Opinion: Abortion access in Eastern Cape falls far short

PHOTO: Marion Stevens

Following the publication of an article by GroundUp News on 21 October 2021, titled “Pregnant Women queue all night outside abortion clinic”, we followed up to determine the state of abortion services offered by the Eastern Cape Department of Health.

We visited Mthatha Gateway Clinic (the clinic mentioned in the GroundUp article), spoke to a number of women seeking abortion services at the clinic, and we called facilities designated by the provincial health department as abortion service providers to verify that these services are, in fact, provided.

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No privacy

During our conversations with the women at the clinic and with staff at various public healthcare facilities designated to provide abortion services throughout the Eastern Cape, we picked up a number of irregularities in how the services are offered in the province. One such example is the experience of Precious Mthembu (not her real name), who approached the clinic to access abortion services.

In her account to us, Mthembu said that patients are not afforded one-on-one consultations with the abortion provider. Instead, they are all addressed in one room. There are no demarcated consultation bays with curtains or partitions for privacy and nursing staff often shout personal and confidential patient medical information to fellow staff members across the clinic within earshot of other patients. Medical exams are performed in full view of other patients and medication is administered with all the patients in one room, with patients passing pills down the queue to each other. This account by Mthembu points to a complete disregard for patient privacy and confidentiality.

What the law provides

Section 14 of the National Health Act states that all patient information, including information relating to their health status and treatment, is confidential. This section explicitly prohibits the disclosure of any information on patients. In addition, Section 7(5) of the Choice on Termination of Pregnancy Act states that the identity of a woman who has requested or obtained a termination of pregnancy shall remain confidential at all times unless she herself chooses to disclose that information. Furthermore, the importance of patient privacy and confidentiality is emphasised throughout the National Guidelines for the implementation of the Choice on Termination of Pregnancy Act published by the Department of Health in 2021 (the guidelines). According to the guidelines, the setting for the abortion, which includes the consultation room, the procedure room, and the recovery room, should respect the need for patient privacy and dignity.

OPEN LETTER: It takes more than a march to remedy systemic challenges to #abortion access. @SECTION27news @marionwish @_SRJC @MY_SRHR @HealthZA @FoMohale @Safe_Abortion @drtlaleng @SweatTweets @SexRightsAfrica @ThuthsM @umunyana_rugege @faranaazveriava
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— Spotlight (@SpotlightNSP) March 4, 2022

For more information on the guidelines and the Act, see our article entitled: “A look at the new abortion guidelines”.

It is clear from the provisions cited above that the clinic’s deviation from these legislative prescripts and policy guidelines is unlawful. Mthembu also mentioned that patients are required to provide reasons for seeking abortion services in the presence of other patients. The reason provided by the patient must be satisfactory to the abortion provider and in the event that it is not deemed satisfactory, the patient is allegedly denied the abortion. Asking patients to provide reasons for an abortion is expressly prohibited by law. Section 2(1)(a) of the Act states that a pregnant woman is entitled to an abortion upon request if she meets certain criteria. (A summary of the criteria specified in the CTOPA is provided below.)

0 – 12 weeks pregnant

Women are entitled to TOP upon request. To be performed by a registered medical practitioner i.e. doctor, registered nurse, registered midwife who has completed the prescribed training.

13 – 20 weeks and 6 days pregnant

Medical practitioner must be satisfied that: Continued pregnancy would pose risk of injury to the women’s physical or mental health; or there is a substantial risk that the foetus would suffer from a severe physical or mental abnormality; or the pregnancy resulted from rape or incest; or the continued pregnancy would significantly affect the social or economic circumstances of the woman. To be performed by a registered medical practitioner i.e. doctor.

Above 20 weeks pregnant

Continued pregnancy would endanger the woman’s life; or continued pregnancy would result in a severe malformation of the foetus; or continued pregnancy would pose a risk of injury to the foetus. To be performed by registered medical practitioner i.e. doctor after consultation with another medical practitioner, nurse, or midwife.

Further, the guidelines make it clear that abortion providers should never require an individual to divulge their reasons for wanting an abortion or judge that individual for the pregnancy or their reasons for wanting an abortion. The guidelines also state that service providers should never require an individual to disclose how they conceived nor should they shame individuals for lack of contraceptive use or any other behaviour.

When minors access abortion services

During our visit to the clinic, we encountered a number of minors who were seeking abortion services at the clinic. Gladys Soyi (not her real name) was accompanied by her maternal grandmother and was refused an abortion because her surname was not the same as that of her grandmother. She was told that she needs to return with an adult who has an identical surname to hers.

The clinic’s requirement that a minor is accompanied by an adult is unlawful. Section 5(3) of the Act provides that pregnant minors shall be advised to consult with their parents, guardians, family, and friends but shall not be denied abortion services in the event that they choose not to do so. Further, section 5(5) provides that no consent other than that of the pregnant individual is required, irrespective of age.

Fuelling illegal and unsafe abortions

According to the guidelines it is estimated that 50% of abortions are provided by informal, illegal, and unsafe providers. Women and girls seeking abortions are forced to seek informal, illegal, and unsafe abortions as a result of barriers as reported above. The unlawful practices exercised by the public sector designated abortion facilities, such as those discussed above, leave women vulnerable to illegal abortion providers.

During our visit to the clinic, we were approached by an individual advertising the services of an illegal abortion provider. From where the woman was sitting at the entrance of the clinic, she could look for women and girls who, for whatever reason, are not assisted in the clinic.

Another factor fuelling illegal and unsafe abortions is the unavailability of safe abortion facilities. In earlier correspondence with SECTION27, the Eastern Cape Health Department confirmed that only 44 of the 54 facilities designated to perform abortion services actually perform these services. After our visit to the clinic, we contacted all 44 of these healthcare facilities but only managed to get through to 29. We found that of these 29 facilities—two facilities, namely Elliotdale Hospital and Qumbu Community Health Centre (CHC), do not perform abortion services at all.

In four facilities, namely Butterworth Hospital, St Patrick’s Hospital, Hewu Hospital, and Adelaide Hospital there is only one nurse responsible for performing abortions and they were on leave at the time of the inquiry (women seeking urgent assistance were advised to go elsewhere).

Although there are two facilities designated to perform second-trimester TOP services, only one facility (Frere Hospital) in the entire province actually does.

The disregard for privacy and confidentiality (as well as the unlawful requirement for minors to be accompanied by adults) corrodes the trust that pregnant women seeking abortions have in the public health system. From the Act and the guidelines it is clear that the system was designed to be as welcoming and as accommodating as possible for women who choose to terminate their pregnancies.  So, when the abortion providers deviate from the provisions of the Act and the guidelines, they create an opportunity for illegal abortion providers to take advantage of desperate and vulnerable women.

*This article is the first of a three-part series in which we examine issues underlying abortion services in the public health sector in the Eastern Cape.

*Mapipa, Ndlela, and Mtsolongo are all with SECTION27.

NOTE: This article is written by employees of SECTION27. Spotlight is published by SECTION27 and the Treatment Action Campaign but is editorially independent, independence that the editors guard jealously. The views expressed in this opinion piece are not necessarily those of Spotlight.