South Africa’s current healthcare landscape is a system directly bequeathed as a result of apartheid and is typically characterised by inequities between those who have adequate, quality access versus those who do not have efficient and satisfactory access. This has a profoundly negative knock-on effect on the average individual, particularly those living in marginalised communities. Though twenty-five years of democracy have yielded significant strides, structural and psycho-social barriers remain a considerable hindrance to many in under-resourced communities.
Local and global trends indicate that there is a socio-economic disadvantage in accessing quality sexual and reproductive health (SRH) services for those living in rural locations, as well as for migrants and adolescents. Women and young girls who fall in these categories are faced with increased odds of unintended pregnancy and reduced safe abortion access.
The enactment of the progressive Choice on Termination of Pregnancy Act (CTOPA) of 1996, serves as a mark of South Africa’s objective to advance women’s right to sexual and reproductive health. Sadly, despite the CTOPA allowing access to safe and legal abortion, many young women and girls continue to opt for illegal, backstreet abortions. As a result of the inequities, within the healthcare system, there are debilitating barriers that include a lack of adequate provision and access to quality information, services and commodities.
For those of us in the coalface of SRH work, a lack of resources and commodities remains the reality under which we operate. Nurses in most, if not all, government hospitals are overburdened not only by the patient load but by the operational burden due to a lack of sufficient resources and the lack of commodities to perform actual abortions. As a result, this also impacts on the patient. The unavoidable waiting period often pushes patients to request second-trimester abortions which further places an additional burden on the system as few medical practitioners are willing to perform surgical abortions while facilities that perform surgically are equally unavailable.
It’s widely known in the health sector that the lack of essential psycho-social and emotional support services for abortion providers, in the form of targeted training, debriefing and counselling is another fundamental hindrance to the quality of SRH and abortion services. This has a direct bearing on the low number of nurses willing to take up abortion provision in the public health sector. The lack of resources and support further deters nurses from working in this stream. Other deterrents include improper working conditions and a lack of incentive programs for those nurses who choose to train and acquire the additional skill of being abortion providers.
Additional strain is placed on providers who deal with management that is anti-choice or that lacks adequate knowledge of abortion and SRH services; whilst also lacking a critical understanding of how to handle and manage urgent abortion and SRH-related crises. This inadvertently leads to many of the already existing providers exercising conscientious objection and refusing to perform abortion services, ultimately opting to be removed from providing this service.
Mitigative measures ought to be implemented by our government to remove barriers that force women to resort to unsafe or illegal abortion procedures. Efforts to integrate safe abortion care into the broader maternal and SRH agenda need to be strengthened along with the provision of quality access.
Structured values-clarification training programs for both healthcare practitioners and managers would contribute to more effective and timeous decision-making. Fiscal resources should be allocated and prioritised to improve the availability and quality of abortion infrastructure and service delivery across all provinces. The government should also ensure that the mandated public health facilities are adequately staffed with trained and willing abortion service providers.
Beyond government measures and efforts, healthcare providers are also obligated to offer compassionate, comprehensive and youth-friendly SRH services. Those working within the healthcare system but who are not abortion providers should also be trained on how to treat women seeking such services. Moreover, policies and guidelines should be expedited to provide systematic guidance on timeous referrals to the relevant facilities.
We need to level the playing field by ensuring equitable access to healthcare for all South Africans. Women and young girls in rural communities and migrants must equally benefit from the policy redress of a post-apartheid, democratic South Africa. While healthcare workers must be enabled and supported in their work through the provision of conducive working environments. It’s time for our policies to translate into action in the corridors of healthcare facilities. Until that is the reality, the work is far from over.
Phumelele Dlamini is the founder of Precious Women’s Reproductive Health Clinic in Durban.