In 2009, Alicia (name changed), a 34-year-old mother of three and originally from Cape Town, was visiting a friend in Mpumalanga when she realised she was pregnant. Unaware of where to go, she saw an abortion advert in the classified section of the paper and phoned the provider. The price for the service was R1, 500. Unable to pay the full amount, Alicia negotiated to pay R500 [$45"> up front.

‘I was told to go to a sign stop and to describe what I was wearing. Someone then led me to an office building in town. Inside was a dark room with a sole, bare mattress lying on the floor. He walked to the corner, lifted a mat from underneath the table and removed a small, white envelope.’

From there, Alicia explains how the ‘doctor’ placed one pill in her mouth and the other inside her vagina. She would start to feel pain and then start to bleed - a sign that the abortion was happening, the ‘doctor’ instructed.

Alicia went home and waited. After five hours, she began to feel abdominal pains, but there was no presence of blood. Starting to worry, Alicia called the doctor who refused to offer any support and simply told her to be patient. Only a few hours later, Alicia was found by her boyfriend, surrounded in a pool of blood. She was rushed to the hospital.

‘I could tell the doctors were suspicious of my situation. But I lied and told them I took painkillers and had a miscarriage, I didn’t want to admit to the truth’.

The fake doctor phoned a couple days later, demanding his outstanding money. When Alicia told him she was unable to pay because she was at the hospital, ‘he just hung up and I never heard from him again.’

LIFE AND DEATH

South Africa has been affirmed for its progressive laws relating to women’s reproductive health. After the transition to democracy, sections of the newly drafted Bill of Rights became the cornerstone for woman’s reproductive freedom, stating that everyone has the right to reproductive health care and bodily integrity.

In 1994, the government enacted a progressive legislation, the Choice on Termination of Pregnancy Act, which allows all women, irrespective of age, race and nationality, to access termination services in state facilities. Within the first 12 weeks of pregnancy, a woman is granted an abortion on the basis of choice.

From week 13 to 20, an abortion may only be authorized if the pregnancy would: risk the woman’s physical or mental health; cause the foetus a physical or mental abnormality; affect the social or economic conditions of the woman; or if the pregnancy resulted from rape or incest.

In short, the Act placed South Africa as one of the few African countries to legalise abortion and provide post-abortion care. And since the Act, the number of legal, state-performed abortions has increased. According to the Department of Health (DoH), 500,000 abortions have taken place since 2004.

However, despite the laws and its subsequent rights, the Act has been faced with controversy and resistance and many suggest its implementation has been inadequate.

At the state level, though services are free of charge, they are often not readily accessible. Similarly, women face harassment and stigma, largely influenced by the social norms and beliefs surrounding abortion in the country.

The country respects an individual’s beliefs (and through interpretation of the Bill of Rights) will allow health care providers to object to performing an abortion on grounds of conscience.

Objections, resistance and scrutiny in addition to structural challenges, has meant that very few facilities end up offering legal and safe abortion services at all.

CONTOURS OF LEGALITY

A 2009 government survey found that only 25% of registered community health centres were actually offering the service to women.

‘The context in South Africa is unique because we’re in a country where abortion is legal, but the perceptions and stigma are similar to countries where abortion is illegal and criminalised,’ adds Sally-Jean Shackleton, Director at the Sex Workers Education and Advocacy Taskforce (SWEAT).

As an alternative to state and public hospitals, women can use registered and approved service providers, like Marie Stopes, South Africa’s largest non-profit provider of quality sexual and reproductive healthcare services. However, unlike free-of-charge state facilities, abortion services at Marie Stopes come at quite a high cost: at R1,300 [$118"> to R3,200 [$290">.

The combination of barriers can ultimately push women to use illegal services. In 2010, the South African Medical Research Council stated that 50% of abortions undertaken by girls (aged 13-19) were performed outside of a hospital or clinic. A similar study found that South African women under 20 were 3 times more likely to go to a hospital with an incomplete abortion.

The presence and gravity of illegal abortions has become a global concern, leading the World Health Organization to advocate against the use of unsafe abortion and defining it 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.

BEWARE: RISKS AHEAD

Risks and complications can arise from illegal abortions, including haemorrhaging and septicaemia, a condition that occurs when bacteria enters the uterus. Both conditions can be fatal if not treated immediately. Depending on the method, women may also face perforation and damage to other internal organs.

Though women may be aware of the risks involved, the discreet nature of backstreet abortions addresses a woman’s concern for privacy and confidentiality. A further selling point is that they are shockingly easy to access.

‘The fact that it is illegal makes it very difficult for us to know the extent in which these abortions are performed in the country,’ adds Joe Maila, Ministerial Spokesperson for the Department of Health. Similarly, the South African Police Service does not keep a record of illegal abortion providers, so the extent to which these providers function is unclear.

Figures of illegal abortion activity may be hard to quantify, but the abundance of flyers and advertisements may be the best indicator to suggest the magnitude of activity occurring in South Africa. The prices for an illegal abortion vary and are at the discretion of the individual. Prices can range from R500 to R2,500.

Marijke Alblas, a Dutch doctor who has been performing abortions in South Africa for over 20 years, notes that fake abortion websites may often cite wrong or inaccurate information. For example, one website claims that the abortion pill could be taken for up to ‘7 months of pregnancy’. The ‘pill’ referred to is Misoprostol and can only be administered up to 5 months of pregnancy. ‘Officially, the pill should only be taken at home for up to 9 weeks,’ says Dr. Alblas ‘when the pregnancy is more advanced, the risk of bleeding increases, which is why the woman has to be admitted.’

WHO PAYS THE PRICE?

While Maila says that there is an ‘explosion of illegal abortionists in South Africa,’ the discussion of who is responsible for apprehending these illegal providers, and shutting down their activity, remains unclear.

Flyers plastered in public areas are managed by the Advertising Standards Authority. While the ASA does not have specific rulings on abortion, the organisation can evaluate the charges against clauses of illegal advertisements or illegal activities. A staff member from ASA explains, 'if someone make a complaint about an abortion flier that alleges that the doctor is not real, we contact the person and ask for medical authenticity.’

Though the agency is in charge of removing the illegal abortion pamphlets, their efforts stop there. They emphasise that it is up to the ‘concerned members of the community to contact the police.’

The Police Service pursues an investigation once a case is reported, though sufficient evidence is needed to link the person to the adverts. Sufficient evidence may require interviews and statements from potential witnesses. But according to Lieutenant General Solomon Makgale of SAPS, reports of illegal abortions are few.

But many experts say that cases may not even reach that point of an investigation, because very few girls and women file a complaint. ‘There is a distrust to report incidents to the police because girls may feel that they would be badly treated for seeking out these services in the first place,’ Shackleton explains.

Similar apprehension to police involvement was echoed by Zarina (a former staff member at MOSAIC). She explains how the clinic would often support women who suffer complications from backstreet abortions. The clinic tried to pursue the matters legally, but was often unsuccessful, as the police did not make an effort to apprehend or charge the illegal provider. ‘Eventually, the police said they could not do anything,’ Zarina explains ‘because the woman was an adult and gave the ‘Doctor’ permission to perform the operation.’

WHO WATCHES THE WATCHERS?

Since abortion is legal in the country, both public and private health care providers can offer the service, explains Joe Maila. Though the service is said to be widely available in both public and private health facilities, the Department of Health does not keep a database of all the legal health care providers offering termination services in the country.

Maila urges women to not trust websites and online sources and rather go to a physical hospital or clinic. Illegal abortion providers capitalize on a woman’s lack of knowledge and pressure to secure a service that is quick and maintains her privacy and confidentiality. However, despite abortion being legal, many women are unaware of their rights under the Act and due to stigma and cultural and social beliefs, many may be given false or inaccurate information.

According to a report in the Reproductive Health journal, 30% of South African women believe that abortion is still illegal in the country.

* Research for this article was funded by the Forum for African Investigative Reporters (FAIR).

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