By Frank Muller
Abortion remains an emotive issue, not least because it affects our very
definition of life.  But, leaving aside the emotionally charged ethical and
moral issues for a while, let’s take a pragmatic approach.  The common
perception is that abortions can be done either for profit (as by the
private sector and by backstreet abortionists) or not (as by state
institutions and a few philanthropists). However, a third reality has
emerged in South Africa (and indeed worldwide) for which no law makes
adequate provision: the two-stage abortion.

What is a two-stage abortion?  Many, if not most South African abortions
nowadays are initiated by misoprostil (Cytotec®).  This is a prescription
medication registered for the prevention of peptic ulcers and normally costs
less than R4 a pill.  Misoprostil has the side effect of inducing labour
(and therefore is contraindicated in pregnancy).  Please note:  the drug
does not normally kill the baby; it merely expels the child (often still
kicking) from the womb.  It has come to my attention that the drug is
provided at high cost by GPs, pharmacists (often without prescription) and
by backstreet abortionists to pregnant women desperate for a discreet and
quick solution to their crisis pregnancy. I have heard quotes for two
tablets of misoprostil ranging from R250 to R1000.

The pill provider typically tells the woman how to use the pills and advises
her to visit a state clinic if bleeding persists after the baby is ejected
(and presumably flushed down the toilet).  The pill provider then pockets
the profit.  But that is not the end of the business in many cases.  The
woman takes the drug, thinking it will be a discreet, one-stop solution to
her dilemma.  After all, she avoids going to the state clinic because of
privacy concerns.  And she goes to extraordinary lengths to get the money
together. But when the bleeding doesn’t stop, she has no choice but to enter
the second stage of the two-stage abortion.  She reports to a state facility
with a “miscarriage” and has to undergo an emergency evacuation in theatre
under general anaesthesia.  This involves her being admitted to hospital and
taken to theatre, where remnants of the pregnancy (such as the placenta) are
removed.  She would often have to stay in hospital for a day or two.  If she
waited for a long time for the bleeding to stop, she most likely requires a
blood transfusion at R1,000 per pint as well. All this on the state budget.

“…misoprostil-induced “backstreet” abortion is not confined to a few cases
but has become a fully fledged industry.”

The problem is that the misoprostil-induced “backstreet” abortion is not
confined to a few cases but has become a fully fledged industry. And the
victims are clogging up limited theatre space in state institutions.
Logically the increase in two-stage abortions translates into more women
needing theatre time for evacuations of their wombs. The problem is that,
since 1997, when abortion was first legalised, theatre capacity at state
facilities has actually decreased (staff shortages being a main reason). The
express purpose of the Abortion Amendment Act was to broaden the
availability and accessibility of abortion services to the general public.
So now we are seeing an even greater demand for increasingly limited theatre
space – which leads to patient backlogs.

More serious than patient backlogs, however, is the following scenario,
playing itself out in rural hospitals in particular.  One of the Millennium
Development Goals’ indicators is the maternal mortality rate – the number of
women who die during or shortly after childbirth. The goal is to reduce this
indicator by three quarters by 2015. But this rate has actually been
increasing (not dropping), from an average 128 per 100000 births in a 2000
research estimate to 147 per 100000 in a StatsSA report from 2004 (with some
provinces reaching a whopping 364 per 100000).  All of this is conveniently
blamed on Aids, but things are not quite so simple on the ground. It is my
contention that two-stage abortions are a significant cause of the increase
in the maternal mortality rate. Let me give a real-life example.  Some time
ago, under conditions of anonymity, doctors from a hospital in the
KwaZulu-Natal Midlands revealed to me that five mothers – not those
undergoing abortions, but those in bona fide labour – died in a 10-day
period at their hospital. For that period, for that hospital, these five
women represented a horrific maternal mortality rate of about 1,250 per
100,000.  During that same period, about 50 women required theatre time for
evacuations.  Most of those needing evacuations confirmed to my colleagues
that they had indeed used misoprostil to induce their abortions. In total
they required about 40 pints of blood to resuscitate and as a group, these
50 women took up some 50 hours of theatre time (an average theatre only
operates 40 hours a week).

As a result, women with complications during childbirth could not access
theatre, but had to wait while the emergency evacuations were taking place.
Five mothers died. This is not an isolated incident. Similar scenes are
repeated in one state hospital after another in the rural areas. Wherever
you go, you find that critical staff shortages are made far worse by
abortion overloading. Clearly legalised abortion will be with us for a long
time to come.  But steps need to be taken now already to prevent two-stage
abortions from killing more South African mothers. Mothers should not be
dying in order to “liberate women”.

Dr Frank Muller is a medical doctor, pharmacologist and medicinal plant
expert with extensive links to rural African hospitals.  He is a director of
the Christian Medical Fellowship of South Africa.

References:
Maternal mortality rate for 2000:
http://www.ijgo.org/article/PIIS0020729200002666/abstract

Maternal mortality rate for 2004:
http://www.plusnews.org/Report.aspx?ReportId