Second-trimester abortions, which occur between the beginning of the 13th and the end of the 20th week of pregnancy, are difficult to access in the public sector. This is mainly due to the lack of designated abortion facilities and the unavailability of abortion providers to provide the service.
Based on our work in the Eastern Cape, we found that these issues prevent women from accessing a second-trimester abortion in the public health system. Out of sheer desperation, some vulnerable women carrying unwanted pregnancies may resort to unsafe and illegal abortion providers.
Designated abortion facilities
A major issue in accessing second-trimester abortion in the Eastern Cape is the low number of designated facilities. In terms of the Choice on Termination of Pregnancy Act, an abortion can only be performed at a facility that meets certain requirements concerning staffing, equipment, resources, and infrastructure. These qualifying facilities are then designated by the MEC for Health in that province.
Of the 54 designated facilities (44 of which are recorded as active by the Eastern Cape Department of Health), only two provide second-trimester abortions. One is Mthatha General Hospital in Mthatha (in the OR Tambo District), and the other is the Frere Hospital in East London (in the Buffalo City Metro).
Given the sheer expanse of the province and the size of its population, two public facilities are wholly inadequate to meet the demand for second-trimester abortions. This is particularly so when you consider that there is no designated public second-trimester abortion facility in Gqeberha (Nelson Mandela Metropolitan Municipality), which is the largest metropolitan municipality in the province. To address the demand for second-trimester abortions, the Eastern Cape Department of Health needs to designate more public facilities (or expand services offered at existing designated facilities) and ensure that they are accessible across the province.
As mentioned in the first article of this series, we visited Mthatha Gateway Clinic in November 2021. The clinic is a stone’s throw from the Mthatha General Hospital, a designated public second-trimester abortion facility. During our visit, we learnt that the hospital was not providing any abortion services. Instead, its abortion services were performed at the clinic.
When we visited the clinic, we learnt that it was providing only first-trimester abortions. In fact, women who were more than 12 weeks pregnant were told that they should get an abortion from a private facility or start attending antenatal care. The lack of second-trimester abortion services at the hospital, therefore, means that there is only one operational second-trimester public abortion facility in the whole province.
Women who try to access abortions in the public sector are among the most vulnerable. They often lack the financial means to bear the cost of travel to abortion facilities, much less to access services in the private sector.
The public healthcare system is designed to ensure that these women are afforded the ability to access reproductive healthcare services such as abortion services to which they are entitled under the Constitution. In fact, even the National Health Act specifically provides that government must provide women with free termination of pregnancy services. These are some of the provisions from which women’s right to access free abortion (and the corresponding state obligation to provide it) are sourced. These rights cannot be undermined by a province’s continued failure to designate abortion facilities and monitor the provision of abortion services at those designated facilities. This would simply be unlawful and unconstitutional.
During our visit to the clinic, we were approached by three women who had been denied second-trimester abortions at the clinic. We met with the Acting CEO of the hospital, Dr Puts Nxiweni to request that the women be provided with an abortion. When SECTION 27 threatened with litigation, a special arrangement was made for the three women. As a result of constraints that prevented our clients from attending the clinic on the scheduled days, only one of the women managed to get an abortion. What is clear is that in the absence of our intervention, it is likely that women in their second trimester of pregnancy who go to this clinic will continue to be denied access to second-trimester abortions.
This situation cannot be allowed to continue.
Recognising the need for a proper system to provide women with a second-trimester abortion, we tried continuously to engage the provincial health department. With the imminent threat of litigation having been averted, our requests to discuss these issues have fallen on deaf ears.
The problem with this silence is that nothing is being done about the continued denial of second-trimester abortion services to women. In fact, except for women who are in or around Frere Hospital and those who can afford to travel there, a pregnant woman in the Eastern Cape who has an unwanted second-trimester pregnancy, is effectively denied an abortion in the public sector.
In the absence of services in the public sector, some women risk their lives and resort to alternative and often unsafe means to terminate their pregnancies. This includes using services provided by unsafe and/or illegal abortion vendors. We wrote an open letter to the Deputy Minister of Health, Dr Sibongiseni Dhlomo who recently led a march in the North West against unsafe and illegal abortions to call out his department and government for failing to make a meaningful attempt at eliminating some of the most pronounced barriers that prevent women from accessing abortions.
Availability of abortion providers
About 25% of abortions performed in this country are second-trimester abortions, yet there are not enough abortion providers rendering this service. Although some healthcare workers are reluctant to provide abortions, research shows that they are even more reluctant to perform the second-trimester (dilation and evacuation) procedure because it requires more active involvement by the provider.
During our visit to Mthatha Gateway Clinic, we learnt that some abortion providers are unwilling to avail themselves to provide abortion services for the following reasons: lack of a financial incentive as having undergone abortion training is not considered a specialisation that warrants additional pay; the lack of debriefing and Values Clarification and Attitude Transformation sessions; and healthcare workers simply failing to understand the scope of their professional duties.
Conscientious objection, which is a healthcare worker’s refusal to provide care on the basis that it offends their conscience, is a threat to women’s access to abortion. The National Clinical Guidelines on the implementation of the Choice on the Termination of Pregnancy Act (2019) recognises that section 15(1) of the Constitution, which entrenches the freedom of conscience, religion, or belief, implicitly accommodates a healthcare worker’s right to refuse care. The guidelines do, however, recognise the fiduciary duties owed by healthcare workers to their patients, and they accordingly state that refusal to care should not be to the detriment of a person seeking an abortion.
Knowledge of the scope and parameters of professional duties is critical to limiting any adverse effect on women. From our visit to Mthatha Gateway Clinic, it was clear that the failure of healthcare workers to understand their fiduciary duties was undermining the provision and the quality of abortion services at the facility. One of the healthcare workers at the facility, in the absence of any assertion of religion or conscience, advised us that on any given day she could request a transfer so that she wouldn’t have to perform abortions. This is something that she had also communicated to women at the clinic who were seeking an abortion. This statement is based on the erroneous belief that providing an abortion is optional for healthcare workers. In fact, it is compulsory, subject to conscientious objection-a very limited exception.
The provincial health department and professional bodies for healthcare workers must continue to reinforce the fiduciary duties of healthcare workers whilst providing them with the necessary support. A failure to do so will not only undermine the integrity of their professions but will also affect the availability and quality of abortion services provided to women.
In the Eastern Cape public health system, it is the responsibility of the provincial department to appoint enough skilled healthcare workers to provide abortion services to realise women’s reproductive health rights. Given that this is a constitutional right, government is bound to respect, protect, promote, and fulfil it. In terms of the National Health Act, it is the responsibility of the MEC for Health in Eastern Cape, Ms Nomakhosazana Meth, to ensure that national health policy and norms and standards on access to abortion are implemented (section 25(1)); and it is the responsibility of the Superintendent-General for Health, Dr Rolene Wagner, to plan, coordinate, and monitor the rendering of services and the development of human resources in the province (section 25(2)(f) and (i)).
With two of the biggest systemic issues in access to abortion having been described above, it is clear that the responsibility to reform the system is on the provincial health department. Its continued failure to ensure that there is a system and plan to provide second-trimester abortions in the public health sector not only infringes women’s reproductive rights, but also constitutes a breach of the duties imposed on government, the MEC for Health, and the Superintendent-General for Health. We, therefore, call on the department to engage us and the public on the continued state of abortion services in the province.
*Ndlela, Mapipa, and Mtsolongo are all from SECTION27.
**This article is the second of a three-part series in which we examine issues underlying abortion services in the public health sector in the Eastern Cape.
NOTE: This is an article written by employees of SECTION27. Spotlight is published by SECTION27 and the Treatment Action Campaign but is editorially independent, an independence that the editors guard jealously. The views expressed in this open letter are not necessarily those of Spotlight.