This week we gear up for the annual 16 Days of Activism for No Violence against Women (and children), and we are being asked to understand how violence permeates through our communities. This past week encouraging leadership was displayed by MEC, Siblongiseni Dhlomo, in addressing the devastating impact of the lack of abortion access in KwaZulu-Natal. There have been reportedly 20,000 illegal abortions in the province, in the past year alone, and at least 12, 031 women were admitted to Kwa-Zulu-Natal hospitals for treatment for botched abortions with 1 455 experiencing sepsis.

The MEC notes what could be described as “violent” attitudes on the part of health workers who do not respect women’s choice to have an abortion, leading them to choose an illegal provider. Dhlomo is to be commended for raising the issue, as one hears few political leaders, including in the National Department of Health, and the Department of Women, voice this level of understanding of the extraordinary violence that vulnerable women experience, in trying to make sense of their lives, and when choosing to legally terminate their pregnancy.

Coincidentally just this past month, an insightful book has been published describing the epidemic of unsafe abortion under apartheid. Drawing on the work of former University of Cape Town scholar, Helen Bradford, and taking it further the historian, Susanne Klausen’s new book Abortion Under Apartheid: Nationalism, Sexuality and Women’s Reproductive Rights in South Africa, details the clandestine abortion industry under apartheid, and the politics leading to the passage of the 1975 Abortion and Sterilisation Act. This book details the bizarre Christian Nationalism that sought to control white women’s sexuality and reproductive health in an attempt to maintain white supremacy. White women were policed in an attempt to prevent them from having abortions, and almost no care in the world was afforded to black women who endured the bulk of suffering of inaccessible health services.

As a health worker who worked in the segregated wards of apartheid, Klausen’s book resonated with me deeply as I remembered how I was fundamentally challenged by the suffering of black women who were admitted with swollen and septic bellies, devastatingly ill from septic abortions procured illegally. The book details the need in many hospitals in the country for separate wards to be created to cope with the enormous burden of women being admitted for care after botched abortions.

I distinctly remember a white ward in Victoria hospital in Cape Town being used by black women with septic abortions in the 1980s. Separate budgets had to be created and developed to cope with this burden on the health system. I also distinctly remember booking a trip to visit my sister in Canada, and seeing a former team-mate from my hockey team at the leafy privileged high school of Westerford, waiting for her ticket to travel too. She was not very forthcoming about her trip and later her travel agent told me candidly that she (the travel agent) ran the Marie Stopes weekend flights for girls and women in trouble and needing abortions. The irony that she had crucifixes all over her travel agency startled me into noticing the intersectional injustices of the “Christian” apartheid health system, and how it impacted on women’s reproductive health. Klausen describes in great detail the admission of desperate women over many years into hospitals around the country, and the experiences of health workers during apartheid, who had to address this challenge. Klausen argues that unsafe abortion was the number one health issue facing gynaecology and obstetrics wards in hospitals across the country.

Klausen details “The Trial the World is Watching”, the Crichton-Watts Trial in 1972, when the head of the gynaecology and obstetrics unit at the King Edward VIII Hospital, Professor Derk Crichton, was charged and convicted along with the self-taught abortionist James Watts of assisting white teenagers to procure abortions. Apartheid cop, Sergeant Dan Matthee, nicknamed “abortion buster” at the time, had direct orders from the Minister of Health to put an end to Crichton’s abortion-related activities, and as a result he relentlessly investigated the world of abortion in Durban, in order to put a stop to white teenagers and women choosing not to have babies for apartheid “volk and vaderland”.

This narrative would make a brilliant movie script, for it has layers of incredible characters, plots and ironies. A spoiler alert: In addition to doing abortions, Crichton was also a surgeon who did transgender affirming surgeries for transgender people in the 1970s. His prosecution was a blow to so many, as we do not live single issue lives. The sobering thing is that now in 2015 the challenge of abortion access remains. White and middle-class women can and do access abortion easily given our internationally lauded Choice on Termination of Pregnancy Act passed in 1996 to redress the injustices of apartheid, and enable abortion on demand. With financial resources or confidence, and resilience to work the system, one can usually access abortion services, especially in the first trimester.

It is black women who are still enduring the injustice and violence of reproductive ill health. With missionary zeal to control the numbers of black women having children, the apartheid government introduced long-term contraception through the injectable contraceptive Depo Provera (DMPA) as a form of population control, as documented by Klausen. This facilitated a culture of giving contraception to women without asking them what option would suit them, nor supporting the skills needed for respectful discussion about safer sex with one’s partner(s). These days it is suspected that Depo Provera enables HIV acquisition by thinning the genital lining, and this is being researched. The SA Department of Health revised their contraception and fertility planning policy for this reason, to address a wider contraception option method mix, yet unfortunately it has just pushed another long term option, namely the Implanon contraceptive implant. So, South African women, and in particular black women, still experience poor quality contraception service with uneven informed consent, and choice of methods. Data on abortion is difficult to research, because the Department of Health’s information system is not viewed as reliable. The Department of Health data report 80,000 abortions per year. Given that some 250, 000 illegal abortions were provided in the 1970s, what the Department of Health is providing is not meeting the needs of the population, and it would be interesting to know what the numbers of admissions are nationally for illegal abortions. Given the wide advertising of illegal abortion providers, there clearly is a booming market.

Women experience institutional violence when they cannot access safe and legal abortion services in South Africa, with currently only 40% of designated surgical abortion facilities being operational. Bear in mind that many women have an unintended pregnancy from rape or denied paternity. Medical termination of pregnancy still needs to be implemented properly by the National Department of Health, as facilities that provide the medical (as opposed to surgical) option with the taking of pills unplanned. The process of enabling cheaper access to Mifepristone through obtaining generic drugs has not had the same imagination and attention that has gone into providing ARV drugs.

At the recent technical task team meeting for the Adolescent Sexual and Reproductive Health and Rights Framework, a medical doctor berated the Department of Health for their lack of leadership and stewardship in providing abortion programming and implementation. A third-year medical student from KZN, troubled by the burden of maternal health, bravely also challenged the Department of Higher Education for the lack of training in abortion provision, noting that when he was qualified, he expected to be an abortion provider. At a meeting to address abortion stigma in Cape Town this month, service providers expressed dismay at poor training plans and implementation in the Western Cape, but also noted that KZN is no better. In general they deplored the lack of accountability throughout all levels the management in the Department of Health. These are some of the challenges to address if we are going to end the violence in the health system that women experience. Klausen’s book should be part of the core curricula for medical and nursing students, because history should not be repeating itself. Hopefully Oxford University Press will decide to bring the book out in a less-expensive soft-cover version before too long, so that it can become accessible to a wide readership.

Abortion under Apartheid details utterances by politicians (that were truly bizarre), police actions which were inhumane, and the suffering of women. Helen Suzman’s efforts to reform the abortion law are known, but what I did not know is the legacy of the Inkatha Freedom Party, leader Mangosuthu Buthelezi, in arguing for abortion reform. Do we learn from history? Local elections are coming up, and will the silence of political leaders on abortion persist? The ANC has good policies related to abortion, yet politicians’ statements on abortion are generally peculiar, and the lack of detail on implementation on abortion is shameful. The DA is a fence-sitter, and if Mmusi Maimane has a history of homophobia, can one hope for better leadership on his position on abortion? And while the Economic Freedom Fighters have a proud statement against homophobia on Johannesburg pride this past week, I wonder if they will be vocal on reproductive justice come election time? Violence against women kills, women do not live single issue lives. Reproductive Justice for all. DM