Self-induction of abortion among women accessing second-trimester abortion services in the public sector, Western Cape Province, South Africa: An exploratory study

Abstract

From 1994 to 2005, the proportion of maternal mortality attributable to unsafe abortion in South Africa (SA) decreased by an estimated 91%. [1] This reduction was attributed to the legalisation of abortion in 1996 with the passing of the Choice on Termination of Pregnancy Act, which provided for abortion on demand through 12 weeks of gestation and for several conditions, including socioeconomic hardship, through 20 weeks of gestation.Self-induced abortion involves the use of medications other than evidence-based medical abortion regimens, as well as other substances or physical trauma, to try to end an unwanted pregnancy. Selfinduction is synonymous with unsafe abortion, defined by the World Health Organization (WHO) as 'a procedure for termination of an unintended pregnancy done either by people lacking the necessary skills or in an environment that does not conform to minimum medical standards or both' .[2] Conditions defining unsafe abortion practices include some or all of the following: absence of pre-abortion counselling, induction by an unskilled provider, procedures undertaken in unhygienic conditions, ingestion of traditional medication or hazardous substances, use of physical devices, or incorrect prescription of medication with inadequate instructions for use and no follow-up. [2] In developed countries with liberal abortion laws, unsafe abortion is generally infrequent, while in developing countries, where access is often restricted, as many as 77% of all induced abortions may be unsafe.[2] The Guttmacher Institute and the WHO estimate that 58% of abortions were unsafe in 2008 in the southern African region, which includes countries beyond SA, [3] and this figure is supported by other country-specific studies. In the 2nd South African national Youth Risk Behaviour Survey, [4] 6% of female high-school learners reported having had an abortion, and 9.8% of male learners reported that their female partners had done so. Of these, only 51.5% reported that the abortion had been performed at a hospital or clinic; 20.5% of respondents had consulted a traditional healer, 10.2% went to 'another place' , and for 5.4% the provider setting was unknown. Neither age nor race was associated with differences in where the abortion took place, but there were associations between seeking help from a traditional healer and both earlier school grade and geographical region. The highest prevalence of using a traditional healer was in KwaZulu-Natal.Data from the USA have shown that self-induction was associated with a delay in seeking or obtaining a clinic-based abortion. [5] Previous research has reported that adult SA women sought abortion care outside designated facilities because of perceived poor quality of services, oversubscribed services, ineffective referral systems within health services, and lack of knowledge of the time-limited nature of the service.[6] More recent research in SA has identified additional barriers to safe abortion, such as uneven provision between rural Self-induction of abortion among women acce...

Sexual violence-related pregnancies in eastern Democratic Republic of Congo: a qualitative analysis of access to pregnancy termination services

“…Though not a pervasive theme in our study, providers’ attitudes towards abortion have been cited as barriers to access of care in other settings [33–36]. Other studies reveal that even with legalized abortion services, women may still seek unsafe or self-induced means of pregnancy termination as a result of stigma, financial reasons, or confusion around the law, emphasizing that efforts must be focused on improving accessibility, increasing the number of skilled providers, as well as addressing the cultural attitudes toward termination [37, 38]. A more detailed understanding of attitudes among both women and providers in this context may help to provide tailored services for women with SVRPs.…”

Abortion attitudes among South Africans: findings from the 2013 social attitudes survey

“…National maternal death reports, which notably no longer distinguish abortion from spontaneous miscarriage, suggest mortality from ‘miscarriage/abortion’ surged 62% between 2002–2004 and 2011–2013 (National Committee for the Confidential Enquiries into Maternal Deaths 2014). Evidence further suggests that women who are of lower socioeconomic status (Harries et al 2015; Trueman and Magwentshu 2013), (Black) African (Constant et al 2014), living with HIV (National Committee for the Confidential Enquiries into Maternal Deaths 2014; Orner et al 2011; Stevens 2012) and/or residing in Gauteng, Limpopo or KwaZulu-Natal (National Committee for the Confidential Enquiries into Maternal Deaths 2014) are at higher risk of unsafe abortion and its health consequences than women who are more affluent, White, living without HIV and/or residing in other provinces. South African women have identified a number of barriers to safe abortion care including fear of discrimination or confidentiality breech, abuse and neglect by health workers, a dearth of abortion providers, waiting lists, gestational limits, long distances, insufficient knowledge about abortion laws and financial constraints (Constant et al 2014; Cooper et al 2004; Grossman et al 2011; Harries et al 2007, 2015; Jewkes et al.…”

“…According to the World Health Organization, a human rights-based approach to health applies seven key principles: availability, accessibility, acceptability, quality of facilities and services, participation, non-discrimination and accountability (United Nations 2014, 76). Researchers in South Africa have previously described how negative abortion attitudes can carry consequences for the availability, accessibility, quality and acceptability of abortion services and how those consequences are inequitably patterned by race, socioeconomic status, HIV status and region (Constant et al 2014; Harries et al 2015; National Committee for the Confidential Enquiries into Maternal Deaths 2014; Orner et al 2011; Trueman and Magwentshu 2013). A human rights-based approach to health, in turn, places these abortion-related indicators in the broader context of women’s rights to comprehensive healthcare, personal dignity and non-discrimination by gender or other social categorisation (United Nations 2014).…”

Articulating reproductive justice through reparative justice: case studies of abortion in Great Britain and South Africa

“…Nevertheless, many women still procure abortions outside of designated clinics, consulting traditional healers (Jewkes, Gumede, Westaway, Dickson, Brown and Rees, 2005) and health professionals performing abortions without licence (Moodley and Akinsooto 2003) or using a readily available herbal infusion (Constant et al 2014). Advertisements for illegal abortion services abound in taxi ranks and city centres.…”