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Medical abortion: the possibilities for introduction in the public sector in South Africa.



Abstract: Medical abortion medical abortion Obstetrics An elective nonoperative abortion effected in the 1st trimester by abortifacients. See Abortion.  is safe and effective and has been approved for use in early termination of pregnancy termination of pregnancy Induced abortion. See Abortion.  in South Africa South Africa, Afrikaans Suid-Afrika, officially Republic of South Africa, republic (2005 est. pop. 44,344,000), 471,442 sq mi (1,221,037 sq km), S Africa.  since 2001. The Department of Health is currently considering its introduction in the public health sector. The attitudes of women seeking abortion and of health care providers towards medical abortion have not previously been described. Data were derived from a quantitative survey of 673 women attending abortion services in the provinces of Gauteng, Mpumalanga and the Western Cape The Western Cape is a province in the south west of South Africa. The capital is Cape Town. Prior to 1994, the region that now forms the Western Cape was part of the huge (and now defunct) Cape Province. . In-depth interviews in Soweto and Cape Town Cape Town or Capetown, city (1991 pop. 854,616), legislative capital of South Africa and capital of Western Cape, a port on the Atlantic Ocean. It was the capital of Cape Province before that province's subdivision in 1994.  were conducted with 20 public health doctors, nurses, a social worker and facility managers, and in Cape Town with four provincial policymakers. Although medical abortion was not yet being offered, 21% of women interviewed were early enough in pregnancy (eight weeks or less) to be eligible for medical abortion. Access to health facilities, including those for abortion, was reasonable for urban women but more limited for rural women. Rural women also incurred greater travel costs to reach a facility. Most women thought medical abortion would be acceptable and would have been willing to try it, had it been available. Policymakers and providers were supportive, as they felt medical abortion could relieve the burden on current services. How to increase access to abortion services in rural areas needs to be addressed.

Keywords: medical abortion, women's eligibility, public health sector, acceptability, South Africa

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Resume

L'avortement medicamenteux est sur et efficace et son utilisation a ete approuvee pour l'interruption precoce de grossesse en Afrique du Sud en 2001. Le Departement de la sante envisage en·vis·age  
tr.v. en·vis·aged, en·vis·ag·ing, en·vis·ag·es
1. To conceive an image or a picture of, especially as a future possibility: envisaged a world at peace.

2.
 son introduction dans le secteur de la sante publique. Les attitudes des femmes souhaitant avorter et des prestataires de soins de sante a l'egard de l'avortement medicamenteux n'ont jamais ete decrites. Les donnees proviennent d'une enquete quantitative aupres de 673 femmes s'etant rendues dans les centres d'avortement des provinces du Gauteng, du Mpumalanga et du Cap-Occidental. Des entrefiens ont ete realises a Soweto et au Cap avec 20 medecins de sante publique, des infirmieres, un travailleur social et des directeurs de centres, et au Cap avec quatre responsables provinciaux. Bien que l'avortement medicamenteux he soit pas encore propose, 21% des femmes interrogees pouvaient y pretendre (huitieme semaine de grossesse ou moins). L'acces aux centres de sante, y compus ceux pour l'avortement, etait satisfaisant pour les femmes urbaines, mais plus limite pour les rurales, ll etait egalement plus onereux pour les femmes rurales de se rendre dans un centre. La plupart des femmes pensaient que l'avortement medicamenteux etait acceptable et auraient voulu l'essayer, s'il avait ete disponible. Les decideurs et les praticiens les soutenaient, car ils pensaient que l'avortement medicamenteux pouvait alleger la charge des services actuels. 11 faut etudier comment elargir l'acces aux services d'avortement dans les zones rurales.

Resumen

El aborto con medicamentos es seguro y eficaz. En 2001 fue aprobado para la interrupcion temprana del embarazo en Sudafrica, donde el Departamento de Salud esta pensando realizar su lanzamiento en el sector de salud publica. Nunca antes se habian descrito las actitudes de las mujeres y de los prestadores de servicios de salud hacia el aborto con medicamentos. Se recolectaron datos por medio de una encuesta cuantitativa entre 673 mujeres que recibieron servicios de aborto en las provincias de Gauteng, Mpumalanga y el Cabo Occidental. En Soweto y Ciudad Cabo se realizaron entrevistas a profundidad con 20 medicos, enfermeras, una trabajadora social y gerentes de salud publica, y en Cape Town con cuatro cuat·ro  
n. pl. cuat·ros
A small guitarlike instrument of Latin America, usually having four or five pairs of strings.



[Spanish, from Latin quattuor, four; see quatrain.]
 formuladores de politicas provinciales. Aunque aun no se estaba ofreciendo el aborto con medicamentos, el 21% de las mujeres entrevistadas eran elegibles para este, ya que tenian una gestacion de ocho semanas o menos. El acceso a los establecimientos de salud era razonable para las mujeres urbanas pero mas limitado para las rurales, quienes incurrieron en mayores gastos de viaje para llegar a ellos. El aborto con medicamentos fue aceptado por la mayoria de las mujeres, quienes habrian estado dispuestas a intentarlo si hubiera estado disponible. Los formuladores de politicas y los proveedores brindaron su apoyo, ya que creian que el aborto con medicamentos podria aliviar la carga de los servicios actuales. Se debe pensar en como ampliar el acceso a los servicios de aborto en las zonas rurales.

MEDICAL abortion (sometimes referred to as medication abortion), using a regimen of mifepristone Mifepristone Definition

Mifepristone is a pill that can be taken as an alternative to a surgical abortion.
Purpose

This medication most often is used for ending early pregnancies.
 and misoprostol has been shown to be a safe, effective and acceptable alternative to surgical abortion in many countries. (1-3)

In South Africa, the 1996 Choice on Termination of Pregnancy (CTOP) Act and its amendments in 2004 are ground-breaking in their intention to provide better access to free abortion services, particularly for poor black women. The law allows for termination on request for pregnancies of 12 weeks or less, provided by a certified nurse practitioner nurse practitioner
n. Abbr. NP
A registered nurse with special training for providing primary health care, including many tasks customarily performed by a physician.
 or doctor. Pregnancies of 13-20 weeks may be terminated by a doctor when continuation of the pregnancy poses a risk to the woman's social, economic or psychological well-being psychological well-being Research A nebulous legislative term intended to ensure that certain categories of lab animals, especially primates, don't 'go nuts' as a result of experimental design or conditions . (4) The National Department of Health (5) designates all abortion facilities in South Africa. However, the provision of abortion services has been restricted by a lack of facilities and shortages of trained health care providers providing abortions. (6) As a result, abortion services are overstretched o·ver·stretch  
v. o·ver·stretched, o·ver·stretch·ing, o·ver·stretch·es

v.tr.
1. To stretch excessively; overstrain.

2. To stretch or extend over.

v.intr.
.

First trimester Noun 1. first trimester - time period extending from the first day of the last menstrual period through 12 weeks of gestation
trimester - a period of three months; especially one of the three three-month periods into which human pregnancy is divided
 abortion is provided at primary care level mainly by nurse practitioners. Second trimester Noun 1. second trimester - time period extending from the 13th to the 27th week of gestation
trimester - a period of three months; especially one of the three three-month periods into which human pregnancy is divided
 abortion is provided at secondary and tertiary levels by physicians. Medical abortion could theoretically be offered by certified nurses in primary care clinics provided that emergency backup services are available for any complications. Nurses at primary care level could also provide surgical abortion backup using manual vacuum aspiration vacuum aspiration
n.
A method of abortion performed during the first trimester, in which the contents of the uterus are withdrawn through a narrow tube. Also called suction curettage, vacuum curettage.
 (MVA MVA
abbr.
motor vehicle accident


MVA Motor vehicular/vehicle accident, see there
) in the small number of medical abortions that fail.

Providing medical abortion as an alternative to surgical services has a number of advantages. Some women may prefer medical to surgical abortion to avoid instrumentation of the uterus. Medical abortion could also potentially increase access in settings where providers are reluctant to provide surgical abortion services. Health care workers may be less opposed to a method of abortion that they do not have to initiate. Medical methods may require less staff input. Provision of medical abortion could increase women's options and broaden access to abortion services. (3,7)

Medical abortion with 200mg mifepristone orally and 800mcg misoprostol vaginally may he used up to nine weeks of pregnancy at home or in the clinic in the first trimester, and using a different regimen, at the clinic in the second trimester of pregnancy. (7) In 2001 the South African Medicines Control Council approved a regimen of 600mg mifepristone and 400mcg misoprostol orally for medical abortions up to eight weeks of pregnancy. This drug regimen is not available at pharmacies but has been increasingly provided by designated private sector physicans and NGOs since 2002. However, data on provision and use is not yet available (Margaret Hoffman, Mediteam Trust, personal communication, 17 August 2005).

The National Department of Health is considering the introduction of medical abortion in the public health sector and the CTOP Amendment Bill of 2003 included medical abortion provision. (7) There have been concerns that women attend abortion services too late in their pregnancies to qualify for early medical abortion and that having to return for repeat visits may dissuade TO DISSUADE, crim. law. To induce a person not to do an act.
     2. To dissuade a witness from giving evidence against a person indicted, is an indictable offence at common law. Hawk. B. 1, c. 2 1, s. 1 5.
 them from choosing the medical option. Further, ultrasound may be needed to determine the length of pregnancy, and the high cost of a 600mg dose of mifepristone, the dosage that was approved, * are additional concerns in a low-resource setting like South Africa.

The attitudes of women seeking abortion and of health care providers towards medical abortion have not previously been described. This paper reports on research that evaluated whether a significant proportion of women seeking abortion in public sector services would be early enough in pregnancy to be eligible for medical abortion. We also investigated the hypothetical acceptability of medical abortion among women, policymakers and providers and whether women would attend for follow-up. The results on the accuracy of clinician clinician /cli·ni·cian/ (kli-nish´in) an expert clinical physician and teacher.

cli·ni·cian
n.
 assessment of length of pregnancy without ultrasound, which was also part of the study, will be reported elsewhere.

Methods

Between November 2001 and March 2002, a prospective cross-sectional survey was conducted among women attending a convenience sample of abortion services at eight facilities in three provinces in South Africa. These were Chiawelo, a primary health care facility in urban Soweto, Gauteng; two primary health care services, two secondary hospitals and two tertiary care tertiary care Managed care The most specialized health care, administered to Pts with complex diseases who may require high-risk pharmacologic regimens, surgical procedures, or high-cost high-tech resources; TC is provided in 'tertiary care centers', often  hospitals in urban Cape Town in the Western Cape; and Philadelphia Hospital, a secondary hospital serving a primarily rural population in Mpumalanga. They are the main facilities providing first trimester abortion in these geographical areas. In the Western Cape, additional secondary and tertiary hospitals were included where women obtain first trimester abortions and where a fuller perspective of health care providers' attitudes and the availability of emergency obstetric care could be obtained. All facilities serve a predominantly low socio-economic population and were similar in the type of services and counselling provided. All have facilities on site or nearby that can deal with any emergency or complication that arises.

In each facility, trained interviewers conducted face-to-face interviews lasting 20-30 minutes with women attending abortion services, using a standardised questionnaire in the woman's home language. Women were interviewed while waiting for care and therefore did not lose their places in the queue. Information collected included demographic characteristics such as age, intimate partner status, education, employment and geographical location in relation to the facility; and reproductive history reproductive history Obstetrics A set of 4 numbers that may be used to define a woman's obstetric Hx–eg, 4-3-2-1, would mean 4 term infants delivered, 3 preterm infants, 2 abortions, 1 child currently living  such as parity, gravidity gravidity Obstetrics The state of being, or having been, pregnant. Cf Gravity.  and prior contraceptive use. Information on seeking abortion was also collected, including time from knowledge of pregnancy to first contact with the health service and details of the woman's decision to have an abortion. Participants were given a description of medical abortion and were asked about their attitudes towards and their perceived willingness to have a medical abortion. They were not offered and did not use the method. All women had an ultrasound examination Ultrasound examination
A medical test in which high frequency sound waves are directed at a particular internal area of the body. As the sound waves are reflected by internal structures, a computer uses the data to construct an image of the structures.
. With the exception of one of the tertiary facilities in Cape Town (n=239) and Philadelphia Hospital, the women also had a clinical examination to determine the length of their pregnancy. This was in order to compare the women's and clinicians' estimates to the ultrasound measurements.

Women attending for first trimester abortion were asked if they were interested in participating in a study on attitudes towards medical abortion. Most women who participated had come to schedule an abortion and may have visited a facility earlier to have their pregnancy confirmed. Data from 673 women were included. In Soweto, all women (n=272) who were approached to join the study agreed but due to time constraints only, 36% of all those presenting for first trimester abortion were interviewed. In Cape Town, 328 women were approached and 287 agreed and were included. There were 29 (10%) refusals and 12 (4%) were excluded post-interview either because the ultrasound showed they were not pregnant or due to insufficient data. At Philadelphia Hospital, all women (n=114) approached agreed to an interview.

Twenty individual in-depth interviews (four in Soweto, 16 in Cape Town) were conducted with public health service providers, equally divided between doctors and nurses performing and not performing abortions, a social worker and facility managers. In Cape Town, in-depth interviews were conducted with four provincial policymakers. Their views on the delivery of abortion services and medical abortion were recorded. Interviews were tape-recorded, transcribed and translated where necessary.

Written informed consent was obtained from all participants. Data were kept confidential and only a study identification number was used. Institutional ethical approval was obtained from the ethics review committees of the Population Council, the University of the Witwatersrand Due to the 1959 Extension of University Education Act the school was only allowed to register a small number of black students for most of the apartheid era, even though several notable black anti-apartheid leaders graduated from the university. , the University of Cape Town Coordinates:
“UCT” redirects here. For other uses, see UCT (disambiguation).
 and Mpumalanga Province.

For quantitative data, percentages were calculated for categorical That which is unqualified or unconditional.

A categorical imperative is a rule, command, or moral obligation that is absolutely and universally binding.

Categorical is also used to describe programs limited to or designed for certain classes of people.
 variables, and means for continuous variables. Bivariate bi·var·i·ate  
adj.
Mathematics Having two variables: bivariate binomial distribution.

Adj. 1.
 analysis was conducted to examine associations between selected variables of interest. We used a grounded theory approach to analyse the qualitative data.

Results

Demographic characteristics

The mean age of women attending the abortion services was 25 years (range 15-44). Just over half (55%) had a regular partner, but were not living with that partner. Thirty-two per cent had completed high school. Approximately 10% had tertiary education Tertiary education, also referred to as third-stage, third level education, or higher education, is the educational level following the completion of a school providing a secondary education, such as a high school, secondary school, or gymnasium. . Forty-one per cent were unemployed.

At the Philadelphia rural site, 31% were teenagers compared with 18% in the urban sites. A higher percentage of rural women did not live with their regular partner (67%). They were more likely to report being a student or scholar (40%) than women at the urban sites (24%). Women in Cape Town (24%) had the lowest rates of unemployment (Soweto 50%, Philadelphia 33%) and were more likely to report being employed full-time (30%) than women in the other sites (Soweto 3%, Philadelphia 4%), and had higher levels of tertiary education (18% vs. 8%).

Reproductive history

Almost all the women in the study (95%) said they knew the date of their last menstrual period last menstrual period Gynecology The most recent time that a ♀ notes menstruation, a datum recorded in a chart during a routine gynecologic visit. See Menstruation.  (LMP LMP left mentoposterior (position of fetus); last menstrual period.

LMP
abbr.
last menstrual period


LMP Last menstrual period, see there
). Just over half (51%) reported knowing when they were likely to have become pregnant although this figure varied considerably by site (Soweto and Cape Town 27%, Mpumalanga 51%). A minority, the same proportion in all sites (36%), reported knowing the exact date they were likely to have become pregnant.

One third reported that they had one living child. This figure was slightly higher among rural women (43%) than in Cape Town (30%). Almost the same percentage (32%) reported no living children, and 21% reported two living children.

The majority of women across all sites reported contraceptive use at some time in their lives (84%). Of these, 65% reported ever-use of injectable in·ject·a·ble
adj.
Capable of being injected. Used of a drug.

n.
A drug or medicine that can be injected.
 contraceptives. One third (31%) had ever used oral contraceptive pills, and one quarter (26%) had ever used condoms. A lower proportion of rural women (75%) reported ever-use of contraceptives. Very few rural women (1%) reported ever-use of condoms in contrast to almost 40% in Cape Town and 21% in Soweto.

Overall, 35% of participants had heard of emergency contraception Emergency Contraception Definition

Emergency contraception or emergency birth control uses either emergency contraceptive pills (ECPs) or a Copper-T intrauterine device (IUD) to help prevent pregnancy following unprotected vaginal intercourse.
. Only 8% of women at Philadelphia knew about emergency contraception, compared to 52% in Cape Town and 27% in Soweto. Of these, 24% had used it. Women with high school education were more likely to have heard of emergency contraception (37%) compared with 8% of those with primary or no schooling, but the trend did not continue for those with tertiary education. Only 6% of all the women reported a previous termination of pregnancy.

Thirty-six per cent of women reported having been using a contraceptive method Noun 1. contraceptive method - birth control by the use of devices (diaphragm or intrauterine device or condom) or drugs or surgery
contraception

birth control, birth prevention, family planning - limiting the number of children born
 when they conceived. A majority (54%) in the rural site reported using a method compared to 28% in the urban areas. Of those reporting contraceptive use, 54% reported using an injectable contraceptive. The largest proportion reported contraceptive failure while using the oral contraceptive pill (54%), followed by condoms at the urban sites (11%) and injectable contraception (26%) at the rural site. The most common reason (36%) for all method failure was that they forgot or chose not to use the method or used it inconsistently.

Abortion seeking and access to services

Seventy-six per cent of women reported that more than one week elapsed e·lapse  
intr.v. e·lapsed, e·laps·ing, e·laps·es
To slip by; pass: Weeks elapsed before we could start renovating.

n.
 between the time they knew they were pregnant and seeking advice about an abortion. Of these, 46% said they waited because they were not sure they were pregnant, 10% because they were undecided about having an abortion, 11% due to partner or family opposition and 7% for financial reasons. Financial concerns were the second most common (20%) reason for delaying for rural women. Four times the proportion of rural women (13%) compared to urban women (3%) delayed seeking an abortion due to insufficient information on abortion and abortion services. Twenty-one per cent did not discuss their decision to have an abortion with anyone; 33% talked with a husband, boyfriend or partner, and 25% with a family member.

As shown in Table 1, most women (58%) and especially urban women (64%) travelled [less than or equal to] 10 km to reach health facilities. Travel distances were longer for rural women: 66% travelled >10 km and 16% travelled >50 km to reach the facility. Most women (79%) used public transport to reach the clinic, with the majority (77%) reaching the clinic in <1 hour. While access was good for urban women (86% travelling <1 hour), the majority of rural women (59%) travelled for > 1 hour. Eighty-one per cent of women spent [less than or equal to] 10 Rands (approximately US$1.25) to reach the clinic. Rural women paid substantially more for transport.

In Cape Town and Philadelphia, 45% and 24% of women respectively had their abortions within a week of first contact with a health facility and the majority (86% in Cape Town, 91% in Philadelphia) within four weeks. The data for Soweto were not comparable, as on analysis it was clear that the question was understood differently.

Using ultrasound examination, the average duration of pregnancy was approximately 11 weeks, with rural women presenting slightly later. Twenty-one per cent of women presented at [less than or equal to] 8 weeks of pregnancy (the cut-off for medical abortion eligibility based on the MCC-approved label for mifepristone), with a slightly lower proportion of rural women (16%).

Women's opinions of medical abortion

Women overwhelmingly supported the theoretical notion of medical abortion. A greater proportion of urban women (98% in Soweto, 74% in Cape Town) reported interest in trying medical abortion than rural women (67%). Eighty-six per cent of the women who were eligible for medical abortion based on the length of their pregnancy expressed interest.

Attitudes of service providers, managers and policymakers towards medical abortion

Many service providers and policymakers raised general issues around barriers to accessing abortion services. These included there being too few facilities offering abortion, lack of sufficient staff to provide services, lack of theatre time or facilities available, lack of support and/or incentives for staff doing abortions, negative attitudes on the part of other health centre staff, inadequate referrals to abortion services at first contact and problems of confidentiality within the health care system. Service providers and policymakers also cited barriers such as lack of knowledge of the law, lack of information on where to access services, lack of knowledge about signs and symptoms of pregnancy, social stigma Social stigma is severe social disapproval of personal characteristics or beliefs that are against cultural norms. Social stigma often leads to marginalization.

Examples of existing or historic social stigmas can be physical or mental disabilities and disorders, as well as
 associated with abortion and negative attitudes towards abortion on the part of families, communities and service providers.

Policymakers and providers expressed generally favourable attitudes toward medical abortion. They felt it could offer an additional abortion method, and that some women would find the less invasive procedure Invasive procedure may refer to:
  • "Invasive Procedures" (DS9 episode), the fourth episode of the second season of the television series Star Trek: Deep Space Nine
  • Invasive Procedures (novel), a 2007 novel by Orson Scott Card and Aaron Johnston
 and their ability to control the process appealing. They also thought it might place less of a load on health service personnel and be easier from a conscience point of view.

"Well, it is so much simpler .. women can get the pills and take it at home and everything is finished. She does not need to keep on coming back, it is more private ... you do not [need] to have any invasive procedure, absolutely, if I had a choice, if I was in need of that, I would go for it. It is also much simpler on the provision of the service because people do not have to initiate anything because the woman takes the pills herself. The onus is on her. She must answer to God, if that is her view, for what she is doing, not the service provider." (Policymaker)

"... if medical termination of pregnancy can be made to be successful it actually decreases the workload on the staff. That reduces the stress ... and makes people more willing to help, I think ... if there are fewer evacuations of uteri ... we will also be able to reduce things like blood transfusion blood transfusion, transfer of blood from one person to another, or from one animal to another of the same species. Transfusions are performed to replace a substantial loss of blood and as supportive treatment in certain diseases and blood disorders.  requirements, hopefully reducing the number of complications from cases like perforated per·fo·ra·ted
adj.
Pierced with one or more holes.
 uteri. You should be able to [choose] a less invasive procedure ... also the idea of encouraging people to present early." (Health care provider)

Discussion

Women in the study seeking an abortion were younger (47% under 25 years) than the general female population (30% under 25 years) of reproductive age. (8) The higher educational status of women attending abortion services than in the general population (24%) (8) may indicate that more educated and younger women have better knowledge of the law and access to services or are more likely to seek an abortion with an unintended pregnancy. Better educated women in developing countries may exercise reproductive choices more successfully. Improved employment opportunities can create more favourable perceptions of their life chances, leading to greater incentives to delay childbearing. (9, 10)

Women in South Africa experience high rates of teenage and unintended pregnancy, with 35% reporting pregnancies by age 19, and 56% unplanned or unwanted pregnancies. (8) The high proportion of teenagers in this study seeking abortion and the data on non-use or ineffective use of contraception provides opportunities for interventions on several levels. Similar to other South African studies African studies (also known as Africana studies) is the study of Africa, and can encompass such fields as social and economic development, politics, history, culture, sociology, anthropology or linguistics. A specialist in African studies is referred to as an Africanist. , (11,12) awareness of emergency contraception appeared to be higher in the cities, while very few rural women seeking abortion knew about emergency contraception. There is an urgent need to promote awareness of emergency contraception, both in a general sense, and as part of contraceptive and post-abortion counselling in order to reduce the high rates of unintended pregnancy.

Given the escalating HIV HIV (Human Immunodeficiency Virus), either of two closely related retroviruses that invade T-helper lymphocytes and are responsible for AIDS. There are two types of HIV: HIV-1 and HIV-2. HIV-1 is responsible for the vast majority of AIDS in the United States.  epidemic in South Africa, with a public sector antenatal an·te·na·tal
adj.
See prenatal.



antenatal

before parturition. Called also prenatal, antepartal.
 prevalence of 29% in 2004 and approximately 20% of the population living with HIV, (13) the low reported condom 1. condom - The protective plastic bag that accompanies 3.5-inch microfloppy diskettes. Rarely, also used of (paper) disk envelopes. Unlike the write protect tab, the condom (when left on) not only impedes the practice of SEX but has also been shown to have a high failure  use is alarming and underscores the need for urgent and vigorous promotion of dual protection for young women who wish to avoid pregnancy and yet are at risk of STI STI systolic time intervals.  and HIV infection from unprotected intercourse.

There is a general perception that women attend abortion services late in pregnancy, i.e. after 12 weeks of pregnancy. In this study, a fifth of women came to the clinic at [less than or equal to] 8 weeks of pregnancy. This indicates that a significant proportion of women would potentially be eligible for early medical abortion.

Legal provisions making access to safe abortion easier since 1997 are generally having a positive impact on urban women's lives. However, this study has confirmed that rural women face more barriers in accessing health facilities, impeding access to abortion. Rural women delayed contacting a health facility to confirm their pregnancy, often travelled a long distance to health facilities and incurred high costs in reaching a facility to schedule their abortion, and needed to return subsequently for the abortion itself. Despite public sector health care being flee, transport costs to reach facilities for rural women are prohibitive.

These factors could also impact on access to medical abortion. Although medical abortion could be initiated immediately upon the woman reaching a facility, two clinic visits are required, one for counselling and provision of the medications and another approximately two weeks later for confirmation of complete abortion.

The higher educational and employment levels of women in Cape Town may reflect easier access to information and services for them; there is likely a need for more information for other women. Rural women were more likely to have inadequate information about abortion services. Poorer health service access for rural women is systemic and not confined con·fine  
v. con·fined, con·fin·ing, con·fines

v.tr.
1. To keep within bounds; restrict: Please confine your remarks to the issues at hand. See Synonyms at limit.
 to medical abortion or abortion access. A general strengthening of health services health services Managed care The benefits covered under a health contract  is therefore needed, to ensure that rural women have better access to contraceptive information and reproductive health Within the framework of WHO's definition of health[1] as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, reproductive health, or sexual health/hygiene  services.

The findings highlight the continued stigma of abortion, evidenced by the fact that almost a quarter of women did not discuss their decision to have an abortion with anyone else. It is of concern that many women with unintended pregnancies have less than adequate social support. South Africa is the only country to have passed a new and progressive law on abortion since the ICPD ICPD International Conference on Population and Development
ICPD Institute for Counselling and Personal Development (Northern Ireland)
ICPD Institute for Conflict Management Peace and Development
ICPD International Conference on the Prevention of Dementia
 that explicitly allows women to obtain legal and safe abortion in terms of their individual beliefs. (14) Nevertheless, discrimination and stigmatisation of women seeking abortion is indicative of the inequitable gender burden borne by women in a society that remains deeply patriarchal and impedes abortion access.

Although abortion is legal, the low percentage of women reporting a previous abortion should be treated with caution. It is likely to be an underestimate, as women may have felt uncomfortable disclosing a previous abortion, anticipating negative reactions from providers.

There are a number of limitations to this study. Firstly, the use of a convenience sample of facilities means that this data may not be representative of all abortion services or women seeking abortion. Therefore the results may not be generalisable to other services in the country. However, both rural and urban facilities were included, as were facilities offering different levels of care in three provinces, providing abortion for the full range of pregnancy lengths. This provides some confidence in the reliability of the data. Secondly, women in this study did not receive medical abortion. While women and health care providers expressed a strong interest in medical abortion being provided in public sector services, conclusions cannot be drawn from this research about what will happen with actual use. Finally, although we used standardised data collection instruments and a common protocol at all sites, we cannot rule out differences in the administration of the instruments or interpretation of the questions that might have an impact on the data.

Conclusion

This study provides additional information on the factors impeding access to abortion services and contraception for a population of South African women. In addition, the study lays to rest a number of concerns regarding medical abortion and its appropriateness for introduction in the public health sector in low resource settings, adding to the evidence base for informed decisions to be made. Now that the World Health Organization has included a regimen of 200mg mifepristone plus 800mcg of misoprostol on the Essential Medicines List, (15) the dose of 600mg of mifepristone approved by the Medicines Control Council in 2002 needs to be lowered to 200mg, as it is a primary factor in the cost-effectiveness of medical abortion. Provision by well-trained certified nurses at primary health care level, as is common practice anyway in South Africa for first trimester surgical abortion, can make it an affordable additional abortion option in the public health sector. (16)

The finding that a reasonably large group of women could potentially use medical abortion through public sector abortion services is contrary to the belief that South African women do not attend services early enough to benefit from this method. Medical abortion would therefore increase women's abortion options and possibly improve access to abortion services. Further operations research operations research

Application of scientific methods to management and administration of military, government, commercial, and industrial systems. It began during World War II in Britain when teams of scientists worked with the Royal Air Force to improve radar detection of
 has been completed to gauge actual use, the convenience and safety of home or clinic use of misoprostol, the feasibility of medical abortion in the absence of ultrasound facilities, the need for and access to emergency services emergency services Emergency care '…services …necessary to prevent death or serious impairment of health and, because of the danger to life or health, require the use of the most accessible hospital available and equipped to furnish those services'  and the success of follow-up of women. (17) Telephonic follow-up may be possible in urban areas and even some rural areas, where cell-phone ownership is common. A telephone help line, similar to that initiated in the Western Cape with respect to emergency contraception, could assist women if they became worried or had questions while going through the abortion process at home.

Promoting new methods for termination of pregnancy in South Africa and hence improving access to reproductive choice for women is particularly important in a global context in which reproductive rights Reproductive rights or procreative liberty is what supporters view as human rights in areas of sexual reproduction. Advocates of reproductive rights support the right to control one's reproductive functions, such as the rights to reproduce (such as opposition to forced  and social justice are potentially being eroded by conservative policies. (18)

Acknowledgements

This study was supported by grants from the Population Council. We are indebted to our clinical colleagues at hospitals, clinics and health centres in Gauteng, the Western Cape and Mpumalanga for their co-operation and support. We would also like to acknowledge the fieldworkers and the participants for their contributions.

References

(1.) Grimes Grimes is a surname, that is believed to be of a Scandinavian decent and may refer to
  • Aoibhinn Grimes
  • Ashley Grimes
  • Barbara Grimes, a Chicago murder victim
  • Burleigh Grimes (1893–1985), US baseball player
  • Camryn Grimes
  • Charles Grimes
 DA. Medical abortion in early pregnancy early pregnancy Obstetrics First trimester of pregnancy : a review of the evidence. Obstetrics and Gynecology 1997;89(5 Pt 1): 790-96.

(2.) WHO Task Force on Post-Ovulatory Methods of Fertility Regulation. Menstrual menstrual /men·stru·al/ (men´stroo-al) pertaining to the menses or to menstruation.

men·stru·al or men·stru·ous
adj.
Of or relating to menstruation.
 regulation by mifepristone plus prostaglandin prostaglandin (prŏs'təglăn`dən), any of a group of about a dozen compounds synthesized from fatty acids in mammals as well as in lower animals. : results from a multicentre trial. Human Reproduction 1995;10(2): 308-14.

(3.) Winikoff B, Sivin I, Coyaji KJ, et al. Safety, efficacy, and acceptability of medical abortion in China, Cuba, and India: a comparison trial of mifepristone-misoprostol versus surgical abortion. American Journal of Obstetrics and Gynecology 1997;176(2):431-37.

(4.) Cooper D, Morroni C, 0rner P, et al. Ten years of democracy in South Africa: documenting transformation in reproductive health policy and status. Reproductive Health Matters 2004 ;24(12):70-85.

(5.) Republic of South Africa. The Choice on Termination of Pregnancy Amendment Bill, 2003. Government Gazette Notice No. 1388 of 2003, 19 May 2003. At: <http://www.info.gov. za/gazettelbills12003/24869b. pdf>. Accessed 6 August 2005.

(6.) Dickson KE, Jewkes RK, Brown H, et al. Abortion service provision in South Africa three years after liberalisation of the law. Studies in Family Planning family planning

Use of measures designed to regulate the number and spacing of children within a family, largely to curb population growth and ensure each family’s access to limited resources.
 2003 ;34(4):277-84.

(7.) World Health Organization. Safe Abortion: Technical and Policy Guidelines for Health Systems. Geneva Geneva, canton and city, Switzerland
Geneva (jənē`və), Fr. Genève, canton (1990 pop. 373,019), 109 sq mi (282 sq km), SW Switzerland, surrounding the southwest tip of the Lake of Geneva.
: WHO, 2003.

(8.) Department of Health, Republic of South Africa. South African Demographic and Health Survey. Pretoria: Department of Health, 2001.

(9.) Klugman B. Balancing means and ends: population policy in South Africa. Reproductive Health Matters 1993; 1:44-57.

(10.) Mamadani M, Garner P, Harpham RP, et al. Review article. Fertility and contraceptive use in poor urban areas of developing countries. Health Policy and Planning 1993; 14:199-209.

(11.) Siebert I, Steyn PS. Knowledge and use of emergency contraception in a tertiary referral unit in a developing country. European Journal of Contraception and Reproductive Health Care 2002;7:137-43.

(12.) Smit J, McFadyen L, Beksinska M, et al. Emergency contraception in South Africa: knowledge, attitudes and use among public sector primary health care clients. Contraception 2001;64:333-37.

(13.) Department of Health, Republic of South Africa. Summary Report. National HIV and Syphilis syphilis (sĭf`əlĭs), contagious sexually transmitted disease caused by the spirochete Treponema pallidum (described by Fritz Schaudinn and Erich Hoffmann in 1905).  Antenatal Seroprevalence seroprevalence Immunology The proportion of a population that is seropositive–ie, has been exposed to a particular pathogen or immunogen; the seropositivity of a population is calculated as the number of individuals who produce a particular antibody divided  Survey in South Africa. Pretoria, 2005.

(14.) Hessini L. Global progress in abortion advocacy and policy: an assessment of the decade since ICPD. Reproductive Health Matters 2005;13(25):88-100.

(15.) WHO Essential Medicines Library. At: <http://mednet3.who.int/EMLib[DiseaseTreatments/MedicineDetails.aspx? MedIDName=443@mifepristone-misoprostol>. Accessed August 2005.

(16.) Cullingworth L, de Pinho H. Cost analysis of service provision of medical abortions in the public health sector at primar3, and secondary level. Monograph. University of Cape Town. June 2002.

(17.) Kawonga M, Blanchard K, Cooper D, et al. Integrating medical abortion into safe abortion services in South Africa. Presentation at Eleventh Reproductive Health Priorities Conference, Sun City, Fourways, South Africa. October 2004.

(18.) Correa S, Germain A, Petchesky RP. Thinking beyond ICPD+10: Where should our movement be going? [Roundtable]. Reproductive Health Matters 2005;13(25):109-19.

* A dosage of 200mg mifepristone has, since that approval was given, been shown to be equally effective. (7)

Diane Cooper, (a) Kim Dickson, (b) Kelly Blanchard, (c) Lee Cullingworth, (d) Nqobile Mavimbela, (e) Clare von Mollendorf, (f) Louis van Bogaert, (g) Beverly Winikoff (h)

(a) Senior Researcher, Women's Health Women's Health Definition

Women's health is the effect of gender on disease and health that encompasses a broad range of biological and psychosocial issues.
 Research Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa. E-mail: dic@cormack.uct.ac.za

(b) HIV/AIDS Advisor, DFID DFID Department For International Development (UK)  Nigeria

(c) President, Ibis ibis (ī`bĭs), common name for wading birds with long, slender, decurved bills, found in the warmer regions of both hemispheres. The body is usually about 2 ft (61 cm) long. Most ibises nest in colonies.  Reproductive Health, Cambridge MA, USA

(d) Research Consultant, Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa

(e) Project Officer, UNICEF, Pretoria, South Africa

(f) Research Clinician, Reproductive Health Research Unit, Department of Obstetrics and Gynaecology, University of Witwatersrand, Johannesburg, South Africa

(g) Specialist Obstetrician-Gynaecologist, Consultant, St Rita's Hospital, Limpopo Province, South Africa

(h) President, Gynuity Health Projects, New York New York, state, United States
New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of
 NY, USA
Table 1. Abortion decision-making, abortion-seeking
behaviour and access to services

                                          Soweto
                                          (n=272)

                                   %            (number)

Time taken to travel
  < 1 hour                        85.3            (232)
  [less than or
  equal to] 1 hour                11.0            (30)
  Unknown                         3.7             (10)

Distance travelled
  0-10 km                         54.8            (149)
  11-50 km                        31.2            (85)
  51-100 km                       4.8             (13)
  >100 km                         1.5              (4)
  Unknown                         7.7             (21)

Mode of transport
  Own transport                   2.9              (8)
  Public transport                84.2            (229)
  Walk                            12.9            (35)
  Other                                   --
Travel cost (Rands)
  No cost (walk)                  13.2            (36)
  < R5                            2.6              (7)
  R5-R10                          70.2            (191)
  R11-R20                         12.9            (35)
  > R20                           1.1              (3)
  Unknown                                 --

Length of
pregnancy
of women
presenting
for abortion

Mean length
of pregnancy                             11.5 weeks
  by ultrasound
  < 8 weeks                       21.0            (57)

Person with whom woman
discussed current
abortion decision
  Husband/boyfriend/partner       34.2            (93)
  Family member
  (mother, sister,
  other member)                   26.1            (71)
  Friend                          16.5            (45)
  Other                           1.5              (4)
  No one                          21.3            (58)
  Not specified/unknown           0.4              (1)

More than one
week elapsed between
knowledge of pregnancy
and seeking advice                97.9            (238)

                                          Cape Town
                                          (n=287)

                                   %            (number)

Time taken to travel
  < 1 hour                        87.5            (251)
  [less than or
  equal to] 1 hour                11.8            (34)
  Unknown                         0.7              (2)

Distance travelled
  0-10 km                         72.2            (207)
  11-50 km                        27.2            (78)
  51-100 km                               --
  >100 km                         0.3              (1)
  Unknown                         0.3              (1)

Mode of transport
  Own transport                   19.2            (55)
  Public transport                67.9            (195)
  Walk                            12.9            (37)
  Other                                   --
Travel cost (Rands)
  No cost (walk)                  17.4            (50)
  < R5                            48.4            (139)
  R5-R10                          18.2            (52)
  R11-R20                         12.2            (35)
  > R20                           3.8             (11)
  Unknown                                 --

Length of
pregnancy
of women
presenting
for abortion

Mean length
of pregnancy                      11.8            weeks
  by ultrasound
  < 8 weeks                       22.3            (64)

Person with whom woman
discussed current
abortion decision
  Husband/boyfriend/partner       34.6            (114)
  Family member
  (mother, sister,
  other member)                   18.5            (61)
  Friend                          14.3            (47)
  Other                           11.3            (37)
  No one                          21.3            (70)
  Not specified/unknown                             -

More than one
week elapsed between
knowledge of pregnancy
and seeking advice                59.7            (169)

                                          Philadelphia
                                          (n=114)

                                   %            (number)

Time taken to travel
  < 1 hour                        29.8            (34)
  [less than or
  equal to] 1 hour                58.8            (67)
  Unknown                         11.4            (13)

Distance travelled
  0-10 km                         29.8            (34)
  11-50 km                        43.0            (49)
  51-100 km                       13.2            (15)
  >100 km                         6.1              (7)
  Unknown                         7.9              (9)

Mode of transport
  Own transport                   1.8              (2)
  Public transport                92.9            (106)
  Walk                            4.4              (5)
  Other                           0.9              (1)
Travel cost (Rands)
  No cost (walk)                  4.4              (5)
  < R5                            14.0            (16)
  R5-R10                          40.4            (46)
  R11-R20                         29.8            (34)
  > R20                           10.5            (12)
  Unknown                         0.9              (1)

Length of
pregnancy
of women
presenting
for abortion

Mean length
of pregnancy                      12.2            weeks
  by ultrasound
  < 8 weeks                       15.8            (18)

Person with whom woman
discussed current
abortion decision
  Husband/boyfriend/partner       28.1            (36)
  Family member
  (mother, sister,
  other member)                   38.3            (49)
  Friend                          10.9            (14)
  Other                           1.6              (2)
  No one                          21.1            (27)
  Not specified/unknown                             -

More than one
week elapsed between
knowledge of pregnancy
and seeking advice                70.2            (80)

                                           Total
                                          (n=673)

                                   %            (number)

Time taken to travel
  < 1 hour                        76.8            (517)
  [less than or
  equal to] 1 hour                19.5            (131)
  Unknown                         3.7             (25)

Distance travelled
  0-10 km                         57.9            (390)
  11-50 km                        31.5            (212)
  51-100 km                       4.2             (28)
  >100 km                         1.8             (12)
  Unknown                         4.6             (31)

Mode of transport
  Own transport                   9.7             (65)
  Public transport                78.8            (530)
  Walk                            11.4            (77)
  Other                           0.1              (1)
Travel cost (Rands)
  No cost (walk)                  13.5            (91)
  < R5                            24.1            (162)
  R5-R10                          42.9            (289)
  R11-R20                         15.5            (104)
  > R20                           3.9             (26)
  Unknown                         0.1              (1)

Length of
pregnancy
of women
presenting
for abortion

Mean length
of pregnancy                      11.4            weeks
  by ultrasound
  < 8 weeks                       21.0            (139)

Person with whom woman
discussed current
abortion decision
  Husband/boyfriend/partner       33.4            (243)
  Family member
  (mother, sister,
  other member)                   24.8            (181)
  Friend                          14.5            (106)
  Other                           6.0             (43)
  No one                          21.3            (155)
  Not specified/unknown                             -

More than one
week elapsed between
knowledge of pregnancy
and seeking advice                76.1            (487)

* In the case of Cape Town and Philadelphia the figures
compute to more than the number of women interviewed as
some women discussed their decision with more than one
category of person.
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xoxoxo
xoxoxo (Member): Re : how can i access abortion services if i stay in other country and what are the prices 2/10/2012 9:42 AM
hello.

could you please help me and t5ell me how can i access the abortion services if i stay out of south africa and which hospitals provide such services and at what rate ?

thank you

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Author:Cooper, Diane; Dickson, Kim; Blanchard, Kelly; Cullingworth, Lee; Mavimbela, Nqobile; von Mollendorf
Publication:Reproductive Health Matters
Geographic Code:6SOUT
Date:Nov 1, 2005
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