A practitioner’s experiences from the Netherlands and South Africa

In over 40 years, practicing as a physician performing first- and second-trimester surgical abortions, I have seldom experienced the situation of women asking to view the products of conception (POC) after an abortion, as Hann and Becker have described in the United States.¹

I worked for 23 years in the Netherlands, where we regularly asked women if they wanted to see the POC, but we asked only when it might help them with conflicting feelings about the abortion. We thought it might help just to show them how little there was to see. My problem in the Netherlands was sometimes that women wanted to take the POC home for burial, but we had to refuse because that was not allowed.

During my 20 years in South Africa as a provider of mostly surgical second-trimester abortions, I remember only one woman asking to see the POC. I explained what she would see, we discussed her feelings and I was convinced that she could handle the viewing. In general, I do not show second-trimester surgical abortion products. When I explain how the procedure is done beforehand (it is usually done under local anaesthesia), I tell the woman that because the pregnancy is more advanced it is not possible to get the POC out with suction alone, since the cervix is not open enough to remove the complete fetus, so I will also have to use other instruments. I make no other mention of the POC. I do not sensationalise the process as the anti-abortion people are apt to do. The only thing women sometimes ask is what will be done with the fetus.

If a woman is undergoing a medical second-trimester termination, the situation can be different, especially if it is a wanted pregnancy and she has the abortion due to fetal abnormalities or her own health problems. In my opinion, other than for these reasons, medical second-trimester abortions are not preferable: the procedures require women to go through the whole birth process, despite not wanting to have a baby. Also, the process is far more painful and takes much longer than a surgical procedure. In South Africa, the shortage of beds is another important consideration, and 10–15 surgical second-trimester terminations can be done in one day, with women leaving the clinic after one or two hours. We usually do not use beds, just reclining chairs. In medical second-trimester abortions, often only two or three women can be helped per day, due to bed shortages, so women have to wait much longer, with one to two weeks delay waiting for a free bed when they will be even further along in their pregnancy. Usually, there is no choice given to the woman between a surgical or medical procedure; the available doctor decides and most often opts for medical abortion. I am one of the few doctors in South Africa willing to do surgical second trimesters. Most doctors, if they agree to any involvement at all, prefer the medical procedure because it minimises their involvement. The nursing staff bear the burden of care, and of course the women bear the delay and trauma.

I understand that many women are grieving, especially the ones with more advanced pregnancies, because they may have waited a long time to make a difficult decision. I do not feel I can offer solace by showing the POC, but I reassure women that a full-grown pregnancy takes 40 weeks, she is less than 20 weeks gestation (the legal limit in SA), and that at this stage in the pregnancy, the fetus does not feel pain. I feel this offers the woman more solace than to see the POC.

It is not entirely clear to me why the topic has arisen in the US. There are so many other, more important issues around abortion to deal with. Here in South Africa, we have one of the most liberal abortion laws in the world, but there is limited access to services and high levels of stigma. More than 50% of women go outside designated health facilities,² many to backstreet providers, who advertise everywhere. The designated hospitals and clinics that perform abortions are not well known and do not have abortions mentioned on their website, so women do not know where to go. I regularly receive emails from women and girls who are desperate and do not know of any facility in their neighbourhood where they do abortions.

Many of the so-called designated facilities which are supposed to perform abortions are not providing the service. The heads of designated hospitals have been known to refuse to set up services. Few health-care providers are willing to be involved and cite conscientious objection, while ignoring the women in need. Many nurses stop providing abortions after a while because they have no support and they feel ostracised. So, despite the law, there is very little support from the government. The result is that South Africa has the highest proportion of second-trimester terminations compared to other developing countries and where abortion is legalised.³

Most recently, a disturbing case was brought to the Pretoria High Court, arguing that women should have a right to bury the POC, in their words, the “unborn life.”⁴ What could also further intensify barriers to accessing safe abortion in South Africa is that on the 11 February 2020, it was reported that

“Thousands of ‘crisis pregnancy centres’ worldwide affiliated to conservative American Christian organisations are using fear and misinformation to persuade women not to have abortions. The local chapter of an international investigation by journalists reveals that these centres have their tentacles firmly in South Africa.”

This report is part of a global investigation by openDemocracy. There are currently 77 of these so called “pregnancy help centres” functioning in South Africa and there is an intention to establish one centre in every town in the country.⁵ Given these worrying reports, it is clear that efforts should be focused on ensuring that the supportive laws we have are implemented with sufficient resources to actually ensure access to safe abortion services for women in South Africa.