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 abortions 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 abortion 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 dilation and curettage 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.