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Women and girls risk unsafe abortions that can lead to serious health complications, and even death, due to persistent barriers to legal abortion services, according to research by Amnesty International and the Women’s Health Research Unit of the School of Public Health and Family Medicine at the University of Cape Town.

The briefing published today highlights how despite South Africa having one of the world’s most progressive legal frameworks for abortion, many women and girls – especially those in the poorest and most marginalized communities – struggle to access safe abortion services. A key barrier is the failure of the government to regulate the practice of ‘conscientious objection’ through which health professionals can refuse to provide abortion services.

“No one, regardless of their social status, should be denied their right to make a decision about their pregnancy. This briefing exposes the deep inequalities in the health system that continue to discriminate against impoverished women and girls,” said Muleya Mwananyanda, Amnesty International’s Deputy Director for Southern Africa.

“The National Department of Health must urgently intervene to ensure women and girls’ access to abortion is no longer at the mercy of health professionals’ personal attitudes.”

Today marks 20 years since the adoption of the Choice on Termination of Pregnancy Act (CTOPA) in the country.

In one case highlighted in the report, a 19-year-old student from Johannesburg died in 2016 following complications from an unsafe abortion. A United Nations representative blamed health system deficiencies, stigma and discrimination as contributing factors in the woman’s death.

Other deaths due to unsafe abortions are harder to document. The briefing highlights the need for disaggregated data on deaths resulting from abortion within the government’s monitoring of pregnancy-related deaths.

It also warns that the implementation of the CTOPA remains inadequate, and could result in violations of the government’s obligations under international human rights law. Under regional and international human rights standards, South Africa has a duty to ensure that conscientious objection does not impact on access to services and that a functioning referral process guarantees timely and appropriate quality care to every person seeking an abortion.

The briefing also highlights the confusion around the limits of conscientious objection and health care professionals’ duties in relation to providing abortion care.

Under the right to Freedom of Conscience in the South African Constitution, health care professionals are understood to have the right to refuse to perform an abortion in certain cases, but never in emergencies, or where the woman or girl’s life is at risk.

The CTOPA further stipulates that any person who prevents or obstructs access to legal abortion services is guilty of an offence, punishable by a fine or imprisonment.

“The lack of clear policy guidelines to service providers creates a vacuum and allows conscientious objection to be applied inconsistently,” said Muleya Mwananyanda.

“A woman’s right to life, health and dignity must always take precedence over the right of a health care professional to exercise conscientious objection to performing an abortion. This is not the reality in South Africa. Regulation and clear policy guidelines are urgently required to correct the current vacuum.”

According to the Department of Health, of the 505 health facilities designated to provide termination of pregnancy services, only 264 currently provide first and second trimester termination services. This results in long distances to facilities and high transport costs. The briefing raises the alarm that a list of the facilities providing safe and legal abortions is not readily available to the public, especially in the context of a plethora of illegal abortion providers advertising in public spaces and online.

Amnesty International is calling on the South African authorities to issue clear guidelines and protocols to all health care professionals and health facility management which clarify the limits of conscientious objection and enforce the ethical duties of health care professionals to prioritize the right of women and girls to access health care. Anyone who exercises their right to conscientious objection must provide accurate information and referrals as well as emergency services when required.

Background

The Choice on Termination of Pregnancy Act (CTOPA) of 1996 came into force on February 1, 1997. The Act gives women and girls the right to have an abortion on request until the 12th week of pregnancy and with certain conditions before the 20th week. The legislation has been credited for advancing women's health and rights.

Abortion related deaths and injuries are estimated to have been reduced by over 90 percent since the CTOPA came into force.

Under international human rights law, South Africa has a duty to ensure that abortion services and information are available, accessible, acceptable and of good quality to all women and girls without discrimination.