The Challenges of Offering Public Second Trimester Abortion Services in South Africa: Health Care Providers' Perspectives

Abstract

Around 25% of abortions in South Africa are performed in the second trimester. This study aimed to better understand what doctors, nurses and hospital managers involved in second trimester abortion care thought about these services and how they could be improved. Nineteen in-depth interviews with abortion-related service providers and managers in the Western Cape Province, South Africa, were undertaken. Data were analysed using a thematic analysis approach. Participants expressed resistance to the dilation and evacuation (D&E) procedure, as this required more active provider involvement. Medical abortion was preferred as it required less provider involvement in the abortion process. A shortage of providers willing to perform D&E resulted in most public sector services being outsourced to private sector doctors. Respondents noted an increased demand for services and a concomitant lack of infrastructure, physical space and personnel to respond to these demands, sometimes resulting in fragmented or poor quality care. At medical induction sites, most thought introducing the combined mifepristone-misoprostol regimen would improve service capacity, although they were concerned about cost. Improving contraceptive services was also seen as a much-needed intervention to improve care and prevent abortion. Ongoing training, including values clarification, as well as emotional support and team-building for providers are needed to ensure sustainable, high-quality second trimester abortion services.

How risky are second trimester clandestine abortions in Cameroon: a retrospective descriptive study

“…This rate is close to that found in South Africa where 25% of abortions were STA [11], but higher than figures for USA in 2008 which revealed that 10.3% of abortions were STA with only 4% at 16 weeks and above [10]. The limit between the first and the second trimesters varies from 12 to 13 weeks according to authors.…”

“…In the past two decades, misoprostol has been very effective in terminating pregnancy at various gestational ages [19]. Misoprostol is still the drug of choice for terminating pregnancy in the second trimester in other studies [11,19]. In our series, misoprostol was not commonly used in terminating STA.…”

“…Some of them conceive and realize that they are pregnant only with quickening (16 to 20 weeks). This is contrary to the situation in USA and South Africa, where women frequently use contraception, many second trimester abortions are frequently wanted pregnancies and abortion is not illegal [10,11]. Moreover, because of under employment and poverty in our country, some women, despite early discovery of the pregnancy might delay in obtaining financial means necessary to terminate that pregnancy [7].…”

“…Consequently, some of them realize that they are pregnant usually in the second trimester and sometimes with quickening. At this moment some of these women still choose to terminate the pregnancy -although in the second trimester- as already noticed by some authors [10,11]. …”

‘I am all alone’: factors influencing the provision of termination of pregnancy services in two South African provinces

“…Difficulties in access to safe TOP services add to HIV and obstetric causes of maternal mortality [11]. The factors that have influenced access to TOP services include: negative attitudes towards TOP services and the staff who provide TOP services; poor infrastructure; staff shortages and lack of support programmes for the few health care providers in existing TOP services [12,13]. …”