An illegal abortion is believed to be the cause of death of 20 year old University Of Johannesburg student, Ayanda Masonda. In SA, 'dodgy 'street doctors' make it easy, but dangerous, to get rid of an unwanted pregnancy.
According to the World Health Organisation (WHO), between 19 and 20 million illegal abortions take place every year. It is estimated that in the region of 68 000 women die due to complications.
A WHO survey on illegal abortions in South Africa showed that although there are legal abortion facilities, women are still turning to unregistered, unsafe abortion facilities.
Why? Who's offering them, and how are they being performed, and is anything being done to clamp down on illegal abortions?
I wanted to find out more, so I called "Dr David", whose details I had found on a poster on the street. I was two months pregnant, I told him, and wanted an abortion.
He told me to meet him the next day at a designated spot, and to bring along R360. He would then take me to the 'clinic'.
I waited for him at the agreed time and place. And waited and waited. I phoned his number several times, but he did not show up. My attempts to get into contact with him again thereafter were futile.
Why women abort
According to the WHO, unplanned and unwanted pregnancies remain the major cause of abortions. It estimates that between 8 - 30 million unplanned pregnancies are the result of inconsistent and incorrect contraceptive use.
Other reasons for the high abortion rate include poor access to family planning facilities, financial difficulties, abandonment, relationship problems with the husband or partner, pregnancy due to rape or incest, and maternal or foetal health risks.
The WHO defines unsafe or illegal abortions as a procedure for terminating an unintended pregnancy carried out either by persons lacking the necessary skills, or in an environment that does not conform to minimal medical standards, or both.
Laila Abbas, spokesperson for Marie Stopes Clinics, says women who turn to illegal service providers "irrespective of age, are all vulnerable, desperate" and may be facing the following circumstances:
fear of rejection
lack of support
not well-informed about their rights
past the 20-week gestation period at which abortions can legally be performed
A survey conducted by the Human Sciences Research Council (HSRC) revealed that nine out of ten South Africans view abortion as wrong, even if a family couldn't afford a child, or if there is a strong chance that the baby could be born with defects. So stigma could be part of what drives pregnant women to backstreet abortionists.
Another theory is based on the results of a 2001 Department of Health (DOH) report, which showed that not all designated facilities perform and delivered Terminations of Pregnancy (TOPs). According to the report, some medical staff said they were "morally" not prepared to provide the service, despite the legislation. There might, therefore, be women struggling to find official facilities at locations that suit them. Midwives claim community attitudes, especially in rural areas, make offering TOP hard for the health workers and for those in need of the service.
Staff attitudes reportedly also make accessing the service difficult especially for teenagers. The DOH National Women's Health status report in 2004 reported that it was extremely difficult for teenagers to access the service as staff members often humiliated them.
"Adolescents are more likely than adults to delay an abortion, resort to the services of unskilled persons who use dangerous methods, and delay seeking care when complications arise," according to Abbas.
The DOH report also found that most women are not aware of the TOP Act.
Who are the abortionists?
According to the WHO, women often self-induce abortions, or obtain clandestine abortions from medical practitioners, paramedical workers or traditional healers.
There is also a breed of abortionist who advertises their services on street corners, or via posters, flyers and even newspapers. The 'doctors' offer safe and pain-free abortions of up to full-term pregnancies. The price tag? It starts at R250.
Abbas explains that there are two methods used: medical and surgical, depending on how far along the pregnancy is. Whichever type of procedure is used, the patient will usually be able to go home the same day.
Medical abortion works in two stages. First the woman is given the drug mifepristone, which blocks a hormone needed to make fertilised eggs stick to the womb lining. After 48 hours, the woman is given a different drug, which triggers contractions and bleeding, and causes the foetus to be expelled from her body.
A medical abortion done after nine weeks of pregnancy is done using the same drugs, but possibly with a heavier dose for the second drug, as expelling of the foetus takes longer.
If a medical abortion is done between 12 and 20 weeks, the attention of a midwife or nurse who has appropriate experience is essential.
Some services offer suction termination up to the 12th week of pregnancy, while others offer it up to the fifteenth week of pregnancy.
Suction termination is carried out with local or general anaesthetic. The entrance to the womb is gently stretched and opened until it is wide enough for the contents of the womb to be removed with a suction tube. A vacuum tube is inserted into the womb of the cervix.
The contents of the womb are sucked through this tube. To facilitate this, there are severeal ways to soften the cervix beforehand, for example by inserting misoprostol into the vagina.
Suction dilation and evacuation (D&E) is used from about 15 weeks. The cervix is dilated (stretched and opened). The foetus is removed in fragments with a suction tube and forceps. General anaesthetic will be needed.
"Any abortion is dangerous if not performed accurately. Most of the illegal operators are opting for the medical procedure and in their opinion it is considered 'safe'. These people are unqualified and they offer both these services, but the methodology adopted is totally incorrect," says Abbas.
Abbas explains that the tablet that they offer is only effective for half of the termination process. This tablet is administered irrespective of the gestational period. The medical pill only opens the cervix allowing for a 'normal' birth process to take place. This pill does not allow the product of conception to detach from the lining nor is it terminated.
"Some abortions are carried out under the 'D&C' (dilatation and curettage) pretext. The equipment used poses a major health risk as well as the method. Too much lining is scraped off often leading to profuse bleeding."
"Many abortions are also carried out using primitive surgical methods: injecting poisonous solutions into the womb or inserting objects intended to dislodge the product of conception," says Abbas.
"There is a higher failure rate with illegal abortions and these are the only ones that come to our attention. We don't know how many others there are. If the termination is not performed properly, chances are that the woman may never conceive again," says Abbas.
Any abortion is dangerous and could have fatal complications. These include profuse bleeding, septicaemia, internal organ damage and tetanus.
Clamping down on illegal abortions
In January 2008 eleven people were arrested in Johannesburg for performing illegal abortions.
Officers found boxes of tablets used to induce labour, a number of used condoms, gloves covered in blood, bloodstains on the floor and panties stained with blood. The building itself was reported to be in a bad condition. Police were still investigating what happened to the foetuses.
The SAPS Journal Online further reports the successful shutting down of two illegal abortion clinics in the Northern Province and in Bloemfontein.
(Leandra Engelbrecht, Health24, updated June 2009)
Abortion rates higher in countries where it is illegal
What women really want
-Laila Abbas, Spokesperson, Marie Stopes Clinic
-Choice on Termination of Pregnancy Act, 1996
-Department of Health. 2005. National Women's Health Status Report 1994-2004
-Department of Health. 2001. Statistical Notes. Termination of Pregnancy
-Department of Health. 2000. An Evaluation of the Implementation of the Choice on Termination of Pregnancy Act. Why are women still having illegal abortions in Gauteng.
-Grimes D, Benson J, Singh S, Romero M, Ganatra B, Okonofua F, Shah I. World Health Organization. October 2006. Unsafe abortion: the preventable pandemic. The Lancet Sexual and Reproductive Health Series.
-Health24. Abortion horror in JHB. January 2008
-Health24. 90% of South Africans against abortion. April 2008
-SAPS Journal Online. Back street abortionists arrested. Police clamp down on illegal abortion clinics in Bloemfontein. www.sapsjournalonline.gov
-World Health Organization. October 2007. Facts on Induced Abortion Worldwide