BACKSTREET ABORTION: WOMEN’S EXPERIENCES

Aim: This was a descriptive study aimed at exploring the personal experiences o f women who induce abortion and the circumstances surrounding induced abortion. Methods: The study was conducted in six public hospitals in four different provinces: Baragwanath (Gauteng), Groote Schuur and Tygerberg (Western Cape), King Edward and R.K. Khan (Kwa-Zulu/Natal) and Livingstone (Eastern Cape). In-depth interviews were conducted with 25 African, Indian and Coloured women admitted to the hospitals following backstreet abortions. The study gave women the opportunity to "speak for themselves” about “why" and “how" and the context in which the unscfe induced abortions occurred Results: The findings show that a host o f factors were important in the circumstances leading to unwantedpregrumcy and induced abortion: socio-economic, cultural, psychological and societal. Disempowerment in relationships combined with firumcial pressures constituted the background as to why women felt forced to termiruite their pregnancies. The perceived need for termirujtion was found to over-ride all other considerations, including religious ones. The ways in which women attempted to procure abortion, both through legal and illegal routes, are presented. Wider social and legal discourses on abortion were foimd to be an important factor in how women experienced


INTRODUCTION
Methodologically, studies of illegally induced abortion are extremely difficult.In countries like South Africa where the legal requirements for induced abortion are restrictive and the public's attitude towards induced abortion is non-permissive, it is anticipated that few women who have an induced abortion will admit to it (Sundstrom 1993).Other problems relate to underestimation of cases presenting at health facilities, reporting errors and the poor quality of recorded information (Coeytaux 1988).Despite these problems, clinical and survey research has contributed to an understanding of public health impact of illegal abortion and the development of services (Adetoro 1991, Adewole 1992, Megafu & Ozumba 1991, Okonofua 1992).However, the emphasis of this type of research has been overwhelmingly on questionnairebased data, the limitations of which are clearly articulated by Coeytau (1988) who advocates qualitative methodology as a means of elucidating the context and "social epidemiology" of induced abortion and providing a broader perspective from the point of view of the women concerned.Understanding the social context of abortion remains a major challenge confronting researchers in countries where abortion is legally restricted: Which women use illegal abortion services?Why do these women have unplaimed pregnancies?What are the circumstances under which women decide to abort?Under what circumstances and from whom are illegal abortions procured?What is the attitude of health service providers towards women who induce abortion?How does it impact on women's health-seeking practices?One way of overcoming this knowledge deficit is to give women a chance to "speak for themselves" about "why" and "how" and the context in which unsafe induced abortions occur, and this was the aim of the current study.

Methods and sample
The study was conducted in six large (500 beds) public hospitals in four different provinces: Baragwanath (Gauteng), King Edward and R.K. Kahn (Kwazulu-Natal), Livingstone (Eastern Cape) and Groote Schuur and Tygerberg (Western Cape).These were chosen in order to gain a geographical mix whilst ensuring sufficiently large numbers of women were available to interview.Due to a limited number of women presenting at rural health centres following unsafe induced abortions, the study was restricted to urban public hospitals.However, some of the women presenting at these hospitals came from rural areas.
Instead of using a formal questionnaire in which the questions would have been based on our assumptions and conceptions of the problem and its roots, an ethnographic approach (Strauss & Corbin 1990), which allowed women to "speak for themselves" was adopted.This method of inquiry does not concern itself with figures, but rather with understanding and meaning.
In-depth semi-structured interviews were conducted with 25 African, Coloured and Indian women admitted to hospital with complications of self-confessed induced abortion.The interviews were conducted by five trained female interviewers in the language chosen by the informants and were tape-recorded, transcribed and translated.The data was analyzed using grounded theory methods (Strauss & Corbin 1990).
The selection of women was obtained from a standardised capture sheet used for a parallel quantitative study, and only women who were Curationis, Vol. 20, No. 2, July 1997 categorised as "probably induced" and "certainly induced" were recruited for the interviews.Recruitment and interviewing took place in the ward.Table 1 indicates that 64% were Africans, 20% were Indians and 16% were Coloured.Twenty women were single, and of the 5 who were married, 3 were separated from their partners.The mean age of the women was 25 years and the average number of children per woman was one.Nearly 50% of the women were teenagers and still studying.Of the remaining women, the majority were unemployed while those employed were mainly labourers: domestic workers and factory workers.

FINDINGS and DISCUSSION
Why did the women have unplanned pregnancies?
The women in the study clearly demonstrated that having some knowledge about contraception is not sufficient to ensure effective use and thus prevent an unplanned pregnancy.All the women in the smdy had heard of contraceptives, but had used them incorrectly, stopped using them or in some cases had never used them.Lay models of the use of contraceptives, as opposed to conventional biomedical ones, were evident.These included taking the pill two days after intercourse or only when the partner came to visit.Those women who had never or only temporarily used contraception cited a variety of reasons for non-use, including undesirable physical side-effects particularly disruption of menstrual cycle, loss of libido, weight gain and fear of sterility and paralysis.Some women said they were "lazy" to use contraceptives, often in part because their partners assured them that pregnancy would not occur, or because they believed they were "too young" to conceive or that "it wouldn't happen to me".Two women took the morning-after pill, but was too late.
Most of the women drew attention to the role of their partner in influencing contraceptive use.Some women reported that their partners disapproved of contraceptives and consequently they were unwilling to use them.This was a common indication of a wider and highly significant dis-empowerment of women within their sexual relationships.However, many women whose partners attempted to deny them access to contraceptives did resist whenever possible by using them secretly.Such strategies are clearly not fail safe as one woman describes how she became pregnant because for three days she could not remember where she had hidden her Pills and yet could not deny her partner sex.Other men initiated sex so suddenly or so forcefully that the women involved were not in a position to negotiate contraception.
Unplanned pregnancy thus resulted from a complex interplay of two factors: women's lack of biomedical information on the use of contraceptives and dis-empowerment within their sexual relationships.
Choosing to abort?One of the most striking insights gained from the study was most of the women did not feel that they were in a position to make a genuine choice about whether or not to continue with the pregnancy, due to instability within their relationships combined with serious financial difficulties.This was highly visible in the language of compulsion and impossibility which entered into the women's speech: "I had no alternative", "I was forced to do it", "It was simply impossible for me to continue with this pregnancy", "Life is just too difficult".
One of the most important reasons for terminating the pregnancy was the reaction of the women's male partners to the pregnancy.Many women felt unable to continue with the pregnancy because they were in unstable relationships.In addition many women reported that their relationship changed irreversibly once the parmer became aware of the pregnancy.Not one of the women interviewed reported that her partner once told about the pregnancy actively wanted her to continue with it.Some men told their partners to seek abortion, saying that if they did not they would be on their own.The reactions of the partners were wide-ranging but were frequently characterised by anger and denial of responsibility and often culminated in the male partoer deserting the relationship, as in the experience of one woman: "I last saw him when he told me he was coming back to discuss this thing and I never saw him again".
Other important reasons for termination were social and economic problems, in particular financial pressures.Terminating the pregnancy was seen as the only option for some women who were themselves unemployed or who had other children to support, or whose partners were either unemployed or on low income.The language of compulsion consistently came up in women's stories: "I never thought I could do it, but I felt that I had no alternative because it was a problem on top of another problem.I had to do an abortion.I was forced to do it."Similarly women who were students had to choose between jeopardising their studies and future prospects and terminating the pregnancy.In both situations termination was seen as the only viable option.
The compulsion to terminate overrode not only legal considerations, but religious ones as well.It is notable that women with strong religious affiliations (Catholic, Muslim and Hindu) were not deterred from seeking termination even though they acknowledged that abortion is highly disapproved of on conventional religious grounds.One woman, a Catholic, actually used her religion to justify the rightness of her decision, she said: "I prayed a lot for the right decision and the right choice.I decided that if I go through this, then it would mean that God thought it was the right thing".
The isolation and loneliness of the women in their situation could not be disguised.Most women could not talk through fear of stigmatisation and lack of trust.The women acknowledged their need to confide in someone but confirmed that under the circumstances there was no one sympathetic and reliable with whom to talk.One student said; "I cannot tell my friends because what would they think of me afterwards?I'll always know what they'll be thinking: that I am not quite a stable person, someone who went off the rails".Some women did not even tell their partoers about the pregnancy and the intention to abort, and this was closely related to the issue of trust and support.Some women said they feared violent reactions from their partners.
The isolation of the women was further heightened by the fact that they could not involve other family members, even female ones, except in two cases.In one case, the grandmother actually advised her 15 year old grand-daughter to seek an abortion, while the other informant had to tell her mother because she was bleeding profusely and could not hide the fact.Fear was repeatedly given as a reason for not telling parents about the situation.In the words of one informant; "I have not told anybody at home -1 was afraid of my parents ... think of the shame and embarrassment I would bring home".
Why did illegal abortion take place?Five of the twenty-five women interviewed sought legal abortion by asking their doctor for help or referring themselves directly to hospital.None of these were granted legal abortions, and therefore went either to self induce or to consult backstreet abortionists.The views of the women were that the restrictive clauses of the current legislation place women requesting abortion under a tremendous burden, during a time of extreme trauma.Much concern was voiced over the lengthy and complex procedures of case evaluation; "they make you feel like an animal in a cage", "they shunt you from one person to the next, one corridor to the next, one building to the next... the second week it was the same process of unfriendly people, forms being stamped, shunted up and down ... you spend a lot of time just sitting and waiting ... and at the end they still reject your application".These problems were compounded by the unsupportive and judgemental attitudes of some hospital staff.The following extracts denote informants' experiences with the health services; "the hospital people, the workers here, the nurses, they are all very abrasive ... very abrasive", "1 was treated like a leper you know ... a complete utter leper...", "there was no support, you know, the awful part in all of this is that you are made to feel like such a criminal, such a criminal", "... they make you feel like an "animal in a cage".
Another very important finding is that many women find an alternative way to abort if the legal route is closed to them.This was clearly articulated by one of the informants; "I went to the doctor, but they said they could not help me.Then eventually I carried on, never stopped taking tablets -for three months -1 was taking Provera and Ponstan and Disprin and everything I could find and eventually I started bleeding on Saturday, but I only came in here (to the hospital) yesterday...I was so scared, crying...I told them I did not know what happened".
How did illegal abortion take place?Women's attempts to terminate were varied.In many cases, the health services were considered to be a last resort or as women put it "to finish the job".Women consulted illegal abortionists who included doctors, nurses and in some cases lay people.Consulting traditional healers seemed to be common practice for rural women although some urban women also admitted seeking help from traditional healers.The rural women came to the urban health services to "finish the job" or "clean the womb" and then returned to their rural homes.Euphemisms such as "cleaning the stomach" and "bringing down the blood" were commonly used to describe the process of self-induction.Self-induced methods included taking laxatives, enemas, pills such as Disprin, herbs.Aloe, Balsam kopifa, Dettol and others such as Super rose lotion.
Fees charged by abortionists for termination varied greatly.Traditional healers and lay people charged between R30 and R500 while professionals, mainly doctors and nurses seemed to charge in the region of RIOOO, and this was common for aU the areas.In spite of their poor socio-economic conditions, most women were willing to pay for termination of their pregnancies, except in one case where a woman refused to pay the balance because she felt she was badly treated, she said; "... there was this doctor ... I mean I still owe him money, I still owe him another R500,1 feel very bad about it, I only paid him part of the fee, do you know what he injected into me to get me to abort, the prostaglandins ... [he] also treated me badly as well, that is probably why I did not pay the rest of the money.I felt he deserved i t ..." Women reported that backstreet abortionists went to great lengths to conceal their activities, with all the women being sworn to silence, and in two cases blindfolded to protect the anonymity of the abortionist.The methods used included inserting a catheter or sharp instrument into the uterus to promote bleeding, without anaesthetic and in many cases without painkillers, or giving prostaglandins injections, with instructions to go to hospital in the event of excessive bleeding or other complications.The experience of several women with illegal abortionists was of increasingly painful return visits when initial attempts to promote bleeding failed.In the following extract one of the informants described her experience; "He [her partner] had heard about this contact where we had to go to this nightclub, we met with this woman who sent me off to these doctor's rooms ... the doctor arranged for this guy ... I could have been cut to pieces, I could have been used in a snuff movie, because this guy was sent to my home, inserted something into my cervix to make it start, I don't know, to rupture it, and then the next day collected me, gave me a painkiller, blindfolded me, took me off in a car.I did not know where I was going, I had nobody with me, got put on a table, no knock out nothing, legs spread-eagle, scrape... scrape.... into a pan.That's what I am saying, I could have been killed because I put my life into someone else's hands, and I got an infection and had to go to hospital ... and 1 was treated like a leper there".
It is significant that the women neither refused to be subjected to the procedures of the abortionists, no matter how painful or humiliating and despite awareness of the dangers involved.Many of the women spoke of the risks involved; "women risk their lives and some do die", "a lot of women do not survive you know, but I still had to go backstreet", "a lot of women in the rural areas die, but it is a silent death because you are not supposed to tell anyone who helped you terminate".The need for help was so great that the women were willing to overlook the person's reputation or credentials, as one informant put it; "all I wanted was to get rid of this thing".

Conclusion and policy implications
The picture presented by the women interviewed was one of disempowermem, ironically disempowerment at a time when women were undergoing a procedure which throughout history has been regarded as socially threatening in its expression of women's ultimate power (Bradford 1990).Women became pregnant because they were insufficiently knowledgeable about their bodies and contraceptive methods or because their men had controlling influences over contraceptive use.Once pregnant, women were forced to seek illegal abortion because their relationships were unstable or had collapsed, or because financially or educationally they could not afford to have the child.The emotional pain of the experience, in many cases combined with physical complications, was worsened by social isolation and the frequently judgemental attitudes encountered in the health services.Finally, because legal routes were not available to them these women were forced to accept illegal methods no matter how unsafe, humihating or expensive.
The study has clearly shown that the current Abortion and Sterilisation Act (1975) fails in its supposed attempt to limit the number of abortions, as women who need to, will and do, find options to bring about abortion if the legal route is closed to them.Public policy and the rights of the individual would best be served by widening the scope of the abortion legislation by making it accessible, safer and cheaper to obtain.Although in the immediate sense, liberalisation of the abortion legislation is not likely to make much impact on societal attitudes and financial as well as educational situation of women, the dangers that exist for women forced to seek backstreet abortions are ones which our society can ill afford.To gain maximum benefit from the liberalisation of the abortion laws, it is imperative that a holistic approach towards meeting women's reproductive health needs is Curationis, Vol. 20, No. 2, July 1997 adopted.This includes widespread provision of safe services, including counselling and appropriate contraceptive information and family planning.It is also time that the message of contraception and family planning be targeted at men.