A rise in the number of healthcare providers who refuse to provide abortion services based on their personal beliefs is having a devastating impact on women and girls around the world, a new study has claimed.



Over the past two decades, at least 30 countries – including, most recently, Ireland, Chile and Argentina – have taken steps to improve access to abortion through legislative changes.

Many medics have sought to exempt themselves from these new laws, however. As a result, doctors, nurses, midwives, pharmacists and even entire hospitals around the world have denied women access to abortion care in countries where the procedure is legal.

The report, Unconscionable: When Providers Deny Abortion Care, published by the International Women’s Health Coalition, is based on consultation with 45 experts in 22 countries, from Italy and Ghana to South Africa and Uruguay. It found that more than 70 jurisdictions have provisions allowing medics to refuse care based on their personal beliefs, a phenomenon known as “conscientious objection”.

South Africa has the most liberal abortion laws in Africa, but this has not resulted in the consistent availability of abortion care and fewer than 50% of licensed facilities provide services. Unsafe abortions outnumber official procedures by two to one in the country.

The Guardian spoke to two practising gynaecologists, based in Johannesburg, about conscientious objection.

Dr Tlaleng Mofokeng

Photograph: Michael Bonfigli/IWHC

Runs a women’s private health practice and is chairperson of the sexual and reproductive justice coalition, which campaigns for safe and legal abortion

“I’ve been an abortion provider for 10 years now and most of my experience has been in the public sector and in the past four years in the private sector.

While South Africa liberalised abortion in 1997, there hasn’t really been a political commitment from the leadership. Now the issue of medics refusing to give women the procedure they are requesting has increased so much that some of us feel the system itself has become an enabler of violence against women. First, it does not discipline health workers who are dishonourable in my view. Second, it doesn’t support providers in the system who are offering abortions.

In South Africa, we are starting to see younger medical students coming up who are interested in studying the procedure. They are finding their medical schools, their consultants, the head of departments of obstetrics, are not helping them in the learning process. A lot of clinical training around abortion is left as an optional extra.

Abortion is stigmatised by health professionals who won’t speak out and affirm the fact that women have a human right to autonomy, and that their rights should be respected. But it is further stigmatised by the system. There are instances where abortion clinics have been moved to the back of the hospital, where there is no signage to say that an abortion is something offered by core services.

Because so few medical doctors and nurses are doing the procedure they find they have a lot of patients to care for on a daily basis, often unsupported by management and with lack of proper medication or stock. Sometimes procedures are delayed, so you might have a patient who comes in at four weeks or six weeks pregnant and, by the time they get an abortion, they are in their second trimester.

A lot of abortion providers speak of being burned out or exhausted. People think this means we can’t do the work, or the work is too much. But what it really speaks to is the lack of support from the rest of our colleagues. So the stigma patients face, a lot of us as service providers are facing from those who do not want to offer abortions.

In rural areas, if one clinic does not offer an abortion a woman might have to travel for as long as five hours just to get to the next facility, where there is no guarantee the response will be any better.

Also, a lot of patients unfortunately have to deal with lifelong complications. Young women often have to have hysterectomies, because in South Africa unsafe procedures outnumber safe procedures by two to one. That is a disgrace if you look at the type of legal framework that we have.

I constantly receive messages from women asking where to go to get an abortion. Some clinics shut down overnight and you never find out why. It is very frustrating for us even as civil society members who want to help, and have the technical knowledge, to actually then get in the system and start doing right by some of our patients.”

Dr Murishe Ledwaba

Gynaecologist and obstetrician based in Johannesburg

“I qualified as doctor in 1984 and became a gynaecologist in 1995. I’m self-employed and have my own private practice in a larger clinic, working alongside other practitioners. I provide antenatal care and carry out gynaecological checkups and operations. The private clinic provides the nursing staff, but I have my own receptionist.

I prescribe contraception, but I do not prescribe the morning-after pill or carry out abortions because of my religious beliefs. I cannot decide which women should have an abortion just based on what that mother feels about the baby. While the law does provide women with the right to abortion, the rules also allow conscientious objectors based on personal beliefs. So we cannot be forced to provide abortion care.

If women approach me about having an abortion I talk them through their reasons. In a situation where the person has an unwanted and unplanned pregnancy, the rationale is not necessarily medical. In that moment abortion may seem like the best option to them but I will discuss with them why they want to terminate. I’ll talk them through their options and alternatives, such as adoption, and I invite them to look at the short-term and long-term consequences.

In terms of the procedure, some women end up requiring blood transfusions. Others suffer damage to their uterus or cervix, or end up with an infection. The effects can be emotional as well, with some women suffering acute depression after the procedure. And there is a risk they might not be able to fall pregnant again.

Patients have the right to choose but, as health providers, we also have rights. I work in a huge clinic and there are other doctors there who provide abortions. Each is an independent practitioner, so there is no overall policy at the clinic.

Many women seeking a termination are not using contraception. If they are not ready, they should be taking precautions. If it was a case that there was a medical problem with the foetus, there are others who will do it. But as a Christian I don’t perform abortion under any circumstances.

Same-day abortion is advertised on a street in Johannesburg. A 2017 study found 32% of South African women do not know abortion is legal.

Legalising abortion has not done anything to stop women having backstreet abortions. You see it openly advertised everywhere. Unlike before, when these people could be penalised, there is no deterrent and services are advertised on the street.

When I was training to become a gynaecologist, my senior consultant did not do abortions. So that was a blessing for me, and in our unit we did not do the full training. I attended one session where it was being demonstrated, but I said I will not be using this skill.

The problem we have is that in some cases women have multiple abortions. There needs to be more done to provide information about contraception.”