Understanding abortion seeking care outside of formal health care settings in Cape Town, South Africa: a qualitative study

Abstract

Background Although abortion was legalized in South Africa in 1996, barriers to safe, legal abortion services remain, and women continue to seek abortions outside of the formal healthcare sector. This study explored the decision-making processes that women undertake when faced with an unintended pregnancy, the sources of information used to make their decisions and the factors that contribute to their seeking of informal sector abortion in Cape Town, South Africa. Methods We conducted 15 semi-structured in-depth interviews in English with women who had accessed an abortion outside of the formal health care sector. Women were recruited with the assistance of a community-based key informant. Data was analyzed using a thematic analysis approach. Results Participants were aware that abortions were legal and accessible in public clinics, however they were concerned that others would find out about their unintended pregnancy and abortion if they went to legal providers. Women were also concerned about judgment and mistreatment from providers during their care. Rather than seek care in the formal sector, women looked past concerns around the safety and effectiveness of informal sector abortions and often relied on their social networks for referrals to informal providers. Conclusions The findings highlight the decision-making processes employed by women when seeking abortion services in a setting where abortion is legal and demonstrate the role of institutional and societal barriers to safe abortion access. Abortion service delivery models should adapt to women’s needs to enhance the preferences and priorities of those seeking abortion care-including those who prefer facility-based care as well as those who might prefer self-managed medical abortions.

Abortion decision-making process trajectories and determinants in low- and middle-income countries: A mixed-methods systematic review and meta-analysis

“…The final abortion decision may be made solely or primarily by the woman herself, jointly with her partner or others, or by others without or with minimal involvement of the woman. 7 , 8 , 10 , 12 , 26 , 27 , 29 , 30 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 44 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 74 However, even cases in which the majority of the decisions are made by woman, male partners and/or parents still influenced her decision. 7 , 35 , 39 , 44 , 74 Thus, decisions made by woman may either be passive in which the woman simply agrees to the decision imposed onto her by others 8 , 30 , 32 , 35 , 37 , 38 , 39 , 44 , 48 ,…”

“… 7 , 35 , 39 , 44 , 74 Thus, decisions made by woman may either be passive in which the woman simply agrees to the decision imposed onto her by others 8 , 30 , 32 , 35 , 37 , 38 , 39 , 44 , 48 , 51 , 54 , 57 , 60 , 64 , 65 , 66 , 70 , 74 or active in which she actively participates in the decision-making processes. 29 , 32 , 36 , 37 , 39 , 40 , 42 , 47 , 53 , 62 , 64 , 65 , 66 , 69 Where the woman is excluded or plays a very limited role in decision-making, threats, coercion, violence, or trickery may be used by their partners and/or parents to coerce her accept their decision 8 , 12 , 32 , 33 , 37 , 41 , 44 , 55 , 56 reflecting varying autonomy in women's abortion decision-making. 33 , 52…”

“…This phase includes the woman's encounter with the abortion providers using safe or unsafe abortion methods in places that may be safe or unsafe biomedically. The abortion procedure includes the actual pregnancy termination which may be carried out clandestinely or overtly, and may involve safe or unsafe procedures or methods, 6 , 10 , 12 , 26 , 27 , 28 , 29 , 31 , 32 , 34 , 35 , 36 , 37 , 39 , 41 , 43 , 44 , 45 , 47 , 48 , 49 , 50 , 53 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 66 , 70 , 74 , 77 , 78 , 79 , 80 , 81 , 82 , 98 place of abortion 6 , 7 , 26 , 29 , 34 , 35 , 36 , 39 , 41 , 43 , 44 , 45 , 47 , 49 , 50 , 53 , 56 , 60 , 61 , …”

“…Safety is understood by women to include not only medical safety (outcome) but also social safety (confidentiality, privacy, secrecy, and reputational safeguarding of the woman and/or her family), legal safety (protection from the law), and financial safety (protection from catastrophic expenditures). 6 , 9 , 12 , 28 , 32 , 35 , 36 , 37 , 38 , 40 , 41 , 44 , 45 , 47 , 48 , 51 , 53 , 54 , 56 , 58 , 59 , 60 , 61 , 62 , 63 , 75 , 78 , 79 , 81 , 83 , 84 , 85 , 98 The post-abortion phase …”

“…Depending on the outcome of the abortion procedure, the woman may develop complications which are managed at different referral points including the hospital and by skilled trained abortion providers such as gynaecologists. 6 , 26 , 27 , 32 , 33 , 36 , 38 , 40 , 44 , 45 , 47 , 49 , 55 , 60 , 61 , 62 , 74 , 81 , 82 , 83 , 84 Adolescents, women living with HIV, and commercial sex workers face additional barriers to access to post abortion care including requirements for consent from parents or partners, or stigma. 36 , 39 , 44 , 61 , 62 In only two of the included studies were women given post-abortion family planning.…”