Shaking a hornets' nest: pitfalls of abortion counselling in a secular constitutional order--a view from South Africa

'Bad choices': Unintended pregnancy and abortion in nurses' and counsellors' accounts of providing pre-abortion counselling

Little research tackles healthcare providers' experiences in conducting pre-abortion counselling sessions in circumstances where pregnant persons may request an abortion. We report on a study conducted in South Africa, in which two nurses and two counsellors were asked about how they conduct these counselling sessions. Using a synthetic narrative approach, we present these health workers' micro-narratives about their motivations for providing abortion services, the purpose of the counselling, their information-giving practices, and whether and how third parties are included in the counselling. We highlight how these micro-narratives are premised on discursive resources that problematise unintended pregnancy and abortion. These resources enable and justify directive counselling that undermines pregnant peoples' reproductive autonomy. We locate such directiveness within dominant anti-abortion discourse and call for training to reframe normative understandings of abortion.

Contradictions in womxn's experiences of pre-abortion counselling in South Africa: Implications for client-centred practice

Pre-abortion counselling may play a key role in abortion seekers' understanding of their decision to terminate a pregnancy and the subsequent emotions that they feel. In this paper, we report on a study conducted in the Eastern Cape province of South Africa concerning womxn's experiences of the pre-abortion counselling offered as part of the implementation of the Choice of Termination Act that governs the provision of legal abortion in the country. Using a narrative-discursive lens, the analysis revealed four micro-narratives in which participants appreciated non-directive and empathic counselling, as well as being provided with information. They also indicated that the counselling was upsetting and hurtful, particularly when providers drew on the awfulisation of abortion discourse to suggest that abortion leads to terrible consequences, and foetal personhood discourse to intimate that terminating the pregnancy is wrong and other alternatives (adoption, parenting) are better. The connection between these broadly positive and negative responses may lie in the dominance of anti-abortion discourses coupled with the powerful positioning of healthcare providers as experts. The attendant disempowerment of clients within the health clinic setting may constrain pregnant people's ability to question such 'expert' information. The implications for feminist client-centred pre-abortion counselling are discussed.

Exploring adolescents and young people's candidacy for utilising health services in a rural district, South Africa

BACKGROUND

We use the 'candidacy framework' to describe adolescents' and young people's (AYP) experiences of health services in a rural KwaZulu-Natal district, South Africa.

METHODS

A qualitative approach was used including group discussions, in-depth and key informant interviews with a purposive sample of AYP (n = 70), community leaders (n = 15), school health teams (n = 10), and health service providers (n = 6).

RESULTS

Findings indicate tacit understanding among AYP that they are candidates for general health services. However, HIV stigma, apprehensions and misconceptions about sexual and reproductive health, and socio-cultural views which disapprove of AYP pre-marital sex undermine their candidacy for sexual and reproductive services.

CONCLUSION

Consideration and understanding of the vulnerabilities and reasons AYP exclude themselves will inform interventions to address their health needs. AYP's participation in the design of health services will increase their acceptability and encourage uptake of services.

Trajectories of women's abortion-related care: A conceptual framework

We present a new conceptual framework for studying trajectories to obtaining abortion-related care. It assembles for the first time all of the known factors influencing a trajectory and encourages readers to consider the ways these macro- and micro-level factors operate in multiple and sometimes conflicting ways. Based on presentation to and feedback from abortion experts (researchers, providers, funders, policymakers and advisors, advocates) (n = 325) between 03/06/2014 and 22/08/2015, and a systematic mapping of peer-reviewed literature (n = 424) published between 01/01/2011 and 30/10/2017, our framework synthesises the factors shaping abortion trajectories, grouped into three domains: abortion-specific experiences, individual contexts, and (inter)national and sub-national contexts. Our framework includes time-dependent processes involved in an individual trajectory, starting with timing of pregnancy awareness. This framework can be used to guide testable hypotheses about enabling and inhibiting influences on care-seeking behaviour and consideration about how abortion trajectories might be influenced by policy or practice. Research based on understanding of trajectories has the potential to improve women's experiences and outcomes of abortion-related care.

Abortion attitudes among South Africans: findings from the 2013 social attitudes survey

Abortion is legal in South Africa, but over half of abortions remain unsafe there. Evidence suggests women who are (Black) African, of lower socioeconomic status, living with HIV, or residents of Gauteng, KwaZulu-Natal, or Limpopo provinces are disproportionately vulnerable to morbidity or mortality from unsafe abortion. Negative attitudes toward abortion have been documented in purposively sampled studies, yet it remains unclear what attitudes exist nationally or whether they differ across sociodemographic groups, with implications for inequities in service accessibility and health. In the current study, we analysed nationally representative data from 2013 to estimate the prevalence of negative abortion attitudes in South Africa and to identify racial, socioeconomic and geographic differences. More respondents felt abortion was 'always wrong' in the case of family poverty (75.4%) as compared to foetal anomaly (55%), and over half of respondents felt abortion was 'always wrong' in both cases (52.5%). Using binary logistic regression models, we found significantly higher odds of negative abortion attitudes among non-Xhosa African and Coloured respondents (compared to Xhosa respondents), those with primary education or less, and residents of Gauteng and Limpopo (compared to Western Cape). We contextualise and discuss these findings using a human rights-based approach to health.

Articulating reproductive justice through reparative justice: case studies of abortion in Great Britain and South Africa

Public health and rights-based approaches to abortion advocacy are well established. Feminists are, however, increasingly using a broader framework of 'reproductive justice', which considers the intersecting conditions that serve to enhance or hinder women's reproductive freedoms, including their capacities to decide about the outcome of their pregnancies. Nonetheless, reproductive justice approaches to abortion are, conceptually, relatively under-developed. We introduce a reparative justice approach as a method of further articulating the concept of reproductive justice. We first explain how this approach can be used to conceptualise safe, accessible and supportive abortion as a key element of reproductive justice in relation to the injustice of unwanted or unsupportable pregnancies. Using Ernesto Verdeja's critical theory of reparative justice and case studies of two countries (South Africa and Great Britain) where abortion is legal, we show how such an approach enables an analysis of reproductive justice within the specificities of particular contexts. We argue that both the rights-based legal framework adopted in South Africa and the medicalised approach of British law have, in practice, limited reparative justice in these contexts. We discuss the implications of reparative justice for abortion advocacy.

A critical review of sanctioned knowledge production concerning abortion in Africa: Implications for feminist health psychology

Taking a feminist health psychology approach, we conducted a systematic review of published research on abortion featured in PsycINFO over a 7-year period. We analysed the 39 articles included in the review in terms of countries in which the research was conducted, types of research, issues covered, the way the research was framed and main findings. Despite 97 per cent of abortions performed in Africa being classifiable as unsafe, there has been no engagement in knowledge production about abortion in Africa from psychologists, outside of South Africa. Given this, we outline the implications of the current knowledge base for feminism, psychology and feminist health psychology in Africa.