Simple solutions to reduce unsafe abortions in South Africa

The WHO estimates that, worldwide, one woman dies every 8 minutes from an unsafe abortion that could have been prevented [1]. To its credit, South Africa has come a long way since 1994 when nearly 45,000 women were admitted to hospitals for spontaneous abortions or complications of clandestine abortions [2]. Since the Choice on Termination of Pregnancy Act (Act 92 of 1996, the Choice Act) came into effect in 1996, maternal morbidity and mortality have dropped [3, 6]. But despite South Africa’s efforts, it is estimated that 50% – 60% of the country’s 260,000 abortions are still illegal and likely unsafe [4]. This trend shows no signs of slowing.nl

safe2choose is a social enterprise whose mission is to provide evidence-based information and counseling on how to have a safe abortion with pills and facilitate access to safe and affordable abortion pills to women who want them. Since we started building a team in South Africa over six months ago, we have been investigating what problems exist with the current systems of service delivery in South Africa and how to improve our global model to help the thousands of women currently flocking to illegal providers in South Africa.

It turns out that even though abortion is a very sensitive topic, many women will openly share their experiences if you ask them in a safe and non-judgmental space. In the spring of 2016, we did just that, asking South Africans from all walks of life about their experiences with abortion.

We met with two members of a sex workers cooperative in Cape Town who shared their stories. One, a woman who has had several abortions herself and the other a transgender woman who has walked many of her peers through the process. As they see it, illegal providers of abortion pills are just as effective and a lot less of a hassle compared to legal public or private clinics. The hassle they are referring to ranges from not knowing which clinics provide terminations of pregnancy, if the necessary staff is available, what / if any documentation is required, getting time off work, arranging travel to the clinic, to potential stigma if seen receiving the service publicly and even judgmental staff providing the treatment.

Similar concerns were raised when we conducted an informal survey during the 2016 Mpumalanga Sexual Health Dialogue. We asked 21 young, mostly rural women their experiences with various reproductive health issues. More than half of these women reported knowing someone who had an abortion and knew how to get an illegal abortion if they wanted.

Taking these stories together with the hundreds of other stories we have heard from around the world, it is clear that the reasons for the continued popularity of illegal providers are diverse. So far, we have defined a list of ten factors including: abortion related stigma, concerns about confidentiality, lack of information about legal options, late detection, long and unclear processes, inadequate counseling, understaffed and overworked staff, cost, distance legal service providers, and the convenience of illegal providers.

safe2choose will be piloting a three phased approach to service delivery in South Africa that we believe can address all the above barriers women face to access safe abortion care services. Phase 1 involves leveraging the systems that already exist by giving women more information about and increasing referrals to existing service providers. Phase 2 seeks to improve existing systems by offering complimentary services like counseling and 24/7 support centers. Ultimately though, access to safe abortion pills is the critical component in successful care delivery. In Phase 3, we will focus on increasing the supply of quality abortion pills through more efficient distribution models.

Although we have a long term vision, we have also decided to start small by focusing on Phase 1 and increasing access to abortion related information. Ultimately, two important data points are helping us define Phase 1. The first fact is that 30% of women report not even knowing that abortion is legal [5]. The second is that, worldwide, women who seek an abortion but are turned away are 35% less likely to report aspirational plans for their lives, even years later. This means that in South Africa, even basic facts like the legality of abortion and where they can get one are poorly communicated to women.

To address these issues safe2choose is piloting a new tool that will launch on Aug 27th to help women find the service provider nearest to them who can actually provide a termination of pregnancy through standard phones using SMS. We will be releasing more details over the coming weeks but the big picture is that we have created a phone number that women can text and be automatically referred to the public clinic, private clinic, adoption center, or counseling office nearest to them. We pull from a list of service providers we have vetted and will continue to update frequently.

This project is part of a larger goal within safe2choose to use contextually appropriate technologies, to reach women who may not normally be able to access our website or services. Combined with related projects we will announce shortly, we are confident that we can use South Africa as an example of the real impacts of providing women with abortion related information that they are seeking.

We understand the challenges we face moving forward and we recognize the importance of listening to all the feedback we will receive. Stay tuned to our blog and social media channels to learn more about what we are up to and to give us feedback.

1 – http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2709326/
2 – https://www.guttmacher.org/about/journals/ipsrh/1998/12/abortion-reform-south-africa-case-study-1996-choice-termination
3 – http://ibisreproductivehealth.org/where-we-work/south-africa
4 – http://www.timeslive.co.za/thetimes/2014/07/14/abortion-hacks-still-kill-in-sa
5 – http://www.mariestopes.org.za/legal-abortion-know-your-rights-to-a-safe-termination/
6 – Rebecca Hodes (2016) The Culture of Illegal Abortion in South Africa, Journal of Southern African Studies, 42:1, 79-93, DOI: 10.1080/03057070.2016.1133086
Image – https://upload.wikimedia.org/wikipedia/commons/c/c5/Abortion_Quick_%26_Pain_Free_sign,_Joe_Slovo_Park,_Cape_Town,_South_Africa-3869.jpg