Victoria Satchwell was desperate when she called the fifth pharmacist asking them to dispense abortion pills for an almost 10-week pregnant client. The woman is a 19-year-old rape victim living in Vredefort, a small farming town in the Free State. Over two days, Satchwell’s team spoke to four pharmacists and they all refused to dispense. Some cited moral reasons, while others simply said they don’t stock misoprostol.

There are two common ways of medical abortion. Home-use misoprostol treatment, the cheaper option, is recommended for up to 10 weeks of pregnancy, while the more effective combined regimen of mifepristone and misoprostol is recommended for up to 13 weeks in South Africa, according to the National Clinical Guideline for Implementation of the Choice on Termination of Pregnancy Act. Misoprostol-only treatment costs around R180, while the combined regime costs around R640.

“She was very close to the cut-off date, which is 10 weeks. So we called pharmacists and they told us they weren’t going to help for religious reasons”, says Satchwell. 

Tele-health service for at home abortion

She leads Abortion Support South Africa, a tele-abortion service launched in February 2023. The organisation provides online consultation for women seeking an abortion and connects them to a healthcare professional registered with the Health Professionals Council of South Africa (HPCSA). The healthcare professional assesses the woman’s situation and based on eligibility, prescribes abortion pills that have to be collected from a pharmacy, with a script. 

Vredefort has two pharmacies. One did not pick up the call and the other said they would not dispense as they “don’t want to get involved with that.” Satchwell then tried Parys, the nearest city. One pharmacist hung up on Satchwell after saying they don’t keep stock. 

Another pharmacist said she wouldn’t dispense due to moral reasons. After Satchwell explained that they were working with a rape victim with severe financial constraints, the pharmacist said they don’t stock abortion pills because unused medicines would expire – misoprostol comes in a box of 60 tablets and a prescription for medical abortion is usually 16 tablets. 

As a last resort, Satchwell contacted the fifth pharmacy on her list. Speaking to the pharmacist, she told her four other pharmacists had denied provision of the service and they needed her help.

The last pharmacist agreed to dispense but it took four days for the woman to gather the R50 taxi fare to get to Parys, where the pharmacy is located. The delay pushed her beyond the 10-week recommended gestational age for medical abortion using misoprostol, and Abortion Support advised her to seek clinical care. 

Dr Margit Endler, a consultant in obstetrics and gynaecology at Karolinska Institutet and an adjunct senior researcher in UCT’s School of Public Health and Family Medicine, told Health-e the effectiveness and safety of medical abortion decrease progressively as gestational age increases. “There’s a risk of heavy bleeding, incomplete abortion or continuing pregnancy. However, in this case, the four days wouldn’t make a big difference as the WHO recommends medication abortion at home for up to 12 weeks. 

She says Abortion Support might have suggested 10 weeks so they do not deviate from South African guidelines. 

Satchwell says the woman told Abortion Support that she was able to travel but not whether she ended up having a successful abortion.

Since February, Satchwell and her colleagues at Abortion Support have contacted 184 pharmacies on behalf of 196 patients asking pharmacists to dispense misoprostol. Around 40 per cent of pharmacists refused to dispense despite being shown a prescription by a  healthcare professional. Satchwell says the vast majority of the pharmacies cite religious or moral reasons or simply say they do not stock common abortion pills. 

It’s typically easy for a pharmacist to order abortion pills from medicine wholesalers the day of or even purchase them from nearby pharmacies, says Jackie Maimin, CEO of the Independent Community Pharmacy Association (ICPA), a non-profit association representing 1 100 independent community pharmacies. 

Abortion rights in laws and government policies

The National Clinical Guideline for Implementation of the Choice on Termination of Pregnancy distributed in 2020 defined the parameters of ‘refusal to care’ when it comes to abortion, 24 years after abortion was legalised in South Africa. 

It’s stipulated that only the direct termination of pregnancy (TOP) provider can refuse care, while ancillary staff such as reception, ward clerks and other healthcare professionals involved in the general care of a patient such as a pharmacist may not refuse to provide abortion care under any circumstances.

This means that the pharmacists who rejected Satchwell’s request to dispense abortion pills were acting against government policies and potentially breaking the law.

South Africa has one of the most liberal abortion laws in the world with abortion rights protected under the Choice on Termination of Pregnancy Act 92 of 1996 (CTOP). The law allows women less than 13 weeks pregnant to end the pregnancy without any given reasons, 13 to 20 weeks under specific conditions such as socioeconomic status and more than 20 weeks if her or the foetus’ life is in danger. 

A direct TOP provider who refuses care based on personal beliefs must refer the individual to a colleague or facility that is able to offer abortion services. 

The guideline also requires keeping a record of the clinical detail of the patient, the referral process and the name of the clinician who refused services. Additionally, healthcare professionals who are reluctant to provide TOP services must inform their facility manager in writing when applying for a position in the facility.

Satchwell says she did not choose to report the pharmacists because she hopes to take “an awareness approach.” She says together with the ICPA, they are drafting guidelines and hosting webinars to inform pharmacists of abortion laws and tele-abortion. 

Lack of awareness of abortion law has serious consequences 

There has never been a large-scale information campaign to inform South Africans about changes in the country’s abortion law, according to Guttmacher Institute, a research and policy NGO that aims to improve sexual health and expand reproductive rights worldwide. 

In the webinars to inform pharmacists of their obligation to dispense abortion pills given a valid prescription, Maimin says many showed confusion and lack of knowledge of existing legislation. 

Makgoale Magwentshu is a senior health system associate at IPAS, an international NGO that seeks to increase access to safe abortions and contraception. 

Magwentshu ran workshops in 2019 in public health facilities in Gauteng and Limpopo. She says she encountered security guards, cleaners and community workers at those facilities who did not know the CTOP Act exists. 

The lack of awareness of abortion laws creates a vicious cycle of women not accessing abortion care: healthcare providers or staff at health facilities obstruct abortion care based on personal beliefs or misinterpretation of the law, women not aware of the law fail to report the healthcare providers, healthcare providers continue to reject legal abortions and women end up in unregulated abortions or carry an unwanted pregnancy.

The Department of Health said in 2018 that between 52% to 58% of the estimated 260 000 abortions taking place in South Africa per year are illegal. Some women end up having abortions outside of formal or legal health settings without medical assistance. 

A grey area in the law

In the two decades after the abortion right was codified in 1996, the policies around ‘refusal to abortion care’ was a grey area in South Africa, says Jewelle Methazia, senior research coordinator at Ibis Reproductive Health, a non-profit organisation focusing on sexual and reproductive health.

“We had the Choice on Termination of the Policy Act right. But we did not have specific guidelines that spoke to some of these issues where a client was turned away, or a provider declined to provide the service,” says Methazia.

A 2008 amendment to CTOP added regulations for obstruction to abortion access: any person who prevents or obstructs access to a lawful termination of pregnancy is liable to a fine or to imprisonment for a period not exceeding 10 years. 

Nevertheless, a conflict is posed by the section in the South African Constitution that says, “everyone has the right to freedom of conscience, religion, thought, belief, and opinion,” which serves as the legal basis of ‘refusal to care’ by healthcare providers.

A study conducted in 2019 surveying 95 staff from 19 public sector health facilities found that healthcare workers reported confusion in applying conscientious objection due to a lack of a clear definition and some shared that objection to abortion care is usually handled verbally and informally, resulting in the objecting provider being transferred to another department.

Though policies around “refusal to care” are now clearly outlined in the 2020 guideline, Methazia says that facilities and healthcare professionals should be retrained with the information from the most updated guideline. Policymakers and researchers also need to dig in deeper to find out whether individuals are actually being referred to proper abortion care after a clinician refuses to provide the service, says Methazia.

“I think we shouldn’t just rely on a natural way for the providers to access this guidance and the information to diffuse amongst health care providers. I think there should be a more targeted and strategic way that everybody is brought up to speed on.”

Magwentshu says the Department of Health has hosted virtual and in-person training with some healthcare workers to disseminate the new guideline since 2020. However, more training facing the general population should be conducted, says Magwentshu. 

“The individuals, these women and girls, come from communities. If communities are not aware of the guidelines, they are not going to be supportive of the rights of women and girls.”

Call for acceptance of tele-abortion 

Maimin from ICPA says some doctors filed a complaint against her at the Department of Health. They accused her of advocating for dispensing pills for tele-abortion, citing the requirement of abortion services to be conducted face-to-face in the guidelines. Maimin explained to the Department of Health the legality of dispensing pills based on a valid prescription through telemedicine and the Department of Health eventually agreed with her. 

However, tele-abortion is not mentioned in any government policies as an alternative abortion service. There’s only a Telehealth Guideline released by the Health Professional Council, which does not detail regulations for specific medical procedures.  

“Telemedicine is one way for us to address the severe access issue. It can expand access to more locations and it can address stigma and discrimination that is often reported by those accessing the services at facilities. It can offer more person-centred care,” says Methazia.

The WHO’s 2022 abortion care guideline recommends tele-abortion as an alternative to in-person interactions with health workers to deliver medical abortion services. Comparing telemedicine with in-person medical abortion services, WHO found no difference between the two groups in rates of successful abortion or ongoing pregnancies. 

A similar result was found in a randomised controlled trial conducted in South Africa that involved approximately 900 pregnant women who needed access to medical abortions at public health facilities in Cape Town. The study shows that the telemedicine approach, with uterine palpation as the only in-person component, was non-inferior to standard care, says Endler, who led the study.

Methazia says clearly defining tele-abortion in the government’s policies of termination of pregnancy is an important way to increase the availability of tele-abortion.

According to Magwentshu, the Department of Health is preparing to launch a digital self-care platform in August that would include tele-abortion services. IPAS serves as a technical advisor helping the Department of Health train staff to provide abortion services.

Health-e News asked the Department of Health spokesperson about how they would expand the dissemination of national guidelines on abortion to raise awareness. We also asked how the Department of Health plans to include tele-abortion in the official pipeline or guidance to increase access to abortion.

The Department of Health did not respond to the questions in time for publishing. —— Health-e News