Source: Mail & Guardian

Controlling fertility is an integral part of the human condition, specifically for women. This is because of the reproductive capacity particular to women's bodies. But interventions in fertility can frequently only happen after conception because of the gendered power imbalance between men and women, which undermines women's ability to influence the terms of sex.

The combination of these factors means the question is not whether women will try to end pregnancy but how pregnancy is ended. Will it be a safe abortion or not?

As Minister of Social Development Bathabile Dlamini told delegates at international nongovernmental organisation Ipas's recent conference, which reviewed 20 years of advancing access to safe abortion services: "Where abortion is permitted on broad legal grounds, it is generally safe, and where it is highly restricted, it is typically unsafe."

Indeed, abortions in regulated circumstances as stipulated by the Choice on Termination of Pregnancy Act of 1996 are safer than carrying a pregnancy to term. But, cruelly, indications are that more women are again dying from unsafe abortions in South Africa.

More than 20 years ago, women inside and outside the country were organising to include women's human rights in a post-apartheid dispensation. Women's health received prominence as a rights matter in deliberations, including at the Malibongwe conference held in Amsterdam in January 1990.

The criticism against the apartheid-era Abortion and Sterilisation Act was that, although it allowed abortions under certain circumstances, it was still highly restrictive, according to University of the Witwatersrand law professor Cathi Albertyn. Therefore, when the Act was promulgated in 1975, white women's middle-class status meant they accessed 85% of legal and therefore safe abortions in that same year.

Many white women who did not meet the criteria in terms of the Act could afford to travel overseas. For example, in 1984 alone some 800 white women travelled to England for safe abortions.

In 1995, before the adoption of the new Act, white women still received more than half of the safe abortions inside the country. In contrast, black women constituted 99% of the 425 women who died annually from causes related to unsafe abortions in South Africa, according to a 1994 Medical Research Council study.

The struggles of women inside and outside the ANC paid off, and sexual and reproductive rights formed part of the final Constitution of 1996. This paved the way for the adoption of the new pregnancy termination Act. After the passing of the law, abortion-related deaths dropped by 90%, demonstrating just how preventable these fatalities are when safe services are available.

Yet the health department's latest available statistics suggest that deaths related to unsafe abortions are on the increase again. Its report on maternal mortality for 2005 to 2007 showed an increase in abortion-related deaths. Inexplicably, the latest report covering 2008 to 2010 has no separate category to count deaths from septic abortions.

Instead, it uses the term "septic miscarriage" to include abortion but also non-abortion-related miscarriages. This change in the categorisation encumbers comparisons with the previous reports. Still, deaths in the category of septic miscarriages increased during 2008 to 2010.

Other factors point to the likelihood that more women are dying from unsafe abortions because of the unavailability of safe services. Only about 53% of the public health facilities designated to provide safe abortions are operational at present. Medical abortion, involving only pharmaceutical drugs, is available in five provinces in the public sector. The stigmatisation of abortion continues, also at the highest levels of government. Plus, illegal abortion providers have proliferated.

Regarding the first factor, the current figure of 53% of facilities being operational marks a decrease from a peak of 67% in 2004-2005. The reasons for the drop are manifold but include stigma. Women often face disapproval and embarrassment from the time they enter a public health facility.

The department's regular support sessions for public sector abortion providers no longer take place. But providers still have to deal with hostile managers and colleagues. "I am shaking a hand dripping with blood" is how a colleague once greeted Dr Eddie Mhlanga, an obstetrics and gynaecology specialist in the Mpumalanga health department. This kind of personal badgering is the daily lot of abortion providers. Thus, many suffer from burnout or simply cannot go on.

The reduced number of public sector providers translates not only into extra pressure on existing providers but also into greater difficulty for patients trying to access the service.

They are frequently turned away without being informed of the next alternative facility. This is in part because of "conscientious objectors", who confuse the right not to perform the procedure on personal grounds with the right to refuse the procedure altogether, which is a far cry from their Hippocratic oath or nursing pledge.

Travel costs and work obligations prevent women from reaching ­alternative safe service providers.

Meanwhile, time is running out. When the pregnancy shifts into the second trimester, abortion as furnished by a nurse or midwife is no longer an option, as only medical officers may provide the service beyond 12 weeks. Again, conscientious objection translates into only three medical officers being available to perform second-trimester abortions in the Western Cape.

Stepping into the breach are unscrupulous abortionists whose flyers promise "same-day abortions". These opportunists indiscriminately provide medical abortion pills, which put women with second-trimester pregnancies particularly at risk of death. Again, stigma contributes to women opting for these "secret abortions".

Indications are that many die at home, which suggests that the number of these preventable deaths is probably even higher than in the departmental report, which only counts deaths at medical facilities.

Although middle-class women of all races can afford to pay for the service safely provided in private health facilities, poor black women are the ones affected by the contraction in the state's provision of safe termination of pregnancy.

In that sense, Dlamini was correct when she told the conference: "We cannot talk of abortion in isolation of the overall goals to empower women socially, economically and politically.

"The right to have an abortion should always be fully located and discussed as part of the rights and the transformation of society that enables the complete emancipation of women."

Although the terrain has shifted since the legalisation of safe abortion, activists now face the daunting task of reclaiming lost ground. Meanwhile, women are dying.

• South Africa