Abortion in Post-Apartheid South Africa:

Exploring Gender, Racial, and Economic Inequities

Elizabeth Mosley, MPH

University of Michigan PhD Candidate

Health Behavior Health Education; Population Studies Center

Feminism and Critical Theory Conference; University of Sussex

June 20-21, 2015

 

 

Abortion in South Africa: Evidence from the Literature

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 Black 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

oppression (Baker, 2010; Coovadia, Jewkes, Barron, Sanders, & McIntyre, 2009; McIntyre &

Gilson, 2002; Trueman & Magwentshu, 2013). In particular, Black women of lower

socioeconomic position (SEP) 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- related

                                                                                                               1 While the terms health disparities, inequalities, and inequities are often used interchangeably, the current manuscript purposefully uses the term “health inequities” to describe differences in health that are unfair or the result of social injustice as defined by Kawachi, Subramanian, and Almeida-Filho (2002, p. 647).

 

 

mortality 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

 

 

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 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 was swiftly passed by

newly-elected ANC leaders and, in short, did not ensure full support of physicians, midwives,

and nurses (many of whom enthusiastically resisted the new legislation) nor did it reflect

community norms, which included substantial social resistance to abortion (Hodes, 2013; Varkey

& others, 2000). In turn, the most common barriers women report are stigma and discrimination,

long distances to a diminishing number of abortion facilities, lack of trained abortion providers,

and abuse or neglect by health workers (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, lack of

confidentiality, 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).

 

 

Worldwide and in South Africa, demand for abortion is typically driven by poverty (de

Bruyn, 2012; Kirkman, Rowe, Hardiman, Mallett, & Rosenthal, 2009; Suffla, 1997);

contraceptive non-use or failure (Dahlbäck et al., 2010; Shah & Ahman, 2009); completion of

desired fertility (de Bruyn, 2012; Kirkman et al., 2009; Orner, de Bruyn, & Cooper, 2011);

interference with education and employment opportunities (Suffla, 1997); and rape, abusive, or

unstable partnerships (Orner et al., 2011; Suffla, 1997). Additionally, in settings with high HIV

prevalence such as South Africa, social stigma of pregnancy and HIV-related health concerns are

also major reasons women seek abortion services (de Bruyn, 2012; Orner et al., 2011). This

disconnect between inequitable access to safe services and demand for abortion is what

ultimately leads to unsafe abortion and associated death and disability among vulnerable groups:

from 2005-2007, for example, 89% of all abortion-related deaths in South Africa occurred

among women who were HIV-positive (Stevens, 2012). Presumably most abortion-related deaths

occurred among women living in poverty, although this remains undocumented in the literature.

Reproductive Justice and Abortion Inequities in South Africa: A Theoretical Framework

While valuable public health research has been conducted on abortion in South Africa, a

number of important questions remain unanswered, particularly related to social inequities.

Researchers have previously documented racial and socioeconomic segregation in access to and

quality of reproductive health services including abortion care (Chopra et al., 2009; Coovadia et

al., 2009; Trueman & Magwentshu, 2013), preliminary evidence suggests poverty is a major

driver of South African women’s demand for abortion (De Wet, 2014; Hodes quoted in Skosana,

2014; Varga, 2002), and 100% of respondents reporting voluntary termination of pregnancy in

the 2013 General Household Survey were Black (De Wet, 2014). Most commonly, the country’s

epidemic of unsafe abortion has been framed as a reproductive rights issue that stands in

 

 

violation of human rights agreements emphasizing women’s rights to choose abortion (de Bruyn,

2012; Guttmacher et al., 1998; Lomelin, 2013; Trueman & Magwentshu, 2013; United Nations

Population Fund (UNFPA), 1995; Varkey & others, 2000). Nevertheless, researchers have yet to

identify the specific mechanisms through which poverty and socioeconomic inequities influence

abortion; few have explicitly investigated the intersections of gender, racial, and economic

oppression; and all have failed to contextualize abortion within the entire spectrum of women’s

reproductive experiences from sexual initiation to motherhood, which are often stratified by race

and SEP (Colen, 1995).

A major component of broader postcolonial feminist theory, reproductive justice offers a

well-suited framework for exploring gender, race, and SEP while expanding the traditional

paradigm of reproductive rights by emphasizing women’s rights to have a child and to “parent

healthily and with dignity” (Davis, 2003; Fried, Ross, Solinger, & Bond Leonard, 2013; Luna &

Luker, 2013, p. 328; Roberts, 1998; Ross, 2006). In the mid-1990s reproductive justice emerged

as a grassroots social movement in reaction to the growing reproductive rights campaign, which

was led by and focused upon White and relatively affluent women who primarily advocated for

increased access to birth control and safe abortion services. In contrast, the reproductive justice

movement centered experiences of gender, racial, and economic oppression that strip away some

women’s rights to safely conceive and mother their own children; for example, historical forced

sterilization and contraception among Black women in both the United States and South Africa.

Today the enduring struggle for racially and economically marginalized women is most

commonly "miserable social conditions, which dissuade them from bringing new lives into the

world" (Davis, 2003, p. 355) In addition to contraception and safe abortion services,

reproductive justice advocates have pushed for resources that support women and their partners

 

 

as parents and full humans including improved wages and working conditions, paid parental

leave, quality education, and access to basic services like healthcare.

Through this approach, reproductive justice effectively builds upon the concepts of

“intersectionality” (Crenshaw, 1989; Schultz and Mullings, 2006) and “stratified reproduction”

(Colen, 1986) by acknowledging that gender, race, and SEP are mutually constructed and

reinforced while social expectations of women’s reproduction are, in turn, patterned by those

gender, race and socioeconomic constructs. The concept of intersectionality, originally coined by

Crenshaw (1989) and recently applied to public health by Schulz and Mullings (2006, p. 5),

explicitly identifies gender, race, and SEP as inherently relational, “socially constructed

categories [that] vary as a function of each other” in specific local contexts. For example,

normative definitions of motherhood are distinct by race, SEP, and geography, which predictably

carries important implications for reproductive health services and outcomes. Further, the

framework of stratified reproduction, first developed by Colen (1995 p. 78), posits that “physical

and social reproductive tasks are accomplished differently according to inequalities that are

based on hierarchies of class, race, gender, [and] place in the global economy.” In essence,

stratification through social, economic, and political processes results in the systematic valuing

and encouragement of White and upper class reproduction while that of non-White and lower

SEP women is devalued, discouraged, and denigrated.

Historical and Contemporary Gender, Racial, and Economic Contexts of Abortion

Social, Economic, and Health Conditions Under Settler Colonialism and Apartheid

In order to understand the current landscape of abortion in South Africa, which medical

historian Rebecca Hodes (quoted in Skosana, 2014) calls a “legacy of Apartheid,” it is first

necessary to understand the historical conditions of Apartheid as they relate to gender, racial, and

 

 

economic inequity. In their investigation of contemporary health inequities in South Africa,

Coovadia et al. (2009, p. 817) described the primary purpose of Apartheid as “the violent

subjugation of indigenous people…to force Black people to work for low wages to generate

wealth for the White minority.” Of course, legal Apartheid did not appear out of thin air but

rather solidified racial and economic oppression that had been mounting throughout South Africa

for centuries. During the settler colonial period (1652-1948), Dutch and British settlers

repeatedly collided with indigenous groups, whose freedom, land, and natural resources were

incrementally and violently stolen (Baker, 2010; Coovadia et al., 2009; Frederickson, 1982).

Following discovery of diamonds and gold on the Witwatersrand in the mid- to late-19th century,

Black men were forced to migrate for short-term, low wage, and dangerous mining jobs while

women and children were relegated to “reserves”- rural areas bereft of employment and

agricultural opportunity that served as a continuous labor supply for the White economy

(Coovadia et al., 2009, p. 819; Frederickson, 1982). Before election of the National Party in 1948

that marked the beginning of legal Apartheid, immense structural and institutional barriers to

Black social mobility had already been erected: all non-Whites were effectively stripped of

suffrage; 90% of all South African land was seized for White residents; a pass system was

inaugurated to limit non-White mobility; and forced labor contracts forbade strikes while

protecting blanket color bans on more profitable occupations (Baker, 2010; Coovadia et al.,

2009; Frederickson, 1982).

This staggering racial and economic oppression was intensified, streamlined, and

formalized when the Afrikaner National Party members began to implement their platform of

“separate development” for each racial federation or “homeland” (Frederickson, 1982, p. 246). A

formal racial classification system separated South Africans into four hierarchical categories and

 

 

required they carry appropriate identification as either European (White), Asian (Indian),

Coloured, or Bantu (Black) (Baker, 2010; Coovadia et al., 2009; Frederickson, 1982). This

segregation dictated all aspects of life including where individuals could live, what occupations

they could hold, who they could marry, if they could vote, and the quality of basic services such

as housing, education, and healthcare. Severe structural, institutional, and interpersonal violence

was waged against non-White groups, particularly indigenous Black South Africans. Non-White

residents were forcibly removed from relatively thriving, racially diverse neighborhoods and

relocated to overcrowded, race-specific townships; millions of others were forced back to Black

homelands assigned to their group. Ultimately, the Apartheid state aimed to achieve

“independence” for each homeland, which would exist as a self-governing unit (Baker, 2010, p.

80). As a result, laborers traveling to urban industrial areas for work were categorized as

temporary migrants who had no citizenship and, therefore, no legal rights. In short, South

African officials took no responsibility in providing these migrants (most typically Black men)

with social or health services- much less for their families, who were often forced to stay behind

in the deeply impoverished Black homelands.

Rural-dwelling Black women felt the injustices of Apartheid most acutely as their

experiences existed at the intersection of gender, racial, and socioeconomic vulnerability. The

underdeveloped homelands in which they lived with their children were characterized by nearly

universal unemployment, poor quality education, and a deeply inadequate health infrastructure

(Coovadia et al., 2009; Kehler, 2001). During this period, up to 80% of adult Black men were

away from home, having migrated to urban centers for jobs. Those women privileged enough to

be employed often worked for insufficient and instable pay in the domestic sector. Such

conditions, including temporary migration for work and entrenched community-level poverty,

 

 

carried enormous effects for reproduction and family formation that are still observed today.

Cohabitation and childbearing outside of marriage, concurrent partnerships for men and women,

and childrearing by extended family members became increasingly common. Today’s

disproportionately high rates of HIV and sexual violence victimization among Black South

African women have even been attributed, in part, to lingering effects of Apartheid on family

structure, gender norms, and sexual socialization (Coovadia et al., 2009).

The social and economic conditions of Apartheid also carried serious ramifications for

South Africa’s health infrastructure, particularly in rural areas (Coovadia et al., 2009). During

the colonial period, healthcare was already segregated by race and overtime the system became

increasingly fragmented both within the public sector and between the public and private sectors.

Under the Apartheid policy of “separate development,” 14 separate health departments were

created (one for each racial federation) with services concentrated at the hospital level and little

provision for primary or preventative care. To say the least, healthcare in the Black homelands

was systematically underfunded and desperately insufficient to address the rising health

inequities experienced by non-White communities- much less the HIV epidemic to come.

Around 1970, the national physician to patient ratio was 1:1,700 compared to only 1:15,000 in

the Black homelands. The Apartheid health system was also characterized by heavy reliance on

private, for-profit healthcare, which catered to relatively affluent, White South Africans. By the

end of Apartheid, over half of healthcare expenditure was allocated to the private sector, where

62% of physicians worked despite minimal accessibility for the general population.

There is perhaps no better example of South Africa’s historical “two nation” (Mbeki

quoted in Baker, 2010, p. 81) approach to healthcare than family planning and abortion services

under Apartheid. A principal goal of the Apartheid state was to diminish Black population

 

 

growth, which was feared to "swamp" the White ruling minority and threaten social order (Hodes,

2013, p. 531). Reproductive health policies at the time were characterized by negative eugenics

against Black women including coercive family planning and the forced removal of "surplus"

women and children to Black homelands (Bradford, 1991, p. 135; Kuumba, 1993).

Simultaneously, officials blocked access to safe abortion services because it was incompatible

with Calvinist, puritanical mores (Hodes, 2013). In 1975, the Abortion and Sterilization Act

(ASA) specified women could only access legal abortion under very strict medical circumstances

approved by the state psychiatrist (Bradford, 1991; Hodes, 2013). Subsequently, the abortion

behaviors of White, relatively affluent women were scrupulously monitored and suppressed by

the state. As safe services became impossible to access, those who could travel internationally

sought abortions by the thousands in places such as Britain and Mozambique (Bradford, 1991;

Hodes, 2013).

In contrast, while still morally condemned by White officials, little attention was paid to

rapidly rising rates of unsafe abortion among Black women who were unable to jump through

the legal loopholes of the ASA or afford the privilege of international travel (Hodes, 2013). By

the late 1980s, between 200-300,000 illegal abortions were being performed each year- almost

exclusively among lower SEP Black women (Hodes, 2013). In addition to seeking services from

under-skilled providers, many women were resorting to dangerous and desperate methods of

self-induction including insertion of knitting needles or injection of detergents through the cervix.

In 1981 alone, over 33,000 surgeries addressing complications of unsafe abortion were recorded.

One doctor observed from the 1980s, "These women, they were just being churned through, in,

out, in, out" (Hodes, 2013, p. 533). Of course, this flood of abortion-related morbidity and

mortality did not reflect the “rainbow nation’s” (Baker, 2010, p. 79) unique racial diversity: of

 

 

the 425 women on average who died every year from unsafe abortion under Apartheid, 100%

were Black and low SEP (Hodes, 2013). One Black woman said of her illegal abortion during

Apartheid, "I had no choice. My two children did not have enough to eat. How could I support

another child?" (Bradford, 1991, p. 140).

Socio-economic Equity and Healthcare in Democratic South Africa

When ANC leaders won their democratic majority in 1994, hopes were high throughout

South Africa and the world for rapid and radical change toward gender, racial, and economic

equity following centuries of brutal subjugation. New national priorities for health and social

equity were reflected in the Constitution, the Reconstruction and Development Program (RDP),

and the National Health Plan (Baker, 2010; Chopra et al., 2009; Coovadia et al., 2009; Kehler,

2001; McIntyre & Gilson, 2002). As stated in its Constitutional Preamble, the ANC aimed to

“transform South Africa as rapidly as possible into a united, non-racial, non-sexist and

democratic country…To fight for social justice and to eliminate the vast inequalities

created by apartheid and the system of national oppression…To promote economic

development for the benefit of all” (African National Congress, 1994a).

The RDP, an ANC economic strategy developed in collaboration with the Confederation

of South African Trade Unions (COSATU), therefore emphasized redistribution of resources and

proliferation of social welfare programs to lift South Africa’s most vulnerable populations out of

poverty (Baker, 2010; McIntyre & Gilson, 2002; Van Vuuren, 2013). In that vane, the National

Health Plan proposed a new decentralized primary health care model built on community health

centers and delivered via a newly-developed district health system, which sought to undo the

highly fragmented, undemocratic, and racially-segregated remnants of Apartheid healthcare

(Baker, 2010; Chopra et al., 2009; Coovadia et al., 2009; McIntyre & Gilson, 2002). The first

 

 

line of the ANC’s Health Vision read, “The health of all South Africans will be secured and

improved mainly through the achievement of equitable social and economic development”

(African National Congress, 1994b, p. 19). Through the Clinic Infrastructure Program, 1,345

new primary health care clinics were built and 263 existing clinics were upgraded (Coovadia et

al., 2009). Moreover, the ANC eliminated user fees associated with women’s reproductive health

care services, which was later expanded to primary care for all in 1996.

Unfortunately, high aims set for social and health equity in South Africa have not yet

translated into reality. In the decade following the ANC’s inauguration, socioeconomic inequity

appeared to grow both between and within racial categories (Baker, 2010). From 1993 to 2008,

Leibbrandt, Finn, and Woolard (2012) found a significant increase in overall socioeconomic

inequality and within-group inequality, particularly among Black South Africans, as a greater

share of income has gone to the top 10% without similar increases for the most impoverished.

These changes were also represented by South Africa’s Gini coefficients, which grew from 0.56

(Coovadia et al., 2009, p. 824) to a high of .67 in 2007 (Statistics South Africa, 2014). While

absolute poverty has significantly diminished in South Africa thanks to social welfare grants,

socioeconomic inequality has remained consistently high: the most recent Gini coefficient was

0.65 in 2011- the highest in the world (Statistics South Africa, 2014; World Bank, 2015).

Narrow-band unemployment rates similarly remain higher than during Apartheid: 24% at the end

of 2014 (Statistics South Africa, 2015) compared to 17% in 1995 (Central Statistical Service,

1996) with enormous disadvantages persisting for vulnerable groups. Today, 8% of White South

Africans are unemployed as compared to 17% of Indian, 27% of Coloured, and 39% of Black

South Africans (Statistics South Africa, 2015). The statistics are even worse for women, who

experience larger racial inequities and significantly lower occupational status than their male

 

 

counterparts: Black women shoulder the highest unemployment burden at 33% (Statistics South

Africa, 2013), another 42% are employed in low-skilled, low-wage occupations (Statistics South

Africa, 2015).

Although an area of debate, many researchers attribute these ever-rising inequities to the

government’s increasing prioritization of economic growth in the global market at the expense of

equitable redistribution (Baker, 2010; Coovadia et al., 2009; McIntyre & Gilson, 2002). As

previously noted, the economic strategy adopted by the ANC in 1994 emphasized national

reconstruction through progressive tax reforms, increased minimum wage, extensive expansion

of welfare grants, and much-needed land reforms. Yet these pro-equity policies quickly came

into conflict with international economic trends and local leaders that strongly promoted

neoliberal capitalist agendas. A dramatic departure, in 1996 ANC leaders adopted the Growth,

Employment, and Redistribution (GEAR) Policy, which prioritized economic growth, reduced

government spending, promoted privatization and deregulation, lowered corporate taxes, and

implemented wage restraints (Baker, 2010; Coovadia et al., 2009; McIntyre & Gilson, 2002).

While early successes from RDP (e.g., child support grants and free health services) were

achieved and maintained, some researchers warned their positive effects were being eroded by

increased privatization, stagnated government spending on healthcare, and enduring

socioeconomic inequity along with increasing rates of unemployment (Baker, 2010; Coovadia et

al., 2009; McIntyre & Gilson, 2002; Van Vuuren, 2013). Thanks at least in part to increasing

social movements and discontent within South Africa along with the election of President Jacob

Zuma, a qualitatively different New Economic Growth Path (NEGP) was revealed in 2010

followed by the New Development Plan (NDP) in 2011. While both emphasize the reduction of

unemployment and social inequality through increased government intervention, economists

 

 

have called the approach a “middle ground framework” that still exhibits neoliberal influences of

globalized capitalism (Van Vuuren, 2013, p. 82). It remains unseen if commitment to job

creation, cash grants, housing, healthcare, and education along with renewed infrastructure

development and land reform will be enough to shift the course of social inequities and poverty

in South Africa.

To date, the South African health system continues to be characterized by low human

resource capacity; poor leadership and management; inadequate skills of health workers; neglect

and abuse of patients; and misdistribution of resources geographically- all of which have been

exacerbated by the HIV epidemic (Chopra et al., 2009; Coovadia et al., 2009). In fact, South

Africa remains one of the very few countries in which maternal and child mortality have

increased since 1990. Notably, the health-related consequences of deepening social inequity and

reduced healthcare capacity such as HIV have disproportionately affected the nation’s most

vulnerable populations, particularly Black women who are living in relative poverty.

Enduring Reproductive Inequities in South Africa Today

In South Africa, as throughout the world, interactions between socioeconomic inequity

and the multiply-marginalized social status of women have resulted in the “feminization of

poverty” (Kehler, 2001, p. 43), which carries significant implications for abortion and

reproductive justice. In their roles as caregivers, primary “breadwinners,” and reproductive

agents, women have been disproportionately affected by cuts to social services, stagnation of

healthcare funding, and restructuring of the job market over the past two decades (Coovadia et

al., 2009; Kehler, 2001, p. 44). Moreover, these gender disadvantages are more severe for

economically and racially marginalized women: low SEP Black women experience significantly

higher rates of unemployment, deeper levels of poverty, and poorer living conditions than both

 

 

White women and Black men (Kehler, 2001; Statistics South Africa, 2015). While there is a

dearth of South African studies applying a reproductive justice framework to explore these

gender, racial, and economic inequities as they are related to reproduction, preliminary evidence

and lessons learned from other settings can be used to to direct future research and intervention.

First, research from South Africa has shown access to safe abortion services is severely

segregated by race, SEP, and geographical region (Blanks, 2014; Trueman & Magwentshu,

2013), and evidence from other settings suggests barriers to safe abortion are most likely to

affect racially and economically marginalized groups (Blount, 2015). In 2013 there were 250

licensed abortion facilities, but only half actually offered abortion services; fewer than one-third

of trained providers provided pregnancy terminations (Trueman & Magwentshu, 2013).

Generally, licensed facilities and providers are restricted to urban areas (CITE). Lower SEP and

Black women are more likely to terminate their pregnancies in public, generally lower quality

abortion clinics as compared to more affluent and White women- an enduring reflection of

Apartheid (Coovadia et al., 2009; Trueman & Magwentshu, 2013). The DOH reported that the

number of abortion procedures in public facilities decreased to fewer than 40,000 in 2010 as

compared to 85,000 in 2009 (Stevens, 2012). This diminished access is more likely to affect low

SEP Black women who rely on the public sector and are less likely to afford private care and

carries serious implications for reproductive justice. In the United States, researchers have found

barriers to safe, affordable abortion care disproportionately affect economically and racially

marginalized women (Blount, 2015; Dehlendorf, Harris, & Weitz, 2013; Fried, 2000; Jones &

Weitz, 2009), but similar analyses have not been published on South Africa.

Secondly, as access to safe abortion services in South Africa is declining, demand is

actually increasing as evidenced by proliferating advertisements for illegal abortion, enduring

 

 

reliance on self-induction, and increasing socioeconomic inequity and poverty. Throughout

urban centers, “backstreet” abortion providers advertise their phone numbers on trash bins,

fences, and lampposts, which suggests a profitability of abortion services particularly from low

SEP women living in urban areas (Trueman & Magwentshu, 2013, p. 398). Additionally, one

study found a significant proportion (nearly one-fifth) of women attending hospitals for abortion

report first trying to self-induce at home, and this was more likely for Black and unemployed

women (Constant, Grossman, Lince, and Harries, 2014). Among those who self-induced, 81% of

women self-medicated with herbal products and 19% were treated by “back-street” abortion

providers who gave them a “tablet” (Constant et al., 2014, pp. 303–304). These results come

from a non-random sample of 194 women from four public facilities in Cape Town, however,

and highlight the need for increased quantitative analyses from larger, more diverse, and

nationally representative samples that better capture the role of socioeconomic conditions in

demand for abortion.

Poverty has been identified as an important and common reason for abortion among

women in South Africa and around the world, which is a testament to the absurdity of trying to

separate abortion from broader contexts of motherhood (de Bruyn, 2012; Dehlendorf et al., 2013;

Kirkman et al., 2009; Orner et al., 2011; Skosana, 2014; Suffla, 1997; Trueman & Magwentshu,

2013). De Wet's (2014) recent analysis of reported voluntary pregnancy terminations in the 2011

General Household Survey revealed that 100% were among Black women, and termination was

more likely with unemployment and lower educational attainment. Globally, reproductive justice

advocates and scholars have suggested this strong relationship between SEP and abortion is the

result of women’s ongoing racial and economic oppression, which makes it difficult to “parent

healthily and with dignity” (Davis, 2003; Dehlendorf et al., 2013; Luna & Luker, 2013, p. 328;

 

 

Ross, 2006). Evidence suggests economically marginalized women are often driven to terminate

pregnancies (regardless of wantedness) due to insufficient support for motherhood including

basic maternal and child health care, safe housing, stable and sufficient income, and freedom

from violence. Generally, the specific pathways through which socioeconomic indicators are

related to abortion among Black women in South Africa remain undocumented. One exception

where substantial investigation has been conducted is among HIV-positive women, who report

that poverty is a common reason for abortion that is further exacerbated by their HIV status (de

Bruyn, 2012; Orner et al., 2011)

Finally, whatever the roles of gender, racial, and economic inequity on women’s access

to and demand for abortion, they are certain to interact with the strongly held social stigma

surrounding abortion in South Africa. It has been shown that social stigma against abortion both

reflects and reinforces social expectations of femininity such as compulsory motherhood (Kumar

et al., 2009). And yet, as previously noted, global patterns of reproduction are stratified such that

the fertility and motherhood of White and high SEP women are promoted while that of non-

White and lower SEP women is targeted for population control and inaccurately blamed for

poverty and negative child outcomes (Colen, 1995; Luna & Luker, 2013; Roberts, 1997). Given

this complex reproductive ideology, it is possible that social stigma surrounding abortion in

South Africa are similarly patterned by gender, racial, and socioeconomic inequity. In fact, from

their qualitative study on HIV, Orner et al. (2011) reported that social norms were only accepting

of abortion under certain conditions including extreme poverty. Notably, HIV-positive women

are caught in a unique “double bind” in which they are simultaneously pressured into

motherhood by patriarchal social expectations while being explicitly discouraged from

reproducing due to their HIV status (Cooper et al., 2007; Ingram & Hutchinson, 2000). To date,

 

 

however, no study has systematically investigated social patterns of abortion stigma in South

Africa, nor how they are contextualized by broader ideologies of race, socioeconomics, or gender

(including motherhood). This carries important implications for self-reporting of abortion (for

example, on nationally representative surveys), which might become the only source of

quantitative data for monitoring and research as the DOH fails to report abortion-related deaths

moving forward.

Conclusion and Future Directions for Research

Despite legal precedents for social equity and the provision of safe abortion services,

South Africa remains characterized by vast inequities that can be linked to patterns of

reproductive injustice such as increasing rates of unsafe abortion and resulting maternal mortality

among low SEP Black women. In the mid-1990s, newly-elected ANC officials sought to address

injustices left in the wake of Apartheid through labor and land reforms, elimination of health fees,

extensive social welfare programs, and legalization of abortion. Nevertheless, gender, racial,

socioeconomic, and health inequities have actually increased over the past two decades as

evidenced in labor force participation, distribution of income, and health outcomes such as

maternal and child mortality. Researchers argue this is a reflection of both the enduring HIV

epidemic and deepening poverty in South Africa, while some specifically lay blame on

unsupportive macroeconomic policies that prioritize economic growth over redistribution and

strengthening of public services.

Researchers have called South Africa’s abortion situation a “legacy of Apartheid,” during

which abortion was illegal and 200-300,000 unsafe abortions were performed every year among

low SEP Black women while White women could and did travel abroad for safe services. Today,

despite a significant decline in overall morbidity and mortality since 1994, abortion-related

 

 

inequities persist regarding access to safe services, overall demand for abortion, and unsafe

abortion-related morbidity and mortality. Affluent and White women are now able to access safe

abortion through private providers and non-governmental organizations (NGOs), while lower

SEP Black women are relegated to the public sector, where the number of clinics and quality of

services is declining. In public clinics, Black women often endure harassment and violence from

health workers, a phenomenon reflecting the country’s intense social stigma against abortion as

well as abortion care provision. Unfortunately, the decline in access to safe abortion through the

public sector has not been matched by a decline in demand for abortion, which has resulted in

increased utilization of illegal abortion in recent years. In 2007 this was reflected in an alarming

44% increase in abortion-related deaths since 2002; more recent DOH reports have failed to

distinguish between spontaneous (miscarriage) and induced abortion.

Globally, public health researchers and community leaders have called for a reproductive

justice approach to addressing abortion inequities that acknowledges root causes including poor

access to contraceptives and safe abortion, structural and institutional racism, and socioeconomic

vulnerability that reduces women’s abilities to provide a safe and supportive environment for

their child(ren) (Dehlendorf et al., 2013). By using this approach and evidence from the literature

as summarized above, it is possible to identify future areas for research and intervention on

abortion in South Africa that would promote health equity. First, researchers and public health

officials must collaborate to identify effective and sustainable solutions to address racial and

socioeconomic segregation in access to and quality of safe abortion services. This will likely

involve broader health systems strengthening approaches, as quality of abortion care in the

public sector is similarly affected by human resource, training, and supply chain management

limitations that must be addressed at the institutional and structural levels. Secondly, further

 

 

investigation is needed to effectively address the mismatch between high demand and poor

access to leads to self-induction and “backstreet” abortions among vulnerable populations.

Additional contraceptive, safe abortion, and maternal resources could be prioritized for those

areas with highest demand for abortion services. Finally, as abortion stigma plays such a large

role in patterns of unsafe abortion and related mortality, additional investigations are warranted

to explore racial and social differences within stigma. Moving forward, research on and

evaluation of abortion in South Africa will likely continue to be severely limited by inaccurate

reporting of abortions and abortion-related mortality from the DOH. Self-reported accounts of

abortion in nationally representative surveys will become increasingly more vital for effective

monitoring and investigation. Abortion is under-reported in face-to-face interviews, however, as

demonstrated by 0% of White, Coloured, or Indian women reporting an abortion in the 2011

General Household Survey. Such underreporting, which is likely related to both abortion stigma

and stratified reproduction, will continue to be a significant limitation of future studies, and

deserves to be unpacked.

 

 

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