In South Africa the Choice on Termination of Pregnancy Act (Act 92 of 1996) replaced the Abortion and Sterilization Act (Act No 2 of 1975). The Abortion and Sterilization Act allowed for termination of pregnancy for specific reasons and conditions. The current Act of 1996 allows for termination of pregnancy at the mother’s request up until the 12th week of pregnancy and under specific conditions up to and including the 20th week of pregnancy. The existence of legal abortion does not mean that the abortion is safe. An unsafe abortion, also referred to as an illegal abortion, is a procedure to terminate an unwanted pregnancy performed either by individuals lacking the necessary skills or in an environment that does not have basic medical standards, or both.
The objective of this systematic review was to critically appraise, synthesize and present the best available evidence in relation to why women choose to undergo an “illegal” or “unsafe” abortion when abortion is legal and readily available in South Africa.
Types of participants
This systematic review considered any qualitative study where the focus was on pregnant women of childbearing age who have had an illegal abortion and who lived in Southern Africa.
Types of intervention(s)/phenomena of interest
The phenomena of interest of this review were the reasons why women choose illegal abortions in situations where abortion is freely available. Social and demographic data of participants were extracted from studies where possible. For the purpose of this systematic review, studies that use terms such as “unsafe” abortion, or abortions conducted in “non-medical settings” were considered to be illegal abortions and were considered for inclusion in the review.
Types of studies
This review considered studies that focused on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research. This review also considered non-research papers such as text and opinion-based papers and reports.
Types of outcomes
Studies that were conducted in public or private health care settings were considered for inclusion in the review. Health care settings may include hospitals, clinics and non-governmental organizations that offer supportive services to women who have had an abortion.
The following initial key words were used:
Childbearing women, illegal abortions, unsafe abortions, backstreet abortions, qualitative research, Southern Africa
The following search strategy was undertaken:
1. A limited search of PubMed and CINAHL to identify relevant keywords contained in the title, abstract and subject descriptors
2. Terms identified in this way and the synonyms used by respective databases were used in an extensive search of the literature. Databases searched in this stage included PubMed, CINAHL, SABINET, Scopus, Africa Journal Online, PsychINFO, SocINDEX, SAePublications and Global Health.
3. Reference lists and bibliographies of the articles chosen from those identified in stage 2 were searched.
4. Gray literature identified through reference lists were searched and where African journals of health care were not identified in databases, appropriate hand searching was done.
Assessment of methodological data
Qualitative papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI)). Any disagreements that arose between the reviewers were resolved through discussion, or with a third reviewer.
Qualitative data were extracted from papers included in the review using the standardized data extraction tool from JBI-QARI. The data extracted included specific details about the phenomena of interest, populations, study methods and outcomes of significance to the review question and specific objectives.
Qualitative research findings, where possible, were pooled using JBI-QARI. This involved the aggregation or synthesis of findings to generate a set of statements that represented that aggregation, through assembling the findings (Level 1 findings) rated according to their quality, and categorizing these findings on the basis of similarity in meaning (Level 2 findings). These categories were then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings (Level 3 findings) that can be used as a basis for evidence-based practice.
JBI-QARI was used to extract findings relevant to the review question from the two included studies. No text and opinion papers were found. Based on similarity of findings, categories were identified and then used to construct a synthesis. Each finding was graded based on its credibility. Only those findings that provided a direct quote from the participant were classed as unequivocal and were given more weight in the synthesis. There were no findings that were classed as credible or unsupported. The nine findings were grouped into three categories and the latter into one synthesized statement.
The evidence as to why women choose unsafe or illegal abortions when legal abortions are available is scarce. Current evidence suggests that reasons are multifactorial and complex. Women seek abortions for personal reasons such as wishing to pursue an education, not being financially secure, being afraid of parental and partner response to the news of a pregnancy, and denial of the pregnancy either by the partner or the woman herself.
1. The Witwatersrand Centre for Evidence Based Practice: an Affiliate Centre of the Joanna Briggs Institute, Faculty of Health Sciences, University of the Witwatersrand