The course of the global HIV/Aids epidemic changed in 1996. Haart (high active antiretroviral treatment) was developed and, in those countries in which treatment was available to the public, Aids-related hospital admissions and deaths declined dramatically. This gave South African activists a new imperative: to fight for access to the drugs. After a protracted struggle between the department of health and the HIV treatment access movement, cabinet committed to the public provision of ARVs in 2003. There are currently more than 1.2 million South Africans on ARVs, one of the greatest public health achievements in history.
The same year saw another landmark in public health in the passage of South Africa’s Choice on Termination of Pregnancy Act. The Act put an official end to apartheid-era legislation, which had restricted access to abortion except in limited circumstances - primarily cases of white women with foetal abnormalities.
South Africa’s legalisation on abortion was the result of collective efforts of women’s rights advocates, public health experts and government officials to reform reproductive health laws and to counter the pseudoscientific and ahistorical arguments of anti-choice lobbyists. Among these is the false contention that abortion never existed in Africa prior to colonisation, that it is – in the broadest sense – “volksvreemd” (not native or indigenous).
In fact, abortion has a long history in South Africa across racial and class lines, with the components of abortifacient remedies known widely among various devout communities in the 19th century and beyond. Whereas opponents argued that abortion was at odds with the religious and cultural practices of South Africans, research has shown that many women who have abortions continue to hold strong religious affiliations (including Catholic, Protestant, Muslim and Hindu), and that, far from preventing them from seeking an abortion, faith guides their decision to do so, often through the medium of prayer.
By the mid-1990s, prior to the legalisation of abortion, approximately 200,000 illegal abortions were being performed in South Africa each year, with concomitant harmful effects on health and mortality. In sum, the medical history of abortion in South Africa has shown that women will procure abortions by any means, whether supported by health infrastructure or not.
During the early years of the democratic transition, South Africa’s rates of HIV prevalence increased rapidly. Doctors and nurses working in the public health sector began to confront the effects of advanced Aids in their patients, with few options for treatment. At least one doctor issued a public call in the South African Medical Journal for the introduction of new legislation to enforce the sterilisation of HIV-positive women of reproductive age. He argued that antiretroviral treatment “should be conditional on voluntary or enforced sterilisation”, and that HIV-positive women should abort their pregnancies “either voluntarily or by law”. Many HIV-positive women were coerced into accepting abortion or sterilisation during these years.
Women living with HIV must balance pro-natal social expectations with the disapproval and discrimination that often attend being pregnant as well as HIV-positive. Despite government’s commitment to the roll-out of ARVs, including for the prevention of mother-to-child transmission of HIV, it has failed to integrate reproductive health services with HIV treatment and prevention programmes. And while activist campaigns for public access to ARVs have won numerous gains for women, the primary focus on their health outcomes as mothers, and the related prioritisation by public health specialists, donors and activists, has shifted attention away from other reproductive health rights, including the right to safe, accessible abortions.
By 2000, just three years after the implementation of legalisation of abortion in South Africa, a study conducted in rural KwaZulu-Natal found the implementation of abortion was hindered by nurses who refused to provide abortions or undergo training to do so. The nurses at this hospital treated rape survivors with contempt, claiming that young women had lied about being raped to access abortions. Across South Africa, opposition and harassment by healthcare workers and clinic managers continues to obstruct patients’ access to abortion. As one obstetrician working within the public health sector explained: “There’s a lot of judgment... we’ve had experiences... in the wards of women undergoing termination of pregnancy not being looked after by the nursing staff, just ignoring them. Or doctors refusing to have anything to do with them.”
Studies indicate that HIV-positive women may avoid seeking antenatal services because they fear the punitive responses of healthcare workers angered by their obvious non-compliance with the “positive living” ethos of continuous condom use. HIV-positive women in South Africa’s public health sector may be required to bargain with nurses, including consenting to sterilisation, to procure certain services. The requirement that women must accept the hormonal injection before they are initiated on antiretroviral treatment was part of the ARV initiation guidelines in at least one South African province as recently as 2004.
Healthcare workers continue to discriminate against women seeking abortions, delaying clinic bookings until women are beyond the gestational limit and must either continue with the unwanted pregnancy or seek an illegal abortion. Other healthcare workers use directive counselling procedures, assuring patients of their right to an abortion, but telling them simultaneously that they would be guilty of murder.
Such responses are premised on the belief that women deserve to be punished for unintended pregnancies, particularly if they are HIV-positive. But in reality, women’s prospects of preventing pregnancy are determined not solely by their individual behaviour, but by complex social factors over which they have little control – including education, gendered power relations, and the provision and accessibility of contraceptive services.
In 2007 maternal mortality and morbidity as a result of unsafe abortions in South Africa had been reduced by 91% and 50% respectively, testifying to the beneficial health outcomes of the legalisation of abortion. However, continuing high numbers of illegal abortions point to the persistent demand for abortion in the informal health sector and the ubiquitous advertisements of “lamp post providers” testifies to their supply.
The issue of abortion remains highly contested. South African society holds strong pro-natal beliefs, in terms of which a women’s value is premised on her role as a mother. The legalisation of abortion and the provision of comprehensive reproductive healthcare, including women with HIV, have raised questions about a “moral”, as opposed to a “moralising” public health policy.
South Africa’s ARV programme has saved thousands of lives and it is crucial that treatment coverage continues to increase - especially in the climate of flagging global financial support for ARV programmes. However, urgent attention must also be focused on improving women’s access to other reproductive health services. Women in the public sector usually have a choice between three forms of contraception: the injection (by far the most widely prescribed), the oral contraceptive pill, and sterilisation. Access to the “morning-after pill” must be increased, and education campaigns mounted to inform the public of the existence of emergency contraception. Moralists may claim this will encourage fecklessness and promiscuity. It will not. But it will provide women with another means of preventing an unintended pregnancy.
However, there will always be women who become pregnant unintentionally and who will seek an abortion whether or not they are supported by their partners, communities or the public health sector. Government’s failure to implement progressive abortion laws and policies points to its failure to put into practice its commitments to women’s rights, and to the urgent need to reconfigure broader beliefs about a woman’s right and ability to control her reproductive destiny. DM
Rebecca Hodes is a medical historian and deputy director of the AIDS and Society Research Unit at the University of Cape Town.