*Published on Sexual and Reproductive Health Matters Journal
CHALLENGES FOR ACHIEVING SEXUAL AND REPRODUCTIVE JUSTICE IN SOUTH AFRICA
Written by Marion Stevens, Director, Sexual and Reproductive Justice Coalition
Reproductive Justice is defined by three principles: The right to have child; the right not to have a child; and the right to parent children in safe and healthy environments.
Twenty years after the evolution of the concept in the United States, the government of South Africa incorporated the concept of reproductive justice into its thinking. In 2014 the concept was introduced and spoken about locally and globally by the Department of Social Development (DSD)1,which houses the National Population Unit. DSD has incorporated the principles of reproductive justice, and taken the concept of sexual and reproductive health and rights (SRHR) further.
Against this backdrop, the Sexual and Reproductive Justice Coalition (SRJC), a non-profit South African organisation, was established in 2015. The SRJC works to provide a platform through which individuals and organisations produce and use evidence to foster informed public debate and consensus building working towards holding policy makers and implementers accountable for progress towards realising sexual and reproductive justice for all.2
SRJC has further developed the concept of sexual and reproductive justice, noting that it encompasses the following aspects:
- Recognising that sexualities and reproduction are impacted directly and indirectly by their intersections within social, economic, cultural, gendered, geographical, political, racialized, age-based, ability-based and other power relations, hence acknowledging that achieving SRJ may require engaging broader power relations;
- Overcoming inequalities and oppressions, including silencing, stigma, judgement and other barriers to accessing information, resources and services;
- Affirming diversity of identities;
- Recognizing different vulnerabilities and abilities;
- Addressing violations, particularly gender-based coercion and violence that occur in many settings;
- Advocating comprehensive care, including mental, physical, emotional and spiritual health;
- Acknowledging and overcoming cross-cutting pervasive social challenges such as transport, safety, water, sanitation, violence, crime, alcohol, drugs, migration, labour exploitation, poverty; and
- Affirming sex positive, sexualities positive and positive reproductive decision-making approaches.
This framing aims to challenge and shift problematic language related to SRHR. For example, it challenges terms such as “unwanted” or “unintended pregnancy”, which centres on and burdens the woman, encouraging a shift instead to the language of “unsupported pregnancy”, a term which highlights a woman’s relationship to a partner or an economic system which enables or denies the ability to continue a pregnancy. Similarly it traces the compounded injustices (such as one’s location or position) including issues such as sex work, refugee status, sexual orientation and gender identity.
Challenging the language and thinking that frames access to SRH services and rights is an important element of sexual and reproductive justice. So, too, is having a legal framework in place to protect these rights, alongside the capacity and will to implement progressive laws and policies. South Africa is lauded for its brilliant legal framework and provisions in relation to SRHR, yet it still faces enormous implementation challenges.
In February of 1997, for example, South Africa enacted a globally renowned law on abortion, motivated to redress the imbalances of the past where 429 black women died each year from lack of access to these health services. This Act came to be known as the Choice on Termination of Pregnancy Act of 1996 (CTOPA). The political act of passing this legislation was historical in laying the framework for reproductive justice in South Africa. Having an act such as CTOPA in place meant that women and pregnant people would be free to make their own decisions regarding their bodies and their futures, and that they have bodily autonomy without being psychologically, physically and emotionally harmed by being lawfully forced into carrying a fetus to term.
Many people who have had access to abortions have escaped being caught in the web of financial deterioration and poverty. Access to this service eliminates the risk and injustice that comes with refusing people who are able to fall pregnant the right to make their own decisions regarding their own bodies.
As monumental as this act has been, however, it hasn’t been without its ongoing challenges.
Despite the act, less than 7% of the country’s health facilities provide abortions, creating a barrier to equal access for all, especially those based in rural communities. There are a range of reasons for this, including poor health systems, challenges with human resources training, lack of adherence to law3, lack of management of training, and disrupted or lack of supplies of reproductive commodities.
The SA Health Products Regulatory Authority has failed to register generic medication abortion products for over 15 years, despite these reproductive health commodities being listed as an essential medicines. There is also poor access to contraception options, with stock outs of contraception options frequently being reported. The recent District Health Barometer released in January 2019, notes the decrease in available contraception options. In particular the numbers of condoms distributed has decreased.
Further, there is very limited public information related to accessing comprehensive abortion services. The National Department of Health does not have any communications available on this service. This subjects women and pregnant persons to risk of accessing unsafe abortions from illegal and unsafe providers.
There is also insufficient training of Health Care Workers, including nurses and doctors4, where they graduate without competency in performing pap smears, IUD insertion and treating of women presenting with incomplete abortions and needing emergency manual vacuum aspiration5. There is limited access to second trimester abortions, resulting in women and pregnant people missing the legal gestation time frame, leaving them with no option but to opt for unsafe abortion providers.
A lack of information further challenges the provision of safe abortions. The National Department of Health, for example, has poor health information systems processes from which to plan improved health services. Deaths from abortion are estimated from miscarriages and from pregnancy related sepsis and account for 10% of direct obstetric deaths. Most of the deaths take place in Gauteng, the wealthiest and most urbanized province in the country.
Some women and pregnant people face multiple barriers to accessing abortion, due to multiple layers of stigma, discrimination, and legal obstacles. Sex work in South Africa, for example, is currently criminalised, pushing sex workers to resort to informal abortion providers outside the formal health system, putting their health at great risk. While sex workers have organised in South Africa and called for the decriminalisation of sex work (a call which is informed by public health and human rights evidence), this has not been realised by the South African Law Reform Commission. Delaying the implementation of legal reform results in sex workers being criminalised and having a lack of access to SRHR services.
Clearly, South Africa continues to face substantial challenges in the provision of safe abortion care to those who need it. Abortion is a safe procedure, and the lack of availability of safe abortion care represents a grave reproductive injustice, mostly affecting black pregnant people. The Department of Health has developed National Clinical Guidelines on Abortion in 2018, yet has not adopted these nor planned budgetary allocations to implement these. As such after more than 20 years since the passing of the CTOPA, much remains to be done in the struggle for reproductive justice in the country.
Now in 2019, 25 years after the formal end of apartheid, the SRJC is petitioning political parties registered in the 2019 South African general election to respond to governance and implementation questions on reproductive justice. The SRJC has developed a reproductive election campaign which has included a petition and a public event to call parties to explain their manifestos and political positions on these issues. This is perhaps a first globally, in calling political parties to account and address reproductive justice issues. It is hoped that the campaign will bring attention to these marginalised issues and enable greater understanding amongst the South African electorate which can inform their democratic rights in choosing how to vote in the political elections to be held in early May.
1 The Department of Social Development is responsible for social welfare and also houses the National Population Unit in Government
4https://www.facebook.com/SCORA.UCT/ See events of UCT medical students arranging extra SRHR training where their curricula falls short
5http://www.hst.org.za/publications/South%20African%20Health%20Reviews/9%20Achieving%20universal%20access%20to%20sexual%20and%20reproductive%20health%20services.pdf, http://www.samj.org.za/index.php/samj/article/view/12244, https://www.sasog.co.za/Content/Docs/Saving_Mothers.pdf
Please note that blog posts are not peer-reviewed and do not necessarily reflect the views of SRHM as an organisation.
Image sourced from Wikimedia Commons, originally posted to Flickr by The Jauretsi at https://www.flickr.com/photos/11901158@N00/3512719621