Reasons why women delayed seeking an abortion were complex and often interrelated and in turn affected the timing when the abortion was carried out. Broad categories to emerge for reasons for experiencing delays in obtaining an abortion were linked to personal circumstances leading to uncertainty and indecision, difficulties in detecting a pregnancy in the first trimester, and health service related barriers that hindered access to TOP services. Almost all women described multiple and interrelated factors that influenced the timing of seeking an abortion.
Socio demographic characteristics
Socio-demographic information was collected from all 27 respondents prior to the interview. The mean age of respondents was 26.8 years (range 16–40), all women had secondary school education, 18(67%) were in a relationship and 4 women (15%) were unemployed. Eighteen (66%) respondents had had previous pregnancies with one woman reporting a prior abortion. Two (7.4%) of respondents reported using a hormonal contraceptive method at the time of conception. The average gestational age at booking was 16.8 weeks (range14 – 19.6) with no differences in terms of gestational age for women presenting at public sector and NGO facilities.
Pregnancy recognition, confirmation and response
Many participants recalled "signs" and symptoms of pregnancy such as tender breasts, certain food "cravings" and nausea, but did not initially relate these symptoms to a possible pregnancy. Moreover, many women reported a history of irregular periods and often waited until the second or third month of a missed period before seeking pregnancy confirmation suggesting that a missed period was not linked to a suspected pregnancy.
Women with a history of irregular periods explained how they had waited until the second or third month of a missed period before confirming their pregnancy. One woman explained:
'I was in my third month, but because I have problems with my monthly period, I just took it, okay, maybe it's one of those months where it's not going to come. And then, when I didn't get it in the third month, I went to the chemist and I bought a self pregnancy test and I tested and it came out positive... But like I said, because my period is on and off, sometimes I get it, sometimes I won't get it. I just took it, okay, maybe it's going to come the next month.'
Almost all women confirmed their pregnancy by administering a home pregnancy test which they bought privately from a pharmacy or drugstore, and whilst experiencing difficulties in initially suspecting a pregnancy, were cognizant of ways to independently confirm a pregnancy.
A woman who typically experienced irregular periods coupled with having had no pregnancy symptoms did not "realize" that she was pregnant. On discovering she was pregnant she waited a further four weeks before deciding to have an abortion as she was "still in doubt". Reflecting on the complex process from suspecting a pregnancy to seeking an abortion, she explained:
'It's something normal that my periods are on and off, sometimes I have, sometimes I won't. You just try to convince yourself that you are not pregnant. But at the end of the day you have to go and take the [pregnancy] test...Maybe it happens that you don't want to admit your responsibility I don't know.'
Participants responded in diverse ways to an unplanned pregnancy ranging from "shock" and disbelief to being "upset and sad" and not "ready to have a child". Whilst some women were initially "happy to be pregnant", upon reflection of their personal and financial circumstances reconsidered their options.
Most women interviewed were not using a contraceptive method. The relationship between non contraceptive use and linking a missed period to a possible pregnancy appeared somewhat elusive and for many, the situation was further compounded by a history of irregular menses. Women were either not using a contraceptive method or reported contraceptive failure. Establishing why women were not consistently using contraceptives was difficult. Reasons mentioned were "forgetting to take the pill", difficulties associated with injectable contraceptives such as weight gain and irregular menses, partner dislike of condoms and not being in a relationship. Explained by a young woman:
'I saw that there was no need for me using contraceptives because I didn't have a man and I told myself that I must stop using contraceptives, then I had a man and I forgot it.'
It would appear that the two respondents who had used contraception, however inconsistently, thought they would be protected which might have prevented them from identifying their pregnancy earlier.
Seeking an abortion: personal and emotional factors
Ambivalence and uncertainty often led to delays in seeking an abortion. Most women indicated that they were not currently able to have a child based on their personal and social circumstances. Some women said they were not "ready" or financially able to have a child, whereas others wanted to continue with schooling and studies or were motivated by partner discord.
A woman with a four year old daughter who wanted two more children before the age of 30 was initially relieved to be pregnant but changed her mind later on.
'When I discovered it ... it was sort of a relief because I was pregnant before 30, so it's like I'm looking forward to having a baby because I love babies. And then when you accept it like that, and then Boom! Then the circumstances, that's when everything just starts to come in... You just look at yourself, you don't have a permanent home, you don't have a permanent job... and then you start looking at all those things. It's like at the end of the day you tell yourself, okay, I understand I need a baby but there's no time for it. There is no time.'
A woman with tuberculosis and newly diagnosed with HIV/AIDS was clear in her intent to have an abortion due to her compromised health status and the need to bring up her young child with limited financial means but still felt that "God would punish [her] for seeking an abortion".
'I can't go through like this because I've got other things on my mind. I've got other problems to sort out, you know, through my life, because, it's my health now and so I decided no, I have to do this because I must think of myself, my health, and my son who needs me because my son's father doesn't help me.'
Family, friends and partners played a role in women's decisions around either continuing or terminating a pregnancy. Responses ranged from support to being afraid to discuss their intention to terminate a pregnancy.
Some women were able to discuss their decision to have an abortion with their boyfriends, yet others were afraid to discuss their decision because of fear of being abandoned.
'I went back and told my boyfriend I was pregnant and we discussed it and made a decision no, I don't want this baby. He already has two kids from a previous relationship and he's in a divorce situation... and that's already not a very nice situation so I said I didn't want to. He was going through some stress of his own, but obviously I made it quite clear that it's my choice.'
Another respondent described how she was unable to tell her boyfriend about having an abortion but was supported by both her mother and a close friend.
'I didn't tell my partner about coming for an abortion, because he wants a baby and I don't want a baby at this time, so I didn't tell him...I told one of my friends...she said, I can't tell you what to do, but if you feel it's the right thing to do then you must do it... She supports me because she knows my reason. I also told my mother where I am going and what I 'm going to do. She didn't shout at me because she knows that I have a child and I'm not going to afford another one because I'm not permanently at work, I'm still on a contract.'
Emotional responses to an unplanned pregnancy such as shame, fear and indecision were contributing factors in delaying access to abortion services. Whilst some women were clear in their intent to have an abortion others felt conflicted and undecided. Women spoke about being "scared and afraid" and not knowing what to expect in terms of the procedure and anticipated pain. A woman described having "sleepless nights" weighing all the possibilities:
'I was hoping ... you just keep on hoping maybe I can get a solution, maybe besides getting an abortion, maybe, I can do something. But then eventually you're just going through it, you know – at the end of the day you just come to think of it, okay, I don't want to give my mum another burden, I don't have to be a burden to someone else.'
Another respondent described the enormous guilt she felt in deciding to have an abortion:
'I didn't want to get up because I feel bad and... I know I'm taking a life – but maybe it's because I feel that I've got no other choice, and at this point in time I won't be able to give the child what is rightfully, his or hers. ... This whole week I didn't feel like going anywhere, just to lock myself up in a room and just let something happen to me because I know that I'm going to be punished for doing what I am going to do today.'
Knowledge of abortion legislation
All women were aware that abortions are legal in South Africa and of their right to seek an abortion, however, they did not necessarily consider it "right" in terms of their religious, personal or moral beliefs. Apart from one respondent, women had little knowledge of the specific details of the abortion legislation, particularly the difference between a first and second trimester abortion and the time restrictions involved, as this interchange suggests:
Respondent: 'I was aware that it was legal... and that you had to be I think 12 weeks or less, and then I basically took a chance because like I said I knew I was around about 3 months pregnant, which is equal to 12 weeks, and I came here and they explained to me, okay, but you can terminate it up until 20 weeks.'
Interviewer: 'Did you know that before?'
Respondent: 'No, I didn't. I guessed that I was around 12 weeks. I thought maybe I will make it, maybe I won't make it. I came here anyway and that was how I found out that they can do it up to 20 weeks.'
Women reported limited prior knowledge of where to obtain an abortion and employed social networks such as family and friends to find out about it. Information was also obtained through print media and through the radio, television and abortion related websites.
Difficulties accessing abortion services
In addition to the personal factors mentioned above, participants raised problems related to accessing abortion providing facilities, particularly in the public health sector, leading to further delays in receiving an abortion.
Many women spoke about negative and judgmental attitudes displayed by staff at public health facilities and related instances where staff were not only rude and hostile but attempted to dissuade them from having an abortion. A respondent described how providers imposed their own religious beliefs by bringing out the Bible during a consultation, resulting in her obtaining an abortion at another facility. This was further underscored by structural barriers ranging from inappropriate referrals and being sent from one facility to another before being seen, to waiting a further two weeks for an appointment as clinics were fully booked.
A woman described how she had visited four facilities and one doctor twice before finally being assisted in obtaining an abortion and by this stage was in her second trimester. All these delays had financial implications as well. For those women who were employed it meant organizing time off work and transport costs incurred by being sent from one facility to another.
Negative perceptions of public sector facilities led some women to seek help within the private sector, which not only had financial implications but also meant a delay in obtaining an abortion as women had to save enough money first.
Moralising and judgmental attitudes displayed by providers made it difficult for women, by creating further discomfort.
'You feel like they are just looking at you, they're just looking at someone who is cheapskate, who doesn't have any morals. Someone who thinks, okay, fine, I'm going to fall pregnant today, tomorrow I'm going to take it out. But what they don't understand is – it's not that simple to come to that kind of a decision. That's the most difficult thing.'
However, not all experiences were negative and some women spoke about friendly and helpful staff that assisted in facilitating the process of obtaining an abortion in both the public and NGO facilities.
Abortion and stigma
Women mentioned that even though abortion was legal in South Africa, it was still stigmatized and not a subject discussed openly in their communities. Some women were reluctant to visit health care providers or clinics within their communities for fear of being recognized and ostracized, consequently impacting on their right to choose.
A woman who chose to obtain an abortion outside of her residential area was still concerned about being seen and described how she was disturbed by anti-abortion demonstrators outside of the clinic. She explained:
'They [demonstrators] totally freaked me out...I looked away, but I told myself that they said something about you know, having a baby is best, whatever, but I thought but I've got my baby, so really, please give me a break. I know ... morally, some people think it's wrong.'
A respondent compared the stigma associated with HIV/AIDS to the stigma associated with having an abortion, suggesting that choice may be double-edged.
'They reject that person because this thing has a stigma like AIDS...because it's a disease that people talk about a lot. They forget that maybe you have a choice and it's up to you ... whether you can do it or not...and people don't want to mix with you if you have had an abortion.'
Most women spontaneously related to their own religious beliefs and how this impacted on decisions to seek an abortion. While they subscribed to religious norms that depicted abortion as "murder" or an "abomination," an unwanted pregnancy placed them in a quandary. Shame and guilt associated with seeking an abortion was often eased by prayer. A highly religious woman, faced with either making a choice or disappointing her family, sought approval through prayer.
'All I'm going to do is pray. I'm still praying with God and I still ask him, is that the right thing I'm doing. ... I've asked him show me the way, don't let somebody tell me the way, you show me the way, and I believe in God, he's going to show me the way. He gives people knowledge and he said use your knowledge on the right time. I think it's for me the right time to use it, do my own will.'
Yet for many women, having an abortion was ultimately a private matter, illustrated by one woman's comment that although "it wasn't right to have an abortion it remained a personal matter between me and my God".