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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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