Assessing The Implementation Of Abortion Services A Review Of Literature And Work-In-Progress

How far are we?
Assessing the
implementation of
abortion services:
A review of literature
and work-in-progress

Research by:
Sanjani Jane Varkey and Sharon Fonn
Women’s Health Project
Department of Community Health
University of Witwatersrand
Published by:
Health Systems Trust : Research Programme
How far are we?
Assessing the implementation of abortion services:
A review of literature and work-in-progress

Published by:
Health Systems Trust : Research Programme
Health Systems Trust
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Funders of the Research Programme:
Department of Health (National)
Department for International Development (UK)
Henry J. Kaizer Family Foundation (USA)
ISBN No. 1-919743-54-5
February 2000
Typeset and Printed by The Press Gang Durban • Tel: (031) 3073240

Acknowledgements
The authors would like to thank:
• Lissette Lugo, for her limitless energy and commitment, during the project stages
of establishing the Research Advisory Committee and conducting the literature
search;
• Nicky Harris for following up universities during the literature search;
• All researchers who gave willingly of their time and insight in interviews;
• Barbara Klugman and Marion Stevens for their input into developing the project’s
methodology;
• Rachel Jewkes and Melanie Pleaner, who responded to the draft with detailed
written comments;
• Those members of the Research Advisory Committee, who gave willingly of their
time and insight;
• Nonhlanhla Makhanya for her supportive role as a key member of Research Advisory
Committee as well as her support in the final writing of this report; and
• Health Systems Trust for financial support.

Executive Summary
This is the first review conducted in South Africa on research addressing the
implementation of the Choice on Termination of Pregnancy Act. A systematic and
detailed methodology was undertaken to identify published and on-going research. Of
the 86 identified studies, 41 were reviewed, 13 were forthcoming studies, three were
published but unavailable, 6 focused on the process of advocacy reform and 23 were
excluded as they did not meet the inclusion criteria. A framework developed for the
review looked service and community factors affecting access of potential and current
abortion service users.
While legalisation for abortion has made services more available, access for specific
groups particularly women from peripheral areas and teenagers remain a problem.
Studies have mainly focused on assessing the service barriers of abortion care, with a
minimal emphasis on understanding and addressing community-related barriers. Within
the various components of quality of care of abortion services, technological advancement
and provider competency have received greater if still a limited focus.
What is therefore required is a need for research to generate solutions for health services
and community on how to: increase equity in access; introduce curriculum into present
training of health personnel, and transform and sustain attitudes of current gate-keepers
of the service in order to institutionalise the delivery of abortion as a routine service at
all levels of health care; provide support for providers and users of the service; increase
information on ones’ own body and health rights; push society’s acceptance of human
rights; increase women’s confidence in themselves; and ensure male responsibility.

Table of content
Introduction 1
What do we know of service factors affecting women’s access to TOP? 5
What do we know of community-based factors that affect women’s access
to TOP? 12
Methodological issues in abortion research 16
What more do we need to know? 17
Conclusions 18
Annotated Bibliography 20
Appendix 1: Members of the Research Advisory Committee 25
Appendix 2: Details of the methodology used in the literature search 26
Appendix 3: Reference for studies on factors leading to the legislative
reform in South Africa 30

How far are we? Assessing the implementation of abortion services: A review of literature and work-in-progress
Introduction
The passing of the Choice on Termination of Pregnancy Act (CTOP) was South Africa’s
tangible expression of a commitment to allow women to attain their right to self-
determination. However, while the removal of legal obstacles to the right to choose
when and if to have children is an essential component, it is not sufficient. Providing
services and ensuring equitable access to services is now the challenge. There has been,
and continue to be, significant action and commitment to making this a reality. The
commissioning of this review of current research to assess the extent of policy
implementation and to inform future research is part of that endeavour.
Methods
Five complimentary processes conducted from April to August 1999 informed the literature
search.
1. Computerised searches of five databases: MEDLINE; POPLINE; SABINET; SOCIAL
SCISEARCH; and HSRC.
2. A manual search on relevant know sources not covered by the computerised databases,
including a journal, four newsletters, five conference proceedings and one research
directory.
3. Contacting South African academic institutions: all universities (faculties covered were:
office on research; obstretics and gynaecology; community health; sociology; nursing;
psychology; philosophy; law; religious studies and social work); three randomly selected
nursing college; and three randomly selected technicons.
4. Contacting additional researchers identified by a Research Advisory Committee (RAC).
A committee comprising relevant individuals in the field of abortion was established to
bring together a pool of expertise, to identify relevant research projects and to comment
on the draft findings of the review. Selection of members aimed to achieve representation
of the different:
• areas in abortion research viz. clinical, policy, health promotion, training, health
systems, rights, and legal;
• levels of service delivery viz. national, provincial, facility and non-government
organisation; and
• research entities.
A list of potential RAC members was generated by Women’s Health Project (WHP), in
consultation with Health Systems Trust. A total of 18 people were invited, of these 14
accepted the invitation. The details of the RAC members are presented in appendix
1.Communication between Women’s Health Project and RAC members were conducted
telephonically.
5. A call for information was put in the Women’s Health News, a newsletter published by
WHP with a circulation of 4500.

Details of the methodology used for the literature search are presented in appendix 2.
86 studies were identified through the above search strategy and were examined either
from their full text or abstracts. Where this was not available, the principal researcher
or student’s supervisor was contacted telephonically. In situations where no written
reports were available, telephonic interviews with researchers were requested. To
eliminate recording biases, transcripts of interviews were sent to the researcher for
their approval. Due to logistical problems with the inter-library loan system, when an
entire thesis was not available, abstracts were requested from researchers, and these
were reviewed.
Studies that meet the following four criteria were included in the review:
a) The study should have been conducted in South Africa, and conducted or published
after 1996;
b) The study should focus on abortions that are requested by clients and not those
initiated by doctors for medical reasons;
c) The publication needed to address implementation of the legislation; and
d) The study had to be methodologically adequate, data based and the conclusions
consistent with the data, as opposed to opinion articles.
23 studies did not fulfil the above mentioned criteria and were excluded. Of these:
• five were opinion articles not contributing towards the promotion of reproductive
rights;
• five did not link findings and conclusions;
• six were legal, theological and philosophical discussions with no explicit focus on
implementation;
• four were on abortions conducted for medical reasons; and
• three had insufficient information on methodology.
Of the remaining 63 studies:
• forty one were further reviewed;
• thirteen were forthcoming studies, i.e. at the conceptual stage or findings were not
available within the time period of the review;
• three completed studies were not available; and
• six presented a retrospective analysis of factors leading to legislation reform. As the
articles on legislative reform fell outside the direct parameters of this review, but
would be essential when understanding the nature of policy advocacy in South
Africa, only their references have been presented in the report.

The report attempts to identify research gaps, by building on the reviewed literature
and through three other processes:
• Managers responsible for implementing the legislation viz. in-charge of women’s
health and primary health care from all the nine provinces, were asked to identify
implementation issues that require research;
• A national planning workshop was conducted with 39 participants. The participants
were provincial MCHW and PHC managers, members of the Parliamentary Health
Portfolio Committee, non-government organisation representatives and researchers;
and
• Lessons from countries engaged in newly passed abortion legislation were reviewed
to identify barriers and tested solutions. This was done by contacting activists in
Guyana and reviewing the recent documentation of Ipas, one of the international
institutions involved in implementing and reviewing abortion policies.
As the promotion of women’s right to choose and the resulting TOP services are
developed for women, the method for assessing delivery is taken from the view point of
service users, both actual and potential. Thus the framework developed for the review
looks at the flip side of delivery, namely access. A paper providing a useful exploration
of factors affecting access to services incorporating the Bruce framework for quality of
care (Timyan et al)a
has been used to develop the framework within which the current
research has been reviewed.
Ensuring access is complex and not sectorally demarcated requiring looking at more
than just health services per se. While the physical provision of services is an essential
prerequisite it is not sufficient, services need to be affordable, appropriate and acceptable
to service users. The supply side of the equation is important and includes organisation
of services, distance barriers, distribution and availability of trained personnel and
affordability of services. The demand side is also important and is often significantly
influenced by issues on the supply side. Service fee becomes a deterrent to use when
clients cannot afford them. Health workers’ attitudes are an obstacle when clients’
perceive disrespect or indifference. In addition, there are other demand-side determinants
specifically those associated with user beliefs, knowledge and practices (Timyan et al).a
Thus the review looks at both the supply side and demand side in the analysis of delivery
of abortion services. The supply side looks at service factors and the demand side explores
community factors, details are presented in the following table.
a Timyan J., Griffry Brechin S.J., Measham D.M. and Ogunleye. Access to care: More than a problem of distance B. In Koblinksy M., Timyan J. and Gay J (eds.)
Access to care: More than a problem of distance. The Health of Women. A global Perspective. Westveiw Press Inc 1993.217-235,

Framework for Analysis
The service factors are presented in section 2 and the community factors are presented
in section 3. The next section (section 4) is not directly related to the framework, but is
critical to research and therefore looks at the methodological issues when studying
abortion. In the presentation of the data where research has been published, the author
and the year of publishing is indicated. Where the reports refer to work in progress, the
author is noted but there is no year of publication. In this way readers can differentiate
between published and unpublished reports. As most of the study designs were
descriptive, where a comparative design was used, it is mentioned in the text. Similarly
as most of the studies were facility-based, when a community-based study was conducted,
it is also specifically mentioned in the text. The details of the reviewed studies are
presented in section 7. References of the forthcoming studies and completed but
unavailable studies are presented in the footnotes.
Service factors Community factors
Service
organisation
a) availability of services
b) availability of trained workers
c) availability of facilities
d) the degree to which women
are involved in planning the
organisation of services
Profile of women using abortion services
Distance
barriers
a) physical distance to services
b) availability of services at the
lowest community level
c) availability of infrastructure to
support access
Information
barriers
a) knowledge of the Act
b) source of information
c) risks, signs and symptoms in
relation to pregnancy and
abortion
d) health rights
Affordability of
services
a) for health sector
b) for users
Women’s self
esteem and
status
a) reasons for unplanned
pregnancy
b) women’s adjustment to
abortion
Quality of
care
a) choice of method
b) provider-client information
exchange
c) provider competence
d) interpersonal relationships
e) constellation of services.
People who
influence access
to abortion
a) providers
b) partners
Socio-cultural factors

0
5 000
10 000
15 000
20 000
25 000
February to
July 1997
August 1997 to
January 1998
February to
July 1998
August 1998 to
January 1999
13 063
16 263
18 995
21 573
Figure 1: Total number of TOPs in South Africa from February 1997 - January 1999
What do we know of service factors affecting
women’s access to TOP?
As presented in the framework for analysis, within the services factors we look at service
organisation, specifically availability of services, availability of trained workers and
facilities, and the degree to which women are involved in planning the organisation of
services. Thereafter we assess distance barriers including physical distance to services,
availability of services at the lowest community level, and availability of infrastructure
to support access such as mechanisms of referral. We then examine affordability of
services for health sector and users. Lastly components of quality of care are assessed
including choice of method, provider-client information exchange, provider competence,
interpersonal relationships, and the constellation of services.
Service organisation
Availability of abortion services
The impact of the previous legislation on creating inaccessible services has been
documented by one national study. This included: a) high numbers of women (44,686
women per year) treated for complications from incomplete abortions; b) high rates of
mortality (37/100 000 live births) and morbidity rates (385 per 100 000 live births)
amongst those treated for incomplete abortions; and c) inaccessible services for young,
black, single women (Rees et al, 1997).
Source: Barometer 1998, Vol.2 (2)
Two years after the passing of the Act, 69 894 TOPs were reported to have been
performed. There has been an steady increase in the numbers of TOPs performed. In
the first six months (February to July 1997) 13 063 TOPs were reported, and this
increased, 16 263 (August 1997 to January 1998), 18 995 (February to July 1998) and
21 573 (August 1998 to January 1999).

Details for TOP reported per province from February 1997 to January 1999 are: Eastern
Cape (5823); Free State (7091); KwaZulu- Natal (6994); Gauteng (34057); Mpumalanga
(3535); Northern Cape (1045); Northern (1446); North West (748); and Western Cape
(9155). Looking at the statistics, Gauteng Province reported the majority of TOPs (49%),
with North West Province registering the lowest (1%). When comparing the number
of reported TOPs against the proportion of the national female population living in
each province, it can be seen that KwaZulu-Natal with the highest female population in
the country (21%) registered 10% of the total TOPs. While Northern Cape Province
with 02% of the national female population, registered 1.5% of TOPs (Barometer 1998
and Barometer).
In one hospital study the increased availability of legal services has led to a significant
reduction of uncomplicated incomplete abortions, although there has been no decrease
in total number of incomplete abortions. The increased number of uncomplicated
incomplete abortions was linked to the possible use of misoprostol by private
practitioners.b
When the availability of second trimester abortions was stopped at this
hospital, it lead to an increase in the number of complicated incomplete abortions
(de Jonge et al, 1999). A national study recently commissioned by the National
Department of Health will document the number of incomplete abortions and the
associated maternal mortality and morbidity.c
Increasing the availability of trained midwives is critical to ensure that women’s needs
are met at primary health care level. This far, 90 midwives have completed the theoretical
training. Of these, 45 have completed the clinical training, with 31 being involved in the
provision of abortion services. Twenty-two physicians have been trained in the MVA
technique to serve as provincial resource persons, who in turn have trained 124 other
physicians.d
Figure 2: Number of TOPs per province February 1997 - January 1999
0
5 000
10 000
15 000
20 000
25 000
30 000
35 000
40 000
E
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5 823 7 091
34 057
6 994
3 535
1 045 1 446 748
9 155
Source: Barometer 1998, Vol.2 (2)
b The use by GPs was also noted by Adhikari, M. Caring for babies who survive an abortion attempt - an ethical dilemma. Letter to the editor. South African
Medical Journal, 88 (5), May 1998.
c Mabote, A. National MCHW directorate. Personal communication. April 1999.
d Gabriel, M. Reproductive Health Research Unit. Personal communication. August 1999.

Figure 3: Number of online and designated TOP Facilities
0
10
20
30
40
50
60
70
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18
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10 10
65
48
13
2
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19
34
Online Facilities Designated Facilities
Source: Barometer 1998, Volume 2(2)
Personal Communicationwith provincial managers September 1999
Regarding health facilities providing TOP and the distribution between urban and rural
areas, of the 248 designated public health facilities 73(28%) are currently providing
services and 99% of these are hospitals. A provincial breakdown of facilities providing
TOP are: Eastern Cape (10); Free State (3); KwaZulu- Natal (6); Gauteng (18);
Mpumalanga (6); Northern Cape (2); Northern (6); North West (7); and Western Cape
(15). There are 138 reported private facilities providing TOP. (Barometer, 1998 and
National dissemination and planning workshope
).
Involvement of users in implementation - No information
Addressing distance barriers to abortion services by:
Meeting needs at primary health care level. Of the facilities providing TOP services,
only two are community health care centres, both located in Gauteng Province
(Barometer, 1998);
Reducing physical distances. Two studies report that women travel long distances to
get to a facility providing TOP. In a Eastern Cape study, 38% of the people had to travel
over 100 kms. to access the service (Bennun); A Free State community-based study
reported that 78% of TOP patients had to travel for about one hour or less to get to the
service. The remaining 24% took as long as four hours. (Engelbrecht et al, 1999).
e Personal communication with provincial managers at the Dissemination and Planning workshop of this review. September, 1999.

Improving mechanisms of referral. In two studies conducted in KwaZulu-Natal and
Western Cape, private practitioners were the main source of referral to access the service
(Adanlawo, 1999, and de Pinho and Morroni).
Increasing access to trained service providers by:
Providing appropriate training. The training of midwives is being undertaken through
a three-year (1998 to 2001) donor-funded national abortion care training programme
(Barometer, 1998). A Northern Cape study reported that plans to incorporate the South
African Nursing College approved curriculum into basic nursing curriculum have so
far not been drawn up (Varkey et al);
Ensuring adequate communication between levels of care. Where referral is the main
method in the Northern Cape, whereby people at the periphery can gain access to trained
staff located more centrally, peripheral staff acted as gate-keepers of the service. This
was either by not providing the results of pregnancy tests or by dissuading women from
having an abortion. As a result users labelled services unhelpful and then presented at
more helpful clinics or providers (Varkey et al).
Providing services that are affordable to clients and the
health sector
Three studies provided cost assessments and a list of factors affecting the cost to treat
incomplete abortion and conduct induced abortions. One pre-CTOP study estimated
that R18.7 million was spent by the Government in 1994 in treating incomplete abortions.
Sharp curettage used in the treatment of incomplete abortions, made the service highly
expensive (Kay et al, 1997). A review of international studies comparing vacuum
aspiration to sharp curettage in induced and incomplete abortions, reported manual
vacuum aspiration (MVA) reduced in-patient load and cost to the health sector, and
decreased levels of major complications (Rees, 1996). One post CTOP study identified
four variables that affect the cost of abortions: gestational age; level of care; length of in-
patient stay and additional use of drugs to induce abortion. If first trimester abortions
are done at secondary level, the costs increase by 26% and if done at tertiary level it
costs 133% more compared to primary level. Similarly if second trimester abortions
were provided at tertiary level, the costs would increase by 89% (de Pinho and Mc
Intyre, 1997).

Improvements in quality of care
Nine studies looked at choice of methods to induce abortion, including a) surgical
induction, b) medical induction and c) drugs for pain relief.
a) A review of 80 international studies compared vacuum aspiration with sharp
curettage in evacuating the uterus in incomplete and induced abortions. It indicated
that vacuum aspiration was more than 98% effective in evacuating the uterus and
that major complications associated with uterine evacuations were substantially lower
for MVA than for sharp curettage (Rees, 1996).
b) When examining possibilities of medical induction, one randomised control trial
comparing misoprostol with placebo, found that 600ug of misoprostol used for
ripening the cervix for first trimester abortions, resulted in a shorter procedure
duration and a procedure which was rated as being more easy by providers. From
ten weeks of gestation, misoprostol provided no additional cervical priming effect
over the physiological process of cervical softening as pregnancy progresses. A
significantly higher level of pre-operative pain was noted in the misoprostol group
in comparison to the placebo group, with no difference in the intra-operative pain
(de Jonge et al).
A second randomised controlled trial comparing placebo and trilostane (an enzyme
inhibitor, which may decrease progesterone production, progesterone being central
to maintain pregnancy) in mid-trimester pregnancy, reported significantly less
induction-to-delivery intervals in the trilostane patients (Tregoning et al). No
information was provided on whether in-patient stay was required after
administering trilostane 48-72 hours prior to misoprostol, as this would influence
costs. A further study was undertaken to assess the efficacy of differing doses of
trilostane.f
There are two forthcoming studies: a randomised controlled trial looking at trilostane
as an outpatient drug for first trimester abortions;g
and an acceptability study of
mifespristone (RU 486) and misoprostol, as a medical abortificant without the need
for surgical intervention or in-patient care.h
c) Three studies looked at the effectiveness and acceptability of pain relief drugs in
the management of incomplete and induced abortions. When combing Fentanyl
with hydroxyzine (Aterax) or midazolam (dormicum) to provide analgesia during
curettage after uncomplicated incomplete abortions, dormicum was found to be
better. Further both hydroxyzine and midazolam were safe as they do not cause
respiratory depression when patient is well resuscitated prior to initiation of
evacuation (de Wet et al, 1997). A randomised control trial looking at the use of
ketorolac and diclofenac in women less than 14 weeks gestation undergoing an
MVA, reported that there was no difference between the two drugs, and that neither
were effective at providing sufficient pain control. One cross sectional study looking
at NSAIDs in uncomplicated incomplete abortions cases undergoing MVA reported
these drugs could not provide adequate pain relief. Age, parity and gravidity did
not affect this outcome (de Jonge et al).
f No information was furnished to Women’s Health Project within the time frames of this review.
g Van der Spuy, Z. Reported as forthcoming in Barometer, September 1997.
h Blanchard, K. Population Council. Personal Communication, 1999.

Provider client information exchange. One forthcoming study in the Northern Cape
study will look at patients’ reporting of what information was given by providers when
requesting an abortion and patients’ opinion on the usefulness of the information (Varkey
et al).i
Eleven studies examined provider competence including a) technical skills, b) knowledge
of the Act and c) attitudes to abortion.
a) One study reported that midwives were competent to use manual vacuum aspiration
(MVA) in evacuating the uterus in uncomplicated incomplete abortions (Jonge et
al 1997). Two studies compared midwives’ clinical ability to estimate gestational
age with ultra sound diagnosis in women requesting TOP (Kalafong TOP unit and
Bamigboye et alj
). The Kalafong study reported that in 81% of patients the clinical
diagnosis of gestational age by midwives was accurate.
b) Two completed and one forthcoming studyi
looked at knowledge of the Act. The
studies reported that most providers’ have a fair knowledge of the Act. A Free State
study reported that 78% of those conducting abortions and 67% of those referring
cases gave correct answers to questions regarding the Act (Engelbrecht et al, 1999).
A KwaZulu-Natal study reported all 25 nurses in the study had heard of the Act
(Harrison et al).
c) Four completedk
and one forthcoming studyh
assessed opinion of providers on
abortion. The studies reported providers to accept abortion under specific
circumstances and to be less open to the idea of minors having free access. Two
studies revealed that less than 8% of nurses and social work students agreed that
‘on request’ was a justifiable reason for women to have TOP (Harrison et al and
van Rooyen, 1996 respectively). A third study reported that of those involved in the
abortion procedure, 56% mentioned on request (Engelbrecht et al, 1999). On the
issue of consent from partners and parents, 81% of those conducting abortions
mentioned that women have sole rights over their bodies and 13% mentioned the
same for minors (Engelbrecht et al, 1999). Ninety four per cent of the social work
students mentioned that minors should be compelled to inform their parents and
88% felt that parental consent should be mandatory (van Rooyen, 1996).
Interpersonal relations were looked at by three completed and one forthcoming study.l
Women who had illegal abortions prior to CTOP complained of negative and judgmental
attitudes of providers of legal services (Maforah et al, 1997). In constrast, since the new
Act was passed, from a community-based Free State study and a Northern Cape study,
providers of TOP services have been well regarded (Engelbrecht et al, 1999 and Varkey
et al). However, in the Northern Cape study women reported that staff directly involved
in providing TOP related to them in a positive way, but other staff (e.g. ward staff,
referring staff) were negative (Varkey et al).
i Varkey, S.J., Fonn, S., Ketlhapile, M. and Tint, K.S. Situational analysis of TOP services in the Northern Cape. The methodology includes key information
interviews with health managers and community representatives, focus group discussions and questionnaires with health workers and community members and
interviews with TOP users. Forthcoming.
j Bamigboye, A.A.; Nikodem, V.C.; Santana, M.A. and Hofmeyr, G.J. Department of Obstetrics and Gynaecology, University of Witwatersrand. Forthcoming.
k One study was completed but was made available after the time period of the review. Shorthall, D. Nurses attitudes to abortion. Department of Clinical
Psychology, University of Cape Town. 1997.
l van Zuydam, E.; Poggenpoel, M. and Myburgh, C.P.H. The study will present women’s description of their interaction with private doctors when being referred
for an abortion. Reproductive Choices. Forthcoming.

Constellation of services included a) the contraceptive usage in TOP patients, b) factors
influencing contraceptive usage, c) prevalence of sexually transmitted infections in TOP
patients and d) availability of counselling services
a) Five studies looking at contraception services found that between 25% - 80% of
women accessing abortion services were not using contraception services (Adanlawo,
1999, Kalafong TOP unit, Dickson-Tetteh et al, Uyirwoth and Chokoe et al,). Of
those using contraceptives, the majority were using the pill (68% - Kalafong TOP
unit and 15% - Chokoe et al) or the injectables (48% - Adanlawo, 1999). Four
studies looking at pre TOP and post TOP contraception usage. They found that
nearly 100% of people expressed their intention to use contraception after the
abortion, with over a third mentioning injectable contraceptive as the method of
choice (Adanlawo, 1999 Dickson-Tetteh et al and Chokoe et al and Kalafong TOP
unit). One study indicated that of the 22% of TOP patients who regarded their
families as complete, 9% choose sterilisation as the post TOP contraceptive method
(Cruywagen et al).
b) Five studies highlighted different quality of care aspects that affect contraceptive
usage including client-provider relationships, level of information and organisation
of services. A KwaZulu-Natal study and a Mpumalanga study reported that people
interviewed felt that family planning services were accessible and client-friendly
(Adanlawo, 1999 and Uyirwoth). A community-based study in the Northern Cape
reported that unplanned pregnancy was due to hostile health services and negative
attitudes to teenage sexuality (Varkey et al). Two other studies attributed unplanned
pregnancy to incorrect information on contraceptive methods (Maforah et al, 1997
and Dickson-Tetteh et al). Three studies reported that between 4%-12% of TOP
users had heard of emergency contraceptives and even fewer could describe it
(Adanlawo, 1999, Uyirwoth and Dickson-Tetteh et al). One study indicated the
separation of contraceptive services from TOP, either by having another health
worker in-charge of contraceptives or having a separate location for contraceptive
services, appears to negatively influence the number of women who left the service
with a contraceptive method (Varkey et al). Another study reported that when the
sterilisation service was organised for the following day, 60 per cent of those who
choose sterilisation went ahead with it. When the service meant being booked after
a scheduled interval, only a fifth of the patients returned for the sterilisation (Kalafong
TOP unit).
c) One study reported that 35% of TOP users had some form of sexually transmitted
infection, and advocated the need to link abortion and STI services (Fernandes et
al).
d) A Northern Cape study noted that on a busy day pre counselling was often skipped
or done as a group event. The decision of whether to provide counselling or not was
at the discretion of the provider (Varkey et al). In a Free State community-based
study, 24% of patients reported having had no pre-counselling service and 56% no
post-counselling service (Engelbrecht et al, 1999).

m South African Demographic and Health Survey. DOH, MRC and MACR. Preliminary report. 1998
What do we know of community-based
factors that affect women’s access to TOP?
Within community factors, first a profile of women using TOP services is provided.
Then informational barriers are assessed including: communities’ knowledge of the Act;
source of information; risks, signs and symptoms in relation to pregnancy and abortion;
and health rights. Given the influence community exerts on women’s lives and decisions,
aspects such as women’s status and reaching people influencing women’s access to
services are examined. Finally socio-cultural factors influencing attitudes to abortion
are assessed.
Profile of women using abortion services
Five case series, two national reports, one national and one hospital study examined a)
user characteristics of TOP services and b) user characteristics of women treated for
incomplete abortion prior to the Act
a) People using TOP services are mainly older (over 18 years from Dickson-Tetteh et
al, Barometer, 1998 and Epidemiological Comments, 1998, or over 20 years from
Adanlawo, 1999, Chokoe et al), single, mutliparous, unemployed, students, and
educated. (Adanlawo, 1999, Chokoe et al, Bennun, Uyirwoth and Dickson-Tetteh
et al, Barometer, 1998 and Epidemiological Comments, 1998).
b) Prior to the Act, women classified as induced cases or treated for incomplete abortions
were young (women under the age of 20 were at greater risk of having offensive
products - Rees et al, 1997) were primiparous, single, and unemployed (Adu, 1996
and Rees et al, 1997).
Prior to the Act as diagnosis was not systematic terms like incomplete or induced were
used interchangeably, making it difficulty to differentiate between voluntary and
involuntary abortions, and hard to correlate. While we can conclude from these studies
and reports that we still don’t know if younger women are getting access, it is evident
that there is limited access for rural women by using education as a proxy measure
Information barriers
Two studies assessing community members’ level of information indicate that knowledge
on the availability of TOP services is higher compared to information on women’s sole
right to consent. In a KwaZulu-Natal community-based study, 94% of rural women
and men had heard of the Act (Harrison et al). A Northern Cape facility and community-
based study amongst peri-urban and urban women and men, 55% had heard abortion is
available on request and 24% heard that parental or partner consent is not required
(Varkey et al). The preliminary report of the South African Demographic and Health
Survey 1998m
indicates that 53% of women were aware that abortions up to 12 weeks
of pregnancy are legal.

Two studies in the Eastern Cape and Northern Cape provinces reported that the majority
(40%) mentioned radio as source of information, and 1% in the Northern Cape study
mentioned the clinic as their source of information (Bennun and Varkey et al).
When looking at information on most likely time of conception and safe termination of
pregnancy, a Northern Cape study indicated that the majority of men and women could
identify later signs of pregnancy and had little knowledge about the most likely time of
conception. Regarding duration of pregnancy up to when an abortion can be done, the
majority (41%) mentioned times between 12 to 20 weeks (Varkey et al). In a national
pre 1996 Act survey, 20% of respondents mentioned any time during the pregnancy
and 5% mentioned up to 6 months (Crother). Studies that looked at the decision making
process of women indicated that, when women recognised their pregnancy, the decision
to abort and present at health services followed immediately. Between 60%-85% of
women knew they were pregnant by about week 8 (KwaZulu-Natal study-Adanlawo,
1999; Free State study-Engelbrecht et al, 1999; Western Cape study-de Pinho and
Morroni; and Gauteng study-Dickson-Tetteh et al). The majority of women presented
to the service by week 10 and 70% had the procedure within a week (KwaZulu-Natal
study-Adanlawo, 1999 and Western Cape study-de Pinho and Morroni).
Three studies examined health rights and indicated limited support for women’s right
to self-determination, even less for younger women. In a KwaZulu-Natal community-
study 18% of respondents expressed support for abortion on request (Harrison et al),
compared to 8% in a Northern Cape study (Varkey et al). From a national pre 1996 Act
survey, of those supporting abortion 15% stated personal choice as justifiable reasons
for an abortion (Crothers). While in a Northern Cape study 60% felt that women should
not require consent from partners, 55% felt that minors should require parental consent
(Varkey et al).
Women’s self esteem and status
Included in this category are community factors that influence unplanned pregnancy
and women’s adjustment to abortion.
One community-based study identified inability to negotiate safer sex as a major cause
of unplanned pregnancy. Younger people expressed difficulties in being able to talk
about their sexuality at home and at health care settings (Varkey et al).
Seven studies identified factors influencing women’s adjustment to an abortion. These
were three community-based studies (Suffla, 1997; McCulloch, 1996; and Rulashe, 1999)
and one facility-based study (Faure, 1999). In addition there is one completedn
and two
forthcoming studies.o p
Studies reported healthy post-abortion adjustment in women
who: held strong views on woman’s right to choose (two studies); had positive beliefs
about their own ability to cope (three studies); had higher education (one study); had
supportive social structures (one study); and were able to talk about their experience
(one study). Factors such as attachment to foetus in women undergoing late trimester
n Pearton, A. Cognitive competence of adolescents to consent to TOP: an ecological perspective. University of Port Elizabeth. Published. Women’s Health Project
was unable to get a copy of thesis, which was required to review the study.
o Sekudu, J. A study exploring the psycho-social implications of TOP on woman. Department of Social Work, University of Pretoria. Forthcoming thesis
p van Zuydam, E.; Poggenpoel, M. and Myburgh, C.P
.H. The study aims to describe the emotional status of teenagers coming for TOP and its impact on teenagers.
Reproductive Choices. Forthcoming.

q Le Routla, D. M. Level of psychological distresses that black adolescence experience prior to inducing abortion. Department of Psychology, MEDUNSA.
Forthcoming thesis
r Lekalakala, K.M. The acceptance of the legal status of abortion and its ramifications on health professionals at Ga-Rankuwa hospital. Department of Nursing,
UNISA. Forthcoming thesis.
abortions (two studies), high trait anxiety (one study), coercion and no support from
partner (one study), and negative social stigma (one study) resulted in negative feelings
after the abortion.
Two completed studies and one forthcomingq
study examined the psychological impact
after first trimester abortions. The completed studies reported low levels of negative
feelings soon after an abortion. The pre and post study indicated that while there were
high levels of state anxiety (anxiety over a specific situation) and moderate to high
levels of depression before the procedure, the levels declined two to three weeks after
the termination. Seven per cent of women reported high levels of depression, 2% reported
high levels of trait anxiety (individual’s proneness to anxiety) and no person reported
high levels of state-anxiety. In 81% of women, the pre-abortion scores of depression
and self-efficacy were able to correctly predict the absence or presence of post-abortion
depression, thus proving to be a good screening tool for clients who may need further
counselling or support (Faure, 1999). One study with women two to six weeks after a
first trimester legal abortion, indicated low percentages of negative post abortion
psychological outcomes (Rulashe, 1999).
People who influence women’s access to TOP
Within this category we have included the influence of a) providers and b) partners.
a) (i) Two studies looked at interventions with health workers on their attitudes to
abortion. Comparing the pre and post-test results from the piloting of the ‘abortion
values clarification workshops’ (VCW), 48% of participants felt that their opinion
or attitudes had changed substantially. The remaining either mentioned ‘somewhat
changed’ (22%), ‘a little changed’ (19%) or ‘no change’ (12%) (Marias, 1996 and
1997). A Free State study and a Northern Cape study indicated that those providing
abortion services required support, due to the negative feed back from their
colleagues (Engelbrecht et al,1999 and Varkey et al). Thus to sustain the momentum
of the once-off VCW initiative, systemic and structural interventions to support
health workers need to be put in place (Klugman et al, 1998). One forthcoming
study will assess the impact of the Act on health workers.r
(ii) In a legal interpretation of the conscience clause that allows individuals to absolve
themselves from getting involved in abortions, one study identified that there is an
overriding responsibility of providers to inform women of their rights and to refer
patients to another provider prepared to do the termination (McQuoid-Mason,
1997).
b) Irrespective of the legal status of abortion, women reported that talking to their
partners about their decision to have an abortion is hard. Two pre-CTOP studies of
women who had illegal abortions, one of which was community-based, reported
that fear of being stigmatised, disapproval and violence had prevented them
disclosing their decision to terminate to their partner and families (Maforah et al,
1997 and Suffla, 1997). From the study with women requesting TOP, 56% mentioned
fear of a negative reaction as the main reason for not telling their partners. Of those
that did disclose, 31% reported a negative reaction (Engelbrecht et al, 1999).

Socio-Cultural factors
Four studies identified factors influencing providers’ attitudes to abortion and two studies
identified characteristics that influenced or did not influence community members’
support for abortion.
Two studies reported religion and one study reported frequency of religious attendance
to affect attitudes to abortion (van Rooyen, 1996, Harrison et al, Marias, 1996 & 97).
Another study argued that gender assumed greater significance, as the rejection by
nurses of abortion was due to their own identification as mothers, nurses and wives,
and the inseparable linkages between these roles (Walker, 1997). In one study, nurses
mentioned that their professional commitment was to save not take away lives and hence
were against abortions (Harrison et al). On the other hand social work students
mentioned that their professional commitment to their patient meant they could
recommend an abortion (van Rooyen, 1996).
In one national survey of attitudes to abortion, support for abortion was steady across
the lower age groups, but falls amongst people above 60 years. Amongst home-owners,
support for abortion was highest and least amongst those in difficult housing
circumstances, and support rose from the uneducated through to the highly educated.
There was no significant difference between men and women on support for abortion,
with slightly higher support amongst non or very infrequent religious service goers
(Crothers). A community-based study also identified no significant difference between
male and female regarding opinion on abortion (Harrison et al).

Methodological issues in abortion research
Two studies looked at methodological issues in abortion research. Everatt and Budlender,
1999 recommended:
a) That dichotomous questions (yes/no) should be avoided as the majority will choose
the negative response
b) Care should be taken during translation as the word abortion in some languages
may not be non-judgmental; and
c) Need to use qualitative methods and find ways of reflecting qualitative nuances in
quantitative form
Jewkes et al, 1997, indicated that categorisation of induced abortion is complex. This
paper looked at comparative methodologies of estimating the proportion of women
presenting to hospitals with incomplete induced abortion. The paper concludes that the
WHO recommended method of categorisation used in a multi-country study of Figa-
Talamancaeta is not the most useful.

What more do we need to know?
The question left is what more needs to be known to implement quality abortion services,
so that the right to self-determination becomes a reality for all South African women.
Going back to the framework on service and community access factors, Table 1 defines
a future research agenda for South Africa.
s Singh, G. Stabroek News, Guyana. July 3, 1999.
Table 1: A research agenda for abortion services
A. Service factors
Increasing a) Identify reasons and solutions for lack of implementation by designated facilities
availability of b) Explore users’ opinion on how abortion services should be organised and
service implemented
c) Collate routine data collected from private and public sector, determine basic and
uniform data requirements and determine usage of information
Increasing access Develop supervision systems and performance indicators in relation to TOP
to personnel
Affordable Assess the social cost of abortions on women and society
services
Improving quality a) Further research into intra and post operative pain and pain relief
of care b) Assess midwives’ skill in conducting MVAs in induced abortion and counselling
c) Examine standards of counselling and contraceptive services. Lack of these
services, four years since legislation in Guyana has resulted in nearly 60% of
abortions being repeat-cases.s
d) Follow up TOP users to assess actual contraceptive usage and barriers
associated with it
e) Identify strategies for integration of abortion services into primary health care
B. Community Factors
Users of service a) What is the extent of unwanted pregnancies being carried to term and what were
barriers to access services?
b) Who are why are women still resort to back street services? What is the role of
general practitioners and health workers in this trade?
Information a) Develop and test effective educational messages, especially for radio
barriers
Women’s self a) Gather clients’ perception on the role of counselling. This along with the
esteem and status conducted research on a screening tool to predict women who require intensive
counselling, could determine what should become part of the counselling service
b) assess psychological impact of second trimester requested abortions
c) investigate the role of social support for women susceptible to post-abortion
depression
People who a) Measure the long-term impact of the ‘values clarification workshops’ on the
influence access implementation of abortion services
b) Develop and test interventions to transform and sustain providers’ attitudes,
including ‘gate-keepers’ of the service
c) Document health workers’ understanding of balancing rights with duties

Conclusions
The commitment displayed by implementers and researchers is significant and obvious.
An assessment of the methodologies used by the studies indicates that the majority of
studies were facility-based using quantitative data collection tools. In addition, very
few studies critically discussed the methodology used, limiting the possibility for a
discussion on the appropriateness of different methodologies. In terms of geographical
location of research projects, most were located in urban areas, with few in rural and
peri-urban areas. There is no known research initiative on abortion services undertaken
in the North West and Northern Provinces, two under resourced provinces of South
Africa.
Research information is spread thin over a wide area of access issues, making it difficult
to draw overall conclusions. The presence of the new abortion Act has made services
more available. However access for specific groups particularly women from peripheral
areas and teenagers continue to be a problem. This is evident from the information that:
users of abortion services are mainly the more educated, have to travel long distances
and use private referral to have an abortion; there are very few health centres providing
abortions; training of health personnel is still being undertaken through donor funded
programmes with plans to incorporate the module into medical and nursing curricula
not yet been drawn; there is a reluctance to provide abortion ‘on request’ and in
acknowledging younger women’s sole right to choose amongst members of society; and
that community members do not have basic information on the fertile period and signs
of pregnancy. Studies that will document reasons for current use of backstreet abortion
will generate further information on barriers to access.
While barriers to access services are both service and community related, a greater
emphasis has been invested in the service-dimension of abortion care. Given that women’s
self esteem, women’s status in society and support from men, play a critical role in
adjusting to an abortion, the lack of attention paid to developing interventions that
would build supportive structures for women and build women’s confidence in themselves
is perturbing. Within studies that examined the quality of health care, technological
advancement and provider competency has received greater if still limited focus.
• Although internationally MVA by itself has proven to be most cost-effective, the
majority of studies have nonetheless looked at combining medical and surgical
methods. This raises questions of whether the research agenda is being driven with
an aim of increasing access and sustainability or by other interests.
• Midwives can to some extent clinically estimate gestational age of pregnancy and
health workers have a fair knowledge of the Act. While health workers seem to be
technically competent, they are less open to abortion on ‘request’, minors’ sole right
to consent, the involvement of their colleagues in providing this service and at times
serve as gate-keepers to the service.
• Studies looking at the constellation of services mainly focused on contraceptive
usage. They report a range of 25-80% of women not using contraceptives prior to
the abortion and nearly 100% of women expressing their intention to use a post-

TOP contraceptive, with injectable being the main method of choice. Within this
research little attention was given to providing appropriate linkages between abortion
and other services, such that it maintains good quality care, increase demand and
use of contraceptive methods, be acceptable to users and providers, and reduce
opportunities to prevent future unplanned pregnancies.
• Very little is known about inter-personal relationships and provider-client
information exchange.
What is therefore required is a need for research to generate solutions for health
services and community on how to: increase equity in access; introduce curriculum
into present training of health personnel and transform and sustain attitudes of
current gate-keepers of the service, in order to institutionalise the delivery of abortion
as a routine service at all levels of health care; provide support for providers and
users of the service; increase information on ones’ own body and health rights; push
society’s acceptance of human rights; increase women’s confidence in themselves;
and ensure male responsibility.

Annotated Bibliography
Adanlawo, M. (1999) Demography and social profile of women requesting termination of pregnancy
(TOP) in King Edward VIII hospital (KEH). Department of Obstetrics and Gynaecology,
University of Natal. pp.1-19. 400 women attending TOP from May to August 1998 were
interviewed using a standarised questionnaire.
Adu, S.S. (1996) Bio-social profile of women with incomplete abortions in Ga-Rankuwa hospital,
Medunsa,RSA. Central African Journal of Medicine 42, 198-202. 355 patients with a history
of period of amenorrhoea and bleeding per vagina were interviewed (131 of induced cases
and 224 of spontaneous cases). The study was carried out in 1993.
Bennun, M. Developing socio-economic profiles of women requesting terminations at Cecilia Makiwane
hospital in the Eastern Cape Province. Department of Obstetrics and Gynaecology, East
London Hospital. 1477 women requesting TOP between October 1997 and April 1998
were interviewed.
Barometer. (1998) Braam, T., (Ed.) Volume 2(2). Reproductive Rights Alliance. pp.3-4. National statistics
from February 1997 to July 1998.
Chokoe, C.J.M.D., Towobola, O.A., Makhathini, V.B. and Sekonde, F.F. Elective TOP in the first and
second trimester (A five month review). Department of Obstetrics and Gynaecology,
MEDUNSA/Ga-Rankuwa hospital. pp.1-25. Record review of 949 women requesting TOP
between February to June 1997.
Crothers, C. Attitudes to abortion in South Africa. University of Natal.
Cruywagen, T., Poggenpoel, M. and Myburgh, C.P.H. (1999) The incidence of abortion amongst couple
who have completed their families and sterilization as contraceptive method. Presented at
the 1999 Reproductive Health Priorities Conference, South Africa. Review of private patient
records in Gauteng (N=200).
de Jonge, E.T.M., Funk, M., de Wet, G.H., Venter, C.P. and Pattison, R.C. (1997) An assessment of a
non-steroidal anti-inflammatory drug (diclofenac) as analgesic for patients undergoing
manual vacuum aspiration after incomplete abortion. South African Medical Journal 87,
816-818. 137 uncomplicated incomplete abortion patients at the Kalafong hospital, Pretoria
were intramuscularly administered 75mg diclofenac 30 minutes prior to procedure. 0.05
mg/kg midazolam, administered intravenously, was part of the rescue protocol. Clinicians
and patients rated pain on different four-level scales, immediately after the procedure and
before discharge, respectively. An audit of patients returning with late complications of
MVA was kept. The study was conducted in 1995.
de Jonge, E.T.M., Pattison, R.C. and Mantel, G.C. (1999) Termination of pregnancy in South Africa in
its first year: Is TOP getting on top of the problem of unsafe abortions? Sexual and
Reproductive Heallth Bulletin 7, 14-15. Two time periods, (1 February 1996 to 31 January
1997 with 1 February 1997 to 31 January 1998) were compared using the Kalafong hospital
records. Results were compared across three terms, with 4 months in each term.
de Jonge, E.T.M., Jewkes, R., Levin, J., Rees, H. Randomised controlled trial of the efficacy of misoprostol
as a cervical ripening agent prior to termination of pregnancy in the first trimester.
Forthcoming. A double blind, randomised, placebo-controlled with 273 women at the
Kalafong hospital. 600ug misoprostol was self-administered vaginally 2-4 hours prior to
MVA. Study conducted between July and October 1998. Forthcoming SAMJ.
de Pinho, H. and Morroni, C. Assessing the accessibility of TOP services in the Cape Metropolitan
region. Presented at the 1998 Reproductive Health Priorities Conference, South Africa.
147 women requesting TOP at a tertiary and 4 secondary hospitals were administered
semi-structured questionnaires.

de Pinho, H. and McIntyre, Di. (1997) Cost analysis of abortions preformed in the public health sector.
Department of Community Health, University of Cape Town. pp.1-33. Used a modified
Delphi technique with 10 key informants to obtain consensus on a management protocol.
Based on the protocol, identified, quantified and estimated cost of resources. Western Cape
data was used to obtain a monetary value for resources.
de Wet, G.H., de Jonge, E.T.M., Venter, C.P., Pattinson, R.C. and Makin, J.D. (1997) Systemic analgesia
for curettage of the uterine cavity in patient with an incomplete abortion. South African
Medical Journal 87, 1459. 100 patients eligible for outpatient curettage at the Kalafong
hospital were randomised assigned to receive fentanyl 1.5 ug/kg intravenously followed
either midazolam titrated against the consciousness level of the patient to a maximum dosage
of 5 mg, or hydroxyine 1.5 mg/kg intravenously.
Dickson-Tetten, K., Beksinska, M., Nkala, B. and Rees, H. Factors that contribute to a woman’s decision
to seek a termination of pregnancy. Presented at the 1997 Reproductive Health Priorities
Conference. 200 women who requested a TOP between August and October 1997, at the
Chris Hani Baragwanath hospital and Chialewo health center, Gauteng Province were
administered a questionnaire by a research-nurse.
Engelbrecht, M., Pelser, A., Ngwena, C., van Rensburg, D. and Heunis, C. (1999) A project management
strategy to overcome impediments to the operation of the Choice on termination of pregnancy
Act of 1996 in the Free State: Findings from the survey. Centre for Health Systems Research
and Development. University of the Orange Free State. pp.1-77. From the 3 state hospitals
providing TOP in Free State province, 16 self-administered questionnaires were collected
from staff providing abortions (67% response rate) and 63 staff who were in a position to
refer TOP patients (public and private). Interviews at a place convenient to 75 women
who requested TOP were conducted.
Epidemiological Comments. (1998) Department of Health. 24, pp.2-9. National statistics from February
1997 to February 1998, complied from provincial monthly reports.
Everatt, D. and Budlender, D. (1999) How many for and how many against? Private and public opinion
on abortion. Agenda 40, 101-105.
Faure, S.C. (1999) Anxiety, depression and self-efficacy in women undergoing first trimester abortion.
Department of Psychology, University of Stellenbosch. pp.1-33. 76 women requesting FTA
from two secondary hospitals and one private clinic, in Western Cape Province were
recruited during an 8-week study period in 1998. Three measuring instruments were
administered an hour prior to the procedure: biographical questionnaire; the State-trait
anxiety inventory (STAI) and the Beck Depression Inventory (BDI). 43 (54%) who
returned for a medical check up after approximately 3 weeks were administered the STAI
and the BDI.
Fawcus, S., McIntyre, J., Jewkes, R., Rees, H., Katzenellenbogen, J., Shabodien, R., Lombard, C.,
Truter, H. and The national abortion reference group (1997) Management of incomplete
abortions at South African public hospitals. South African Medical Journal 87, 438-442.
Methodology same as Rees, 1997.
Fernandes, L., Mahomed, M.F., Mazibuko, D.M. and Hoosen, A.A. Sexually transmitted pathogens in
women attending for termination of pregnancy. Geneeskunde 40, A series of tests were
conducted on 128 consecutive women requesting TOP at Ga-Rankuwa hospital.
Funk, M., Pistorius, L.R. and Pattison, R.C. (1996) Manual Vacuum Aspiration in the Management of
incomplete abortion. Sexual and Reproductive Health Bulletin 2, 4-5.

Harrison, A., Montgomery, E.T., Lurie, M. and Wilkinson, D. Barriers to implementing South Africa’s s
Termination of Pregnancy Act: A case study from rural KwaZulu/Natal province. Centre
for Epidemiological Research in South Africa (CERSA)Hlabisa, Medical Research Council,
South Africa. Draft. A self-administered structured questionnaire was filled by 18 nurses
(response rate = 72%) on duty in the maternity ward of a district hospital. In-depth interviews
with 9 nurses were conducted. The community survey was part of a larger project on STD
and RH, conducted in one rural district. Two areas were represented, one close to a major
highway and the other more remote. A random stratified sampling technique was used to
select respondents (n=138, males=24, females=114). In-depth interviews were conducted
with 9 women.
Jewkes, R., Fawcus, S., Rees, H., Lombard, C. and Katzenellenbogen, J. (1997) Methodological issues
in the South African incomplete abortion study. Studies in Family Planning 28, 228-234.
Kay, B.J., Katzenellenbogen, J., Fawcus, S. and Karim, S.A. (1997) An analysis of the cost of incomplete
abortion to the public health sector in South Africa- 1994. South African Medical Journal
87, 442-447. The design involved a cost analysis with two modified Delphi panels, the first
panel consisted of 15 selected senior obstetrician/gynecologists and the second of 11 selected
nurses in charge of acute gynaecology wards, representing the different hospital levels in 7
provinces. The first panelists developed three symptom severity categories, by responding
to five developed scenarios. The second panel provided information on hospital resources,
through a written pre-tested questionnaire. Unit-cost schedules of the Department of
Planning, Groote Schuur hospital were used. Hospitalisation costs (excluding those
mentioned by the second panelists) were estimated from a sample of 7 hospitals.
Klugman, B., Stevens, M., van den Heever, A. and Federl, M. (1998) Maternal Health. In: Anonymous
Sexual and reproductive rights, health policies and programming in South Africa 1994-
1998, pp. 60-69. Women’s Health Project, University of Witwatersrand. Review all the
sexual and reproductive rights health policies and programming in South Africa over 1994
to 1999. The section on TOP has been included.
Maforah, F., Wood, K. and Jewkes, R. (1997) Backstreet abortion: women’s experiences. Curationis 20,
79-82. 6 large urban hospitals, from 4 different provinces (Gauteng, WC, EC, KZN) were
purposively chosen. In-depth semi-structured interviews were conducted with 25 women,
admitted with complications of induced abortion. Recruitment was based on information
obtained for another study (Rees, H. et al, 1997).
Marias, T. (1996) Provisional overall results from values clarification workshops pilot study. Planned
Parenthood Association, Cape Town. pp. 1-31. A pre and post-test abortion-attitude
questionnaire was administered to the 110 participants during the pilot initiative.
Marias, T. (1997) Abortion values clarification workshops for doctors and nurses. HST Update Issue 21,
pp. 6-7.
Matambo, J.A., Moodley, J. and Chigumadzi, P. (1999) Analgesia for termination of pregnancy:
Diclofenac or Ketorolac? O&G Forum 13-16. 220 women (>14 weeks) requesting TOP
were randomly distributed into two groups, one receiving 75 mg Diclofenac and the other
30 mg Ketorolac. 600 ug misoprostol was inserted per vagina, followed by 400 ug after 8
hours. Intra muscular analgesia was given 45 minutes prior to procedure. Pain was assessed
by clinicians using visual analogue scores.
McCulloch, U.R. (1996) Women’s experience of abortion in South Africa. Department of Psychology,
University of Cape Town. pp.1-90. 12 volunteers (students and staff) of the University of
Cape Town were interviewed using a semi-structured guide.

McQuoid-Mason, D.J. (1997) State doctors, freedom of conscience and termination of pregnancy. The
Human Rights and Constitutional Law Journal of Southern Africa 1, 15-17. To explore
and interpret the conflict between the rights to access reproductive health care and to make
decisions concerning reproduction v/s freedom of conscience, both embodied in the
Constitution.
Rees, H. (1996) Manual vacuum aspiration-an appropriate technology in abortion management. Sexual
and Reproductive Heallth Bulletin 2, 2-3. In a review of 80 studies conducted internationally
involving more than 500 000 women.
Rees, H., Katzenellenbogen, J., Shabodien, R., Jewkes, R., Fawcus, S., McIntyre, J., Lombard, C.,
Truter, H. and The national abortion reference group (1997). The epidemiology of incomplete
abortion in South Africa. South African Medical Journal 87, 432-437. A cross-sectional
using a stratified (non-proportional) random sampling design was used. N= 61 hospitals.
The sample included all hospital with > 800 beds, and randomly selected smaller hospitals,
stratified by province. All women presenting with either spontaneous or induced incomplete
abortions, at any hospital wards, and under 22 weeks’ gestation, were included. Health
personnel filled a standardised data captured sheet. Field workers conducted a validation
study in 6 randomly selected hospitals. For data analysis, three clinical severity categories
were developed. The study was conducted in 1994.
Rulashe, L. (1999) The psycho-social dimensions of abortion amongst Xhosa speaking women. Faculty
of Health Sciences, University of Port Elizabeth. pp. xii -xiii & 101-110. 55 Xhosa speaking
women from Port Elizabeth were interviewed within two to six weeks after the termination.
Suffla, S. (1997) Experiences of induced abortion amongst a group of South African women. South
African Journal of Psychology 27, 214-222. Five black women who had an induced abortion
within a period of three months of the study were contacted. An open-ended interview was
conducted at a location convenient to women. Each individual respondent verified the
finding.
TOP unit, Kalafong Hospital Clinical versus ultrasound estimation of gestational age: the effects of safety
on TOP services. Department of Obstetrics and Gynaecology, University of Pretoria.
Unpublished. Review of hospital records of 531 patients attending TOP from 1 February
to 31 May 1997.
TOP unit, Kalafong Hospital To evaluate patients contraceptive behaviour after a TOP. Department of
Obstetrics and Gynaecology, University of Pretoria. Unpublished. A mutli-operator
comparative study, (sample would be part of groups, the clinical assessment and the
ultrasound groups). Study evaluators were blinded to the ultrasound findings. Data was
collected from 8 trained midwives examining 300 consecutive women requesting TOP.
Tregoning, S.K., Zinn, P.M., van der Spuy, Z.M (1999) Inhibition of progesterone secretion as an
interceptive strategy. Department of Obstetrics and Gynaecology, University of Cape Town.
Unpublished. 48 women presenting for TOP over 13 weeks gestational, were randomly
assigned to the trilostane or placebo group, which was administered 48-72 hours prior to
administration of misoprostol.
Uyirwoth, G. Rising to the challenge of service delivery. Bethal Hospital. 244 successive TOP clients
were interviewed at admission and before discharge, during a three-month period.
Van Rooyen, C.A.J. (1998) Abortion: A study of final-year social work students’ responses to abortion-
related issues. Social Work 34, 295-306. Using the survey approach and purposive sampling,
70 students (31 from University of Natal and 39 from University of Zululand) were
administered questionnaires, achieving a 100% percent response rate. The study was
conducted in 1996.

Varkey, S.J., Fonn, S., Ketlhapile, M. and Tint, K.S. Nearly three years since the abortion legislation
reform: Assessing awareness of and opinion on the Choice of Termination of Pregnancy
Act (work in progress). Presented at the 1999 Reproductive Health Priorities Conference,
South Africa. The study was conducted in two regions of the Northern Cape Province, in
April 1999. 67 questionnaires were administered to women (50) and men (17), at the health
facility. 12 focus group discussion with 148 participants {teenage girl (n= 50), teenage boys
(n= 34), adult women (n= 42) and adult men (n= 22). A further 196 questionnaires and 2
focus groups with community members will be conducted.
Varkey, S.J., Fonn, S., Ketlhapile, M. and Tint, K.S. Perception & Information on conception & prevention
of Pregnancy (work in progress). Presented at the 1999 Reproductive Health Priorities
Conference, South Africa. Same as above.
Walker, L. (1997) My work if to help the woman who wants to have a child, not the woman who wants
to have an abortion: Discourses of patriarchy and power amongst African nurses in South
Africa. African Studies 55, 43-67. 27 nurses were interviewed. Some interactions with clients
were also observed. An analytical framework by Deborah Posel was used to analyse the
urban African gender relations.

Appendix 1: Members of the Research Advisory Committee
S. No. Name Organisation Experience
1 Rachel Jewkes Centre for Epidemiological Research in Research (policy)
South Africa, Medial Research Council
2 Helen de Pinho Women’s Health Research Unit, Department of Research
Community Health, University of Cape Town (system and policy)
3 Kim Dickson-Tetteh Reproductive Health Research Unit, Department Research and
of Obstetrics and Gynaecology, implementation
University of Witwatersrand (training & monitoring)
4 Melanie Pleaner Planned Parenthood Association - SA Implementation
(training)
5 Tersia Crywagen Reproductive Choices Implementation
(service provision)
6 Eric de Jonge Department of Obstetrics and Gynaecology, Research (clinical)
University of Pretoria
7 Tamara Braam Tshwaranang Legal Advocacy Centre Monitoring
(editor of Barometer)
9 Michelle Engelbrecht Centre for Health Systems Research and Research (system)
Development, University of the Free State
10 Cathi Albertyn Centre of Applied Legal Studies Research (legal)
11 Aletta Thupane Kimberley Hospital, Department of Health Implementation
(service facility manager)
12 Alinah Mabote National MCHW, Department of Health Implementation
(national)
13 Liz Dartnall National Health Sytems Research, Research Research (national)
Co-ordination and Epidemiology,
Department of Health
14 Ester Snyman KwaZulu-Natal, Department of Health Implementation
(programme manager)
Invited to be part of the Research Advisory Committee, but were not available
1 Denise Ackerman University of Western Cape Women’s Rights and
theologian
2 Agatha Zwane Chiawelo clinic, Gauteng Implementation
(service provision)
3 Thabo Magoba Theologian and
psychologist
4 Mpho Leshabana National Primary Health Care Network Implementation
(service provision)

Appendix 2: Details of methodology used in the literature search
2a. A Computerised search on five relevant data bases was conducted
I. MEDLINE: A clinical and medical database maintained by the US National Library of Medicine.
Keywords used: abortion and South Africa; termination of pregnancy and South Africa; TOP and
South Africa; CTOP and South Africa; abortifacient and South Africa. Years - 1996 to 1999
POPLINE: A database maintained by JHU, which features population and family planning articles.
Keywords used: abortion and South Africa; termination of pregnancy and South Africa; TOP and
South Africa; CTOP and South Africa; abortifacient and South Africa. Years - 1990 to 1999
SABINET:
Keywords used: abortion; termination of pregnancy; TOP; Choice on Termination of Pregnancy
Act; Misoprostol; Cytotec.
Years - 1996 to 1999
II. SOCIAL SCISEARCH: Catalogues social science research articles from all over the world
Keywords used: abortion; termination of pregnancy; TOP; CTOP; termination of pregnancy Act.
Years - 1996 to 1998
III. HSRC: Catalogues all current and completed research projects conducted at universities
Keywords used: abortion; termination of pregnancy; TOP; CTOP;abortifacient.
Years: 1996 to 1998
2b. A manual search on other sources not covered by the computerised databases was conducted
A manual search was conducted on one journal, four newsletters, five conference proceedings and
one research directory
I. Journal: Curationis. Issues covered included
1996: March Vol 19 No. 1; June Vol 19 No. 2, September Vol 19 No. 3
1997: March Vol 20 No. 1; September Vol 20 No. 3; December Vol 20 No. 4
1998: March Vol 21 No. 1; September Vol 21 No. 3; December Vol 21 No. 4
II. Newsletters
a) Sexual and Reproductive Health Bulletin - Planned Parenthood Association South Africa. All
issues since 1997?
b) DENOSA Nursing News. 1998 vol 22 No. 3 (March) to No. 11 (Nov)
c) Update- Health System Trust. Included all issues since September 1998 to March 1999
d) Barometer- Reproductive Rights Alliance. Included all issues since the start of the publication
in 1997
e) Women’s Health News and Views- Women’s Health Project. Searched all issues since 1996

III. Conferences
a) PAFMACH, 1996
b) Reproductive Health Priorities Conference, 1997 and 1998
c) Sociology Association of South Africa, 1998
d) Epidemiology Association of South Africa, 1998
e) Health System Trust Conference, 1998
IV. Health Systems Trust Research Directory, 1997
2c. Contacted South African academic institutions (universities, nursing colleges and technicons)
1. All universities were telephonically contacted to assess if any research had been or is being conducted
by staff and student, in any of the faculties. Where available, the central body overseeing research
was first contacted, followed by contacting specficied departments. If no such central body was
avaiable, then relevant departments from the faculties of medicine and humanities were contacted.
This included the departments of Obstrectics and Gynaecology, Community Health, Nursing,
Psychology, Sociology, Theology or Philosophy. Every person contacted through this process was
asked if they knew of other abortion research initiatives.
a) University of Witwatersrand
• Research Ethics Committee of the Humanities and Medical faculties
• Head of the Department of Obstretic and Gynaecology, Baragawanth Hospital
• Reproductive Health Research Unit, Department of Obstretic and Gynaecology
• Department of Paediatrics and Child Health
b) University of CapeTown
• Office of the Deputy Vice Chancellor for Research (staff and student)
• Head of Department of Obstretic and Gynaecology, Grootse Schuure Hospital
• Women’s Health Research Unit, Department of Community Health
• University web site dated until 1997
c) University of Durban Westville
• Research Department (staff and student)
• Law faculty
d) University of Natal
• Department of the Deputy of Research and Development Portfolio and Administration
(staff and student)
• Department of Obstretic and Gynaecology
e) University of Free State
• University web site for past three years
• Department of Obstretic and Gynaecology
• Department of Community Health

f) University of Western Cape
• Office of the Dean of Research (staff and student)
• Centre for student counselling
• Department of Theology
• Department of Sociology
g) University of Stellenbosch
• Department of Social Science Research
• Department of Psychology
• Staff working on the nexus data system
h) Rand Afrikaans University
• Department of Biblical and Religious studies
• Department of Nursing Science
• Department of Philosophy
i) University of Port Elizabeth
• Department of Educational Psychology
• Department of Postgraduate studies and education research
j) MEDUNSA
• Head of Department, Research, (staff and student)
• Department of Psychology
• Department of Obstretics and Gynaecology
k) University of South Africa
• Department of Advanced Nursing Science
• Department of Philosophy
l) University of Pretoria
• Office on Research
• Department of Social Work
m) University of the North
• Department of Theology
n) University of Zululand

o) Department of Department of Philosophy, University of Transkei
p) Office on research, Potchefstroom University
q) Department of Industrial Communication, Potchefstroom University for Christian Higher
Education
r) Department of Nursing Science, University of Fort Hare
s) Department of Professional Education, VISTA University
t) Office on Research, Rhodes University
u) Office on research, Venda University
v) Office on research, North West University
II. From the list of all South African nursing colleges, three provinces were randomly selected, followed
by randomly selecting one college each from the three provinces.
a) Principal of Anne Lasky College - Gauteng Province;
b) Principal of Hendrietta Stockdale Nursing college - Northern Cape Province; and
c) Acting Vice-Principal of Excelsius Nursing College - North West Province.
III. From the list of all South African technicons, three provinces were randomly selected, followed by
selecting one technicon from each of the three provinces.
a) Registrar’s office at Cape Technicon - Western Cape Province ;
b) Executive Officer of the Research Committee at Technicon KwaZulu-Natal - KwaZulu Natal
Province; and
c) Directors’ office at Technicon Southern Africa- Gauteng Province.
2d. Additional researchers identified by RAC members were contacted
I. Max Bennun from Cecilia Makiwane Hospital, Eastern Cape
II. G Uyirwoth from Bethal Hospital, Mpumalanga
III. Morishna Govender from Kimberly Hospital, Northern Cape
IV. Contacted gender and law experts through the GRALE email group. This is a discussion group
interested in gender and law issues, co-ordinated by the Law, Race and Gender Unit at University
of Cape Town.

Appendix 3: Reference for studies looking at factors leading to
the legislative reform in South Africa
1. Albertyn, C. Goldblatt, B. Hassim, S. Mbatha, L. and Meintjes, S. Engendering the Political Agenda.
A South African case study. United Nations International Institute of Research and Training for the
advancement of Women Dominican Republic. July 1999.
2. Klugman, B. Empowering women through the policy process: the making of health policy in South
Africa. In Presser, H. and Sen, G. (eds.), Publication of conference papers from the seminar on
female empowerment and demographic processes: moving beyond Cairo. Oxford University Press.
Forthcoming.
3. Stevens, M. Factors impacting on the development of a pregnancy termination Bill. Faculty of
Management, University of Witwatersrand. 1998.
4. Sarkins, J. In the South African Human Rights Year Book 1996 Volume 7 (115-137). Centre for
Socio-Legal Studies, Durban. 1998.
5. Reproductive Rights Alliance. Documentation of the passage of the Choice on Termination of
Pregnancy Act in SA, in order to share strategies for legal reform with other countries. Forthcoming.
6. Reproductive Rights Alliance. Documentation of the process and outcomes of the oversight hearing
on CTOP. This hearing is planned for mid-2000 and aims to assess the implementation of the Act
and to review the legislation, if required. Forthcoming.

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