnel. Al- References 21. Reproductive Rights Alliance, Provincial access to 1. Cope J, A Matter of Choice: Abortion Law Reform in though to date no resources have been TOP: are all provinces equal? Barometer, 1997, 1(1):3. allocated for such work, a National Abor- Apartheid South Africa, Pietermaritzburg, South Africa: Hadeda Books, 1993. 22. Reproductive Rights Alliance, Overview of new abor- tion Task Force has been set up, and is to tion legislation, Barometer, 1997, 1(1):1–2. meet quarterly to assess the situation in each 2. Bradford H, Herbs, Knives and Plastic: 150 Years of Abor- tion in South Africa: Science, Medicine and Cultural Imperi- 23. Department of Health, Republic of South Africa, Epi- province. To equalize provision of services alism, New York: St. Martin’s Press, 1991, pp. 120–145. demiological Comments, 1998, 24(3):2–9. throughout all of South Africa’s nine 3. Bradford H, You call that democratic? struggles over 24. National Committee on Confidential Enquiries into provinces, the government will have to eval- abortion in South Africa in the 1970s, paper presented at Maternal Deaths, First interim report on confidential en- uate access as it is affected by differences be- the Wits History Workshop, University of Witswatersand, quiries into maternal deaths in South Africa, Department tween health care provision in urban and Johannesburg, May 1994. of Health, April 1998, p. 6.

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