Roe v Wade and the Gag Rule
Although the Biden administration ended the global Gag Rule—at least for the duration of his term—which prohibited any international organisation receiving US funding from promoting or being seen to promote abortion, the recent Supreme Court ruling on Roe v Wade has reverberations throughout Africa.
Amongst other things, the ruling lends credence to the anti-abortion mill and puts a question mark over the funding streams of pro-abortion nonprofits (Van Dyk, 2022). The ruling might push abortions further underground when what’s needed is clarity, honesty, and access.
The “debate” and the silence
Abortion—and the fundamental principle of bodily autonomy underlying the right to abortion—is frequently negotiated in one of two ways: ‘debate’ and silence.
The ‘debate’ around abortion in particular, and sexual and reproductive health (SRH) in general, tends to move the goalposts around without improving anyones health outcomes. Negotiations over gestational age, circumstances of a pregnancy, maternal age, contraception types, the value of sex education, etc, distracts from the practical matter of providing care.
However, in South Africa, abortion is a protected right. There is little to no debate to be had. The problem many pregnant people face instead is access. Legally they are entitled but the infrastructure, resources, and willingness isn’t always there. Everything from a fear of stigma and discrimination to a dangerously underfunded public health care system prevents individuals from getting the care that they need, when they need it.
Stigma gives us the second most popular strategy for dealing with the topic of abortion: silence. In Southern Africa in general, the process of seeking an abortion is shrouded in secrecy for both the pregnant person and potential providers. Often the process is so opaque, not to mention expensive and convoluted, people resort to clandestine and unsafe abortions.
As it is, the system places the burden on individual clinicians and individual clinics to provide care it ostensibly guarantees to everyone. This means that, unless they have prior knowledge, the 83% of the population that relies on public health services are forced to traipse from clinic to clinic, risking discrimination at each one. Many simply cannot afford to make these kinds of journeys.
For migrants, documented or undocumented, the issue is compounded.
Popular discourse lays the blame everywhere but the doorstep of underfunded public infrastructures. Top of the list of scapegoats are, of course, migrants, whose mere presence in South Africa supposedly puts a strain on the public welfare system.
Grappling with a stalling economy, high youth unemployment, a crumbling patronage system and an overwhelmed healthcare system, many South African’s are turning to xenophobic narratives. Even individuals as senior as certain regional health ministers have been found criticising and berating migrants seeking healthcare. This age old scapegoat has served well to rally support behind groups operating as enforcers in the absence of direct rule.
In reality, there has been no significant increase in immigration over the last ten years. Instead, the moral panic surrounding migration is a predictable but highly destructive outlet for these numerous, compounding existential anxieties. Ironically, the fallacy of the migrant burden often only entrenches existing problems by directing attention away from the issue at hand.
Similarly, abortion and other forms of reproductive healthcare such as sexually transmitted infection (STI) testing and contraception generate moral panics that obscure root causes. While civil society organisations do incredibly important work to improve access to reproductive healthcare for people of all backgrounds, the debilitating silence around abortion stifles attempts to broaden their reach.
Combined, the situation for migrants in need of sexual and reproductive healthcare is bleak.
Policy vs practice
The legal framework is there. People capable of pregnancy, whether South African, documented or undocumented, are entitled to primary healthcare in South Africa—including abortion, with some limits on gestational age. In fact, in many respects, South Africa is considered a “safe haven” for migrants coming from other parts of the region for it’s relatively liberal reproductive healthcare laws as well as it’s platform of anti-discrimination with regards to sexual orientation, gender identity, and race.
In practice, however, migrants are often faced with healthcare providers reluctant to treat them—a practice that is protected under broad “conscientious objection” provisions. Plus, the expectation of stigma and discrimination preemptively prevents some from seeking care.
Although paperwork is not a requirement at point of access, some providers ask to see it anyway. This is likely intended to weed out so-called “illegal” migrants but invariably, we see this impact South Africans without documentation. There is arguably no better illustration of why care should be provided without discrimination. Such practices will inevitably affect those who aren’t the intended target and make life more difficult for everyone.
Folks come from afar in search of safety and many of them find more hardship. That said, the legal and, to some extent, ideological progressivism of South Africa does present opportunities.
Many migrants form networks and communities that share information about where to access things like healthcare and employment. Through such communities of care, otherwise vast and potentially overwhelming city spaces become navigable and intelligible to newcomers. Individuals find the help they need, when they need it.
This happens everywhere and is one of the ways migrants adapt to their new environments. In these communities and these spaces, migrants and locals find workarounds on infrastructural shortages and weaknesses.
This is not universal coverage but it provides a baseline for more substantial national and regional reform of the Southern African SRH space.
Moving the frame
Perhaps the best way to achieve universal coverage is by:
- Shifting the conversation away from unhelpful ‘debates’.
- Reducing stigma by talking about reproductive health care, who gets it and when and why and where.
- Listening to migrant women, trans men, and intersex or nonbinary folks seeking abortions, contraception or STI testing to make sure frameworks and infrastructures are reaching those that need them.
- Teaching clinicians about the law, about the social and economic impacts of reproductive healthcare, as well as the medicine.
Already, the Southern African Development Community and the African Union are developing and implementing regional frameworks for health that incorporate gender and mobility to varying degrees. Moving forward there is space for the incorporation of queer perspectives, destigmatising the need for sexual and reproductive healthcare of all kinds for all people.
There is nothing to debate when it comes to bodily autonomy. This is about more than abortion, it’s about our right to self-determination and self-possession. Let’s talk about how we build infrastructure, redistribute resources, cut red tape, give people the confidence and safety to seek help without fear of retribution, discrimination, or ostracisation.
This issue was heavily informed by conversations with Langa Mlotshwa, Jo Vearey, and Joan van Dyk. Thank you so much for your time and expertise.