Twenty years after the fall of Apartheid, South Africa remains characterized by gender,
racial, and socioeconomic inequities1 that are only continuing to grow. Significant advances such
as emerging Black2 African elite and middle classes, increased racial diversity in human
resources across major governmental sectors, national economic growth, and legal protections
for equity have failed to lift South Africa’s most vulnerable populations out of social, economic,
and political marginalization (Baker, 2010; Coovadia, Jewkes, Barron, Sanders, & McIntyre,
2009; McIntyre & Gilson, 2002; Trueman & Magwentshu, 2013). In particular, Black women of
lower socioeconomic position continue to experience considerable barriers to employment,
education, and basic social services (Coovadia et al., 2009; Kehler, 2001). Such barriers are
reflected by vast racial and economic inequities in women’s access to, utilization of, and
outcomes from reproductive health services including abortion care (Chopra, Daviaud, Pattinson,
Fonn, & Lawn, 2009; Coovadia et al., 2009; R. K. Jewkes et al., 2005; Stevens, 2012).
Following the African National Congress (ANC) democratic victory in 1994, South
African leaders legalized abortion, which significantly reduced abortion-rated mortality. The
Choice on Termination of Pregnancy Act (CTOP), effective as of 1997 and one of the world’s
most progressive abortion policies, now legally protects abortion “on request” for free up to 12
weeks gestation and in cases of socioeconomic hardship, rape, incest, or threats to the woman’s
mental or physical health up to 20 weeks (R. K. Jewkes et al., 2005, p. 1236). By 2001, CTOP
had dramatically reduced abortion-related morality by 91%: the largest abortion- relatedmortality decline ever documented in the world (R. Jewkes & Rees, 2005; Trueman &
Magwentshu, 2013).
As a highly stigmatized health behavior and service, abortion is significantly
underreported and difficult to measure; nevertheless, available data suggest that while mortality
and the overall rate of abortion have declined since Apartheid, unsafe abortions remain
surprisingly common. In 2008, South Africa’s legal abortion rate was 6 per 1,000 women of
reproductive age (15-49 years), but this masked a significant number of abortions occurring
outside the formal medical system (Singh, Sedgh, Bankole, Hussain, & London, 2012).
Evidence from the broader Southern African region (where 90% of the female population is
South African) suggest the actual abortion rate was closer to 15 abortions per 1,000 women, 58%
of which were unsafe (Guttmacher, Kapadia, Naude, & de Pinho, 1998; Sedgh et al., 2012; Singh
et al., 2012). This does demonstrate remarkable progress since 1995, however, during which the
country’s overall abortion rate was estimated at 19 per 1,000 women and nearly 100% unsafe
(Guttmacher et al., 1998; R. Jewkes & Rees, 2005; Sedgh et al., 2012; Singh et al., 2012).
Despite this initial progress, it appears that unsafe abortion-related morbidity and
mortality among South African women are on the rise in recent years (National Committee for
the Confidential Enquiries into Maternal Deaths (NCCEMD), 2011). Following a routine inquiry
into maternal deaths, the Department of Health (DOH) reported that 194 women died from
abortion-related complications during 2005-2007, a 44% increase from 2002-2004 (NCCEMD,
2011, p. xi). Researchers have attributed this rise in mortality to increasing utilization of unsafe
abortion services in the wake of diminished access to legal abortion clinics and the low quality of
public abortion services, although additional research is needed (Stevens, 2012; DOH, 2011).
More recent reports from the DOH have failed to distinguish spontaneous miscarriage, ectopic
3
pregnancy, and unsafe induced abortion as direct causes of maternal death (NCCEMB, 2012,
2013), which officials justified as alignment to new World Health Organization (WHO)
guidelines that classify all “pregnancies with abortive outcomes” together (WHO, 2012).
Alternatively, this lack of transparent reporting (immediately after a documented increase in
abortion-related mortality) (Trueman & Magwentshu, 2013) might further support some
researchers’ allegations of a “conspiracy of silence around abortion” in South Africa (Hodes
quoted in Skosana, 2014; Stevens, 2012).
Researchers have demonstrated that women face numerous barriers to safe abortion care,
while simultaneously experiencing a myriad of factors that create demand for abortion including
poverty, unintended pregnancy, and HIV (Cooper, Harries, Myer, Orner, & Bracken, 2007; R. K.
Jewkes et al., 2005; Singh, Sedgh, & Hussain, 2010). Notably, CTOP did not ensure full support
of physicians, midwives, and nurses who were to provide abortion services nor did it reflect
community norms, which included substantial social resistance to abortion (Hodes, 2013; Varkey
& others, 2000). In turn, the most common barriers to safe and legal abortion services are
directly related to abortion stigma at various ecological levels including abuse or neglect by
health workers, fear of discrimination or breach of confidentiality, long distances to a
diminishing number of abortion facilities, and lack of trained abortion providers (R. K. Jewkes et
al., 2005; Kumar, Hessini, & Mitchell, 2009; Stevens, 2012; Trueman & Magwentshu, 2013).
Additional barriers include insufficient knowledge about CTOP, financial constraints, coercion
by intimate partners, not knowing about the pregnancy, unsuccessful attempts at self-induction,
and gestational limits of CTOP (Constant et al., 2014; Grossman et al., 2011; Jewkes et al., 2005;
Lomelin, 2013; Varga, 2002).