The International Centre for Journalists (ICFJ) is now recruiting for young journalists interested in covering health issues to attend and report on a conference in India in December 2018. Selected journalists will travel to Delhi for an orientation and to attend the 2018 Partners’ Forum, hosted by the Partnership for Maternal, Newborn and Child Health (PMNCH) and the Government of India.
Zoleka Gqumisa is an abortion counselor in Khayelitsha. She works at three different clinics, and sees over twenty clients a day. At the Nolungile Youth Clinic her clients are mostly young women between the ages of 16 and 25, many still in school and pregnant for the first time.
At a gathering in Gugulethu in 2012, Zoleka noticed that a woman was smiling at her. Unsure of how she knew her, Zoleka asked her whether they had met before. The woman whispered,
‘Yes, from the clinic. You helped me very much’, she said. ‘I was so scared, and you made me calm. The procedure went well. I don’t like to tell others about it, to tell them that I had an abortion done. But I was protected at the clinic’.
Women presenting for abortions at public health clinics in South Africa have had to make difficult decisions. Their social context determines that they must be sexually available to their male partners, but that, should this result is an unwanted pregnancy, they are to blame. Research has shown that the primary reason given by most women for abortion is socio-economic.
Despite the inherent responsibility that a woman takes in ending an unwanted pregnancy because she cannot provide for the baby, social stigma surrounding abortion remains rampant. Many women fear that they will be ostracized by their friends and families, that they will be condemned by their churches and communities, and that they will be ill-treated by the staff at the clinic. They also fear the procedure itself – that it will be painful, humiliating, harmful to their health and damaging to their future capacity to bear children.
It is for these reasons that the educational and supportive roles played by abortion counselors are so crucial. Zoleka and her colleague, Nomafu Booi, are the only dedicated abortion counselors working in the Western Cape’s public health sector. According to the Provincial Government of Western Cape’s Sexual and Reproductive Health division, they are in fact the only two abortion counselors in South Africa that are attached to a public health facility. The work done by Zoleka and Nomafu is part of the City’s commitment to providing women with comprehensive healthcare at its clinics, rather than scattering these services across different sites. Instead of a stand-alone service, offered at only a small number of clinics, termination of pregnancy should be available to women as one component of women’s healthcare, and it should be provided together with other services, including screening for sexually transmitted infections and HIV, pap smears and sexual abuse counseling.
Abortion was legalized in South Africa in 1996 with the passing of the Choice on Termination of Pregnancy Act. The Act mandates that woman who seeks an abortion in the public health sector must be provided with counseling. The purpose of counseling is to explain to a woman that it is up to her to decide whether or not to have the procedure, and that she alone (rather than her family, or the man with whom she has conceived) must make this decision.
Zoleka and Nomafu use their counseling sessions to answer whatever questions women may have, including about the abortion procedure itself. They also provide women with information about pregnancy, family planning, HIV testing, and the prevention and treatment of sexually transmitted diseases.
A third of women in South African become pregnant by the age of 19. These high rates of teenage pregnancy are often blamed on irresponsible sexual behaviour and on the failure of young women in particular to use contraception. But this belies the complex social dynamics that determine how and when South African women have sex, whether they use condoms, or if they have been taught the biology of conception and pregnancy. Nor do these explanations account for the high rates of violence that women confront, or the fact that, for many women in South Africa, the only sex they know is coerced. For these women, government safe sex campaigns that hinge on messages about ‘taking responsibility’ and ‘avoiding risk’ are irrelevant. The slogan of the government’s extensive HIV Counseling and Testing campaign, during which an alleged 15 million people were tested for HIV, was ‘I am responsible, you are responsible, South Africa is taking responsibility’. For women who are unable to choose when and how to have sex, ‘taking responsibility’ becomes a luxury. What’s more, if their apparent failure to listen to these messages translates into blame and derision at health facilities, in their communities, and in their families, this contributes to the isolation of women who already constitute the most marginal groups in our society.
One reason that women are given insufficient information about contraception is that, in many cases, the nurses themselves have not received adequate and updated training. In recent years, the provincial government has collaborated with organisations like Médecins Sans Frontières (Doctors Without Borders) to pursue creative ways of training and supporting nurses. One result has been onsite training to expand nurses’ use of different contraceptives, including the intra-uterine device, meaning that women are given a wider choice of family planning methods at certain clinics. The strengthening of partnerships between government, clinics and health advocacy groups, particularly in relation to women’s health in the Western Cape, has established new knowledge and support structures for nurses, linking them to other experts who confront similar challenges and enabling them to both provide and gain greater clinical insights.
In many clinics, there remains little time in a day of long queues and steady demands for nurses to counsel their clients thoroughly. It is for these reasons that Zoleka and Nomafu have been employed to counsel abortion patients in Khayelitsha, so as to ease the workload of the nurses at these busy clinics, and to ensure a high quality of service for their patients. Part of this service is in-depth pre- and post-operative counseling on the importance of contraception in helping a woman to prevent an unwanted pregnancy. This is why Zoleka and Nomafu are approached by women in their communities, on the streets and at social gatherings, who are grateful for the counseling they received.
Nomafu explained how most of the young women who seek abortions are still in school, and believe that continuing their pregnancy would prevent them from completing their education, and open them to ridicule from their classmates and teachers. Despite the moral panic about young girls who are supposedly becoming pregnant to get access to child support grants, research on the perceptions of young woman has shown how, for many adolescents, pregnancy while in school is viewed as a profound disruption, associated with economic strain, limited employment prospects, emotional stress and social stigma. In one study, teenage girls who became pregnant reported that they felt ‘ruined’. In Nomafu’s experience as an abortion counselor, many women recounted the resentment of their partners as a reason not to continue with the pregnancy. This anecdotal experience is qualified by research conducted by the Reproductive Rights Alliance, which found that approximately a third of men reacted with ‘anger’ to the news of a pregnancy, and had put pressure on their partners to abort.
Since abortion has been legalized in South Africa, abortion related morbidity and mortality has plummeted by 90%. Whatever a healthcare provider’s moral stance is on abortion, the fact is that its legalization has led to drastic improvements in women’s reproductive health. But despite the fact that abortion is legal, social stigma and the opposition of nurses and others means that abortion is not always accessible for women. This points to the gap between so many of South Africa’s policy commitments in the fields of health and human rights, and the obstruction of these rights when the politics of communities and individuals are at odds with public health or human rights imperatives.
The existence of dedicated counselors helps to ensure that women seeking abortion are given the information they need to make the right decision for themselves about whether to continue or end a pregnancy, and are able to understand the abortion procedure and the mechanics of conception and pregnancy. The support of counselors like Nomafu and Zoleka helps to ensure that these women leave the clinic with the information they need to help prevent another unwanted pregnancy. As Nomafu explained: ‘We take the clients to the counseling room and we explain to them what is going to happen. We touch the clients, we hold their hands, and we tell them to relax. When the procedure is over, we sit with the client until she is ready to go home.’
Rebecca Hodes is the Director of the AIDS and Society Research Unit (University of Cape Town).
Marion: The State of the Nation speech happened last week and despite a number of health challenges continuing to face South Africans, far less was said about this than would have been the ideal. In fact, more was said about the Rhino protection programme.
Within health the broad epidemics of HIV, Tuberculosis (TB), Violence against women (VAW) and substance abuse were noted and plans to remedy these through antiretroviral Treatment (ART) and TB treatment programmes, speaking out against VAW and tobacco control were proposed.
As I was digesting this input the face of a black woman with a bruised face surfaced repeatedly on my media platforms, following her expulsion from the House in the EFF scuffle. This disconnect was jarring.
In my area of focus (reproductive justice) women, and in particular black women, continue to bear the brunt of ill health in South Africa. We need leadership and the implementation of our good policies in order to truly transform the lives of women accessing reproductive health services. Schools need to provide comprehensive sexuality education and provide condom access (both female and male). We also need to continue Human Papilloma Virus (HPV) vaccination programmes to reduce the risk that women will contract cervical cancer late in life.
Women and girls need information about the range of contraception options available and to be able to have a conversation with a health provider and choose the method that is most suitable for them. Should contraception fail and a pregnancy takes place women should have access to HIV testing and also have access to a safe and legal abortion and not have to have to resort to an illegal provider. Maternal health programmes need to continue to welcome women and to provide them with good information about their pregnancy and planned delivery.
The Department of Health needs to strengthen it’s work on sexual and reproductive health and rights and the leadership needs to refrain from using misinformed language that suggests that women use abortion as a form of contraception. Commodities, supplies in relation to reproductive health from female condoms to IUCDS need to be strengthened. These suggestions are not new, our Department of Health has fabulous policies, but little leadership and stewardship to implement them.
Are Rhino’s more important than the health of women in South Africa?
Rebecca: There is good news and bad news.
The good news:
By the end of 2010, over 1 million people in South Africa had been initiated on ART (Republic of South Africa 2010). By 2013, this figure had escalated to 2 010 340 adults reported to be receiving ART in South Africa’s public health services (UNAIDS 2013: A86). The expansion in ART provision was testament to the efficacy of a broad-based alliance of healthcare workers, patients, activists, researchers, government officials, donors and other partners who continue to collaborate in the expansion and improvement of the national HIV response. South Africa’s ART programme has begun to reverse the precipitous decline in life expectancy, wrought by AIDS mortality, that came to characterise South African demography in the late 1990s. Due to the provision of ART, life expectancy in South Africa has increased by six years, and mortality among children and adults has declined by 43% and 20% respectively (Mayosi et al, 2012). By 2010, the life expectancy of patients initiating ART was around 80% of normal life expectancy (Johnson et al. 2013: 5).
The bad news:
The structural factors that increase vulnerability to HIV infection and transmission pose persistent challenges to the progress in South Africa’s health sector, and to the democratic transition more broadly. These factors are manifest in enablers of HIV infection, including unemployment, alcohol abuse and gender violence. While health and social interventions to diagnose, treat and manage HIV have provided some of the services necessary to address the needs of patients, the deep-seated determinants of risk and resilience towards HIV infection in South Africa have remained largely intact.
In South Africa’s struggle for public access to treatment, the attention of health care workers and activists was focused on initiating patients onto antiretroviral treatment. Now that South Africa has the world’s largest cohort of patients on antiretrovirals, we must confront the challenges posed by sustaining a massive public health intervention at a time in which resources for health are declining and there is donor fatigue for funding HIV treatment programmes (Mills et al., 2010).
The stigma surrounding HIV remains prohibitive, preventing the vast majority of HIV-positive people from disclosing their status openly and publicly. While antiretroviral treatment has saved the lives of many, recent studies have shown that, contrary to the expectations of public health specialists, the public provision of treatment has not alleviated HIV stigma in South Africa.
While the fight for public access to ART has won numerous gains for women, the primary focus on their health outcomes as mothers, and the related prioritisation by public health specialists, donors and activists of Prevention of Mother To Child Transmission (PMTCT) initiatives, has shifted attention away from other reproductive health rights. Health interventions that have prioritised treatment for women as mothers has placed primary value on their reproductive capacity rather than their individual health outcomes (Eyakuze, Jones, Starrs & Sorkin, 2008, p. 33).
In spite of the requirement in many healthcare settings that HIV-positve women accept contraception as a pre-requisite for access to ART, social sanctions and individual factors compelling people to become parents continue to play a formative role in the reproductive choices of people with HIV. If the roll-out of ART is to continue to improve the health outcomes of women in Southern Africa, sexual and reproductive health must be repositioned at the centre of HIV prevention and treatment programmes.
South Africa has among the highest rates of rape and sexual assault in the world, but research has shown that very few women report rape or seek healthcare services after being raped or assaulted.[i] Survivors of rape and sexual assault have the right to free medical advice and medications, as stated in the Sexual Offences Act (2007).
Jen: In terms of mentioning women specifically, the 2015 SONA limited itself to describing the fact that ‘some progress had been made in fighting crimes against women and children.’ Whilst that can be debated in other platforms, what is important to consider for women’s health is the very strong linkages between violence against women and HIV and sexually transmitted infection contraction.
In addition to what Rebecca describes above, the links between violence and HIV have been well documented by the World Health Organisation and can be summarised as follows:
rape and sexual violence usually result in trauma to women’s genitalia, increasing the likelihood of contracting HIV and other viruses;
sexual abuse in childhood has been linked to risky sexual behaviour in adulthood, increasing the chances that an individual will contract HIV;
violence or fear of violence can reduce the likelihood that a woman feels safe or empowered to negotiate condom use;
violence or fear of violence, in addition to societal stigma and the gendering of disease, can make it less likely for women to go for HIV and other STD testing; and
violence can make it less likely for women to go for antenatal testing when pregnant, thus reducing the efficacy and reach of programmes designed to prevent mother to child transmission.
Another element that was left out of the State of the Nation was South Africa’s extremely high maternal mortality rate, and the fact that over the past years this has only reduced marginally. South Africa is far off from achieving the maternal mortality rate set by the Millennium Development Goals as made clear in Part 1 of this series. The leading causes of death were non-pregnancy related infection (most often HIV related illnesses) and high blood pressure. It seems essential then that the outreach of maternal health services should be widely expanded.
Our teen pregnancy rates also remain high. Early pregnancy has long term impacts on the lives of girls, and because of patriarchal gender norms continues to impact on girls education and life choices far more than it does on boys. In addition, the number of pregnancies that happen in school should be a serious concern as many of these are legally rape. Where healthy consensual sexual activity happens between adolescents, problems with the legislation around sexual offences have the impact of limiting adolescents access to sexual and reproductive health services, making it more likely that they will not seek treatment for sexually transmitted infections or pregnancy. Possible amendments to this legislation are currently before the Portfolio Committee on Justice. This must be addressed as soon as possible.
The State of the Nation will never be the speech that will solve all women’s health problems. However, there was certainly more space available to address these significant challenges than was used.
We know that gender and sexual violence are major problems in South Africa. We know that we have shockingly high rates of rape, domestic violence and femicide. What is not always recognised however is a different form of violence against women. This is violence that is perpetrated predominantly by women and which targets other women when they are in one of their most vulnerable moments. We are talking here about birth violence that happens to women during labour and when they are giving birth to a new life. While reports of abuse in maternal health services have been fairly widespread since the early 1990s, these incidents are often not framed as a form of violence against women. Some view these incidents as the work of a few bad apples and not indicative of wider attitudes. We know from writing on the issue that the factors involved are complex and multiple, including an over-burdened public health system, lack of resources, highly stressed staff and health-care providers and a long apartheid legacy that still marks our healthcare system. We appreciate the point made by others [i] that healthcare-workers, nurses and midwives need to be validated, supported and cared for so that they can do the work of caring for women during labour and birth. This is important. At the same time, however, we feel that something about this issue is being squashed and silenced.
Shouting at and insulting women, engaging in forms of physical violence such as slapping and rough treatment and deliberately shaming, humiliating and neglecting women during one of the most vulnerable moments of their lives is unacceptable. It is unacceptable regardless of work-loads, lack of support or difficult working conditions. That our healthcare system and society at large continues to largely ignore, and in some cases tolerates these abuses, is indicative of a much wider problem of gender relations in South Africa. Of course it is not simply women in general who are the recipients of such abuse. Privileged and middle-class women, protected by their resources and cultural capital, usually escape gross mistreatment. Other forms of obstetric violence (such as unnecessary caesarean section) however do still occur in the private healthcare system. However, it is predominantly poor and marginalised women (including teenage and HIV-positive mothers) that are targets of violence.
Abuses often seem fuelled by normative ideas about who is a ‘good’ and a ‘bad’ mother. Being poor and coming to a public health clinic without appropriate baby clothes and supplies often automatically marks a woman as a ‘bad mother’ who is then sometimes punished by healthcare providers through insults or deliberate shaming. [ii] Other forms of violence, often not recognised or reported, are institutional in nature and involve the shoddy treatment of women in general in public sector health clinics. Examples include dirty toilets, spatial arrangements at maternal obstetric units which do not allow for any privacy during birth and which often preclude women being allowed to have a partner or companion with them during labour, lack of basic supplies such as blankets, pillows and cutlery (one woman told of how all the women had to share one mug) and not being offered any food after going through the exhausting process of labour and birth [ii].We have to ask serious questions about this mistreatment of women. Why has the National Department of Health (NDoH) been so reluctant to address these problems despite evidence of abuses reported since the 1990s? What does this mistreatment and abuse say about how our society sees and values women?
Thankfully there are signs that efforts are being made to begin to address these issues. There have been calls for increased accountability and institutional reform by some academic obstetric departments (such as the University of Cape Town). The Human Rights Watch also pulled no punches in their report on maternal health abuses in 2011, which was tellingly titled, ‘Stop making excuses’ [iii]. Pressure on various fronts has led to some notable recent actions, including the passing of a policy in 2013 by the Western Cape Department of Health (WCDoH) called the ‘Code of Practice for Patient-Centred Maternal Care’. There has also been the introduction of a new national mobile health programme, ‘Momconnect’ which will enable women to directly report abuses. A hotline has also been set up in the Western Cape to make complaints (0860 142 142). At the same time, however, the NDoH has not widely supported or allocated funding for attempts being made in the Western Cape to address these problems. There thus still seems to be a shocking lack of will by governmental bodies to tackle abuse and violence in maternal healthcare settings.
We have to begin to ask why? Perhaps it is difficult or disturbing to recognise a form of violence against women that is perpetrated largely by women ‘caregivers’. Perhaps wider societal attitudes and discriminatory stances towards poor and marginalized women regard the ‘care’ received in public health settings as ‘good enough’ for them. Maybe wider society and government just don’t care about how low-income women are treated. Maybe society in general fails to value women’s reproductive labours and life-giving efforts. Maybe we just don’t value mothers or the precious new lives that they give birth to? One thing is certain – the ways in which women are treated during the vulnerable time of labour and birth says a lot about wider societal and governmental attitudes towards women. We need to confront and expose these unacceptable attitudes. As a nation we can no longer simply ignore or tacitly tolerate these abuses.
Honikman, S . & Meintjies, I. ‘Nurses are stressed, ill-treated, burdened’, Cape Times, 9 September 2011.
Rachelle Chadwick, ‘The right to dignity in childbirth’, National Research Foundation Report, 2013.
Rachelle Chadwick is a lecturer and Research Career Fellow in Gender Studies (School of African & Gender Studies, Anthropology & Linguistics) at the University of Cape Town. She has a PhD in Psychology from the University of Cape Town. Rachelle is a recipient of a National Research Foundation Research Career Advancement Award and is currently working on a new research project titled, ‘Intimate ethnographies of giving life: the bodily-emotional worlds of childbearing for low-income South African women and their partners’. She has published research articles and book chapters in the areas of qualitative methodology, gender theory, sexuality, childbirth, embodiment, narrative resistance and reproductive health.
Marion Stevens has a background as a midwife, in medical anthropology and in public and development. She has worked in the area of sexual and reproductive health and HIV/AIDS for some 20 years. She is currently the coordinator of WISH Associates (Women in Sexual and Reproductive Rights and Health) a network of nine South African consultant activists and a research associate at the African Gender Institute at the University of Cape Town.