The complex decision making process women with an unintended pregnancy are faced with impacted on timely access to abortion services. Women were undecided in their decision to terminate a pregnancy which led to delays in seeking an abortion. These delays were further compounded by health service related barriers such as inappropriate referrals and long waiting-periods.
Similar to other studies, our study findings suggest that problems in suspecting a pregnancy were an important cause of delay [11,12,14]. Reported problems with irregular periods and poor recall and recording of menses, resulted in difficulties recognizing pregnancy symptoms, which, if identified earlier, may have prompted women to confirm a pregnancy sooner.
Overall poor contraceptive uptake amongst study participants in a relatively well resourced urban area of South Africa is cause for concern. South Africa has a relatively high contraceptive prevalence (61%) compared to other sub-Saharan African countries with the Western Cape Province having better overall reproductive health care services than most other areas of South Africa[15].
Despite limited or no contraceptive use, women did not make the link between amenorrhea and a possible pregnancy. On the one hand, women experienced difficulties in detecting a pregnancy with at least two months elapsing prior to pregnancy confirmation. Yet on the other hand, they were prompt in confirming a pregnancy through independent means by administering a home pregnancy test. Attention to one aspect of reproductive health and not to another would require further exploration. It is interesting to note that women did not access pregnancy testing services within the public sector. The latter is not surprising. A recent study in a similar setting suggested poor utilization of urine pregnancy testing in public sector clinics [13].
Whilst women knew that abortion was legal, most were not aware of the time restrictions involved [6], suggesting that merely knowing when, where and who can request an abortion is not enough. Information on the availability of abortion services particularly the time restrictions involved should be included in reproductive health care counselling so that women with unintended pregnancies are able to make informed choices.
Most women described multiple barriers to obtaining an abortion before the second trimester and did not necessarily identify one reason as being more important than another. Women tended to relate more to social and personal issues than service related barriers. However, with further probing it did become clear that many women had reservations about judgmental and negative attitudes displayed by providers at public sector facilities and overall concerns about being further stigmatized for seeking an abortion.
This study revealed several important shortcomings in the health care system and with regards to abortion care provision. Initial delays in suspecting a pregnancy was underscored by further delays once women decided to have an abortion. Delays due to inappropriate referrals evidenced by women attending numerous facilities before obtaining an abortion, waiting periods of over two weeks and difficulties locating a facility providing second trimester abortions is concerning. Women's access to abortion care services is further compromised by general resistance of health care workers to provide second trimester abortion care [5,16]. As a result, second trimester abortion services are being discontinued at some public health care facilities [5].
Women intimated that reproductive choice was often difficult, particularly in a climate of judgmental and negative attitudes displayed by healthcare providers. Antipathy and staff rudeness is not an unexpected issue to emerge and has been reported in South Africa within both family planning and abortion care services [4,5,17]. This situation underscores the need to destigmatize abortion. Opportunities for values clarification training designed to promote more tolerant attitudes by service providers should continue and extend to health care providers working within all areas of reproductive health. Such interventions would play an important role in improving the quality of care and long term health outcomes of women seeking an abortion. The possibility of NGO's supporting the public sector in providing client centred, supportive abortion care services in areas where TOP services are not available should be further explored.
Partners, family and friends played an important role in decisions whether to have an abortion, yet women independently emphasized their own decision-making autonomy. Religious beliefs could have been a contributing factor in delaying seeking an abortion. Fear of being ostracized from the church, family and wider community and difficulties reconciling religious beliefs around the sanctity of life with "taking a life" were underscored by the realities of women's daily lives and personal circumstances.
Limitations
This study has possible limitations. Despite efforts to provide a non threatening environment, respondents may have experienced difficulties discussing sensitive information and finding out about the actual reasons for waiting until the second trimester of pregnancy was often difficult. Moreover, the findings reflect the circumstances affecting a particular population, i.e., women located within an urban area with better health care infrastructure and more designated abortion facilities than women located within the rural areas of South Africa. We also did not explore whether there were differences between women seeking abortion services earlier compared to those seeking a second trimester abortion [13] but focused more on the circumstances.
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