Comparative situational analysis of comprehensive abortion care in four Southern African countries

ABSTRACT

We report on a comparative situational analysis of comprehensive abortion care (CAC) in Botswana, Eswatini, Lesotho and Namibia. We conducted systematic literature searches and country consultations and used a reparative health justice approach (with four dimensions) for the analysis. The following findings pertain to all four countries, except where indicated. Individual material dimension: pervasive gender-based violence (GBV); unmet need for contraception (15−17%); high HIV prevalence; poor abortion access for rape survivors; fees for sexual and reproductive health (SRH) services (Eswatini). Collective material dimension: no clear national budgeting for SRH; over-reliance on donor funding (Eswatini; Lesotho); no national CAC guidelines or guidance on legal abortion access; poor data collection and management systems; shortage and inequitable distribution of staff; few facilities providing abortion care. Individual symbolic dimension: gender norms justify GBV; stigma attached to both abortion and unwed or early pregnancies. Collective symbolic dimension: policy commitments to reducing unsafe abortion and to post-abortion care, but not to increasing access to legal abortion; inadequate research; contradictions in abortion legislation (Botswana); inadequate staff training in CAC. Political will to ensure CAC within the country’s legislation is required. Reparative health justice comparisons provide a powerful tool for foregrounding necessary policy and practice change.

KEYWORDS:

• Abortion
• post-abortion care
• Southern Africa
• reproductive justice

Introduction

In this paper, we provide a comparative situational analysis of comprehensive abortion care (CAC) across four southern African countries: Botswana; Eswatini; Lesotho; and Namibia. About one in five pregnancy-related deaths (across the three countries for which there are data) is owing to complications arising from abortion: 21% in Botswana (Statistics Botswana, 2019); 23% in Eswatini (Eswatini Ministry of Health, 2015); 20% in Lesotho (Lesotho Ministry of Health, 2015a). In Namibia, abortion-related complications make up 23% of Maternal¹ Near Misses (women who nearly die but survive a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy) (Heemelaar et al., 2019).

Given the high proportion of pregnancy-related deaths (or maternal mortality ratio (MMR)) accounted for by abortion, as well as each country’s commitment to the Sustainable Development Goal (SDG) of reducing MMR, the reduction of unsafe abortions and an improvement in CAC in the region is needed. CAC is defined by the World Health Organisation (WHO) as provision of information, abortion management (including induced abortion and care related to pregnancy loss) and post-abortion care (World Health Organization, 2022). Access to CAC is marred by numerous barriers in southern Africa. These include restrictive legislation (Matshalaga & Mehlo, 2022), stigma, healthcare providers being ignorant of CAC protocols (Klingberg-Allvin et al., 2018), poor access to, and low quality of, post-abortion services (Ngalame et al., 2020), women living in rural areas having less access than their urban counterparts, and a neglect of adolescent-specific services (Aantjes et al., 2018). Klingberg-Allvin et al. (2018) stress the importance of information provision and capacity building in overcoming these challenges in the region. They argue for the sharing of recent scientific evidence, guidelines and training programmes aimed at increasing women’s access to CAC at the lowest effective level in the healthcare system. This paper contributes to these efforts.

The comparative method we used enables lessons to be learnt across countries as well as highlighting commonalities. Through its use of a reparative health justice approach, this comparative methodology is in line with the gender-transformative approach called for in sub-Saharan Africa (and elsewhere) to address gender-based health inequities through minimising unsafe abortions (Shah et al., 2021).

The selection of the four countries is convenient as each (supported by WHO and United Nations Population Fund – UNFPA) engaged in the process of a Strategic Assessment (World Health Organization (WHO), 2007) on unintended pregnancies, contraception, abortion, sexual- and gender-based violence and HIV. Nevertheless, the countries share the following commonalities: part of the Southern African Development Community (SADC); topographical features that make access to and the provision of healthcare a challenge (two – Botswana and Namibia – have large swathes of desert and a low population density, while the other two are largely mountainous, with higher population densities); signed the Beijing Declaration and Platform for Action (United Nations, n.d.), which contains obligations to attend to reproductive rights, as well as the SADC Protocol on Gender and Development (Southern African Development Community, 2008).

Pertinent country background information

Table 1 outlines some pertinent background information on each country. The Human Development Index (HDI) of the countries differs: Botswana has the highest and Lesotho the lowest. The maternal mortality ratio (MMR) in Eswatini and Lesotho is considerably higher than it is in Botswana and Namibia. All countries’ MMR are more than double the SDG aim of 70 per 100,000 live births. The total fertility rate of all four countries is higher than the global average of 2.5.

Table 1. Pertinent background information.

Country	Population density (people/km^2)	HDI (2020)(United Nations Development Programme, 2020)	MMR (2017)(World Bank, 2022c)	Total fertility rate^a (2020)(United Nations, 2020)
Botswana	3.7 (Statistics Botswana, 2018)	0.735 (high)	144	2.8
Eswatini	63 (Eswatini Central Statistical Office, 2017)	0.611 (medium)	437	2.9
Lesotho	72 (Lesotho Bureau of Statistics, 2018)	0.527 (low)	544	3.1
Namibia	2.8 (Namibia Statistics Agency, 2017)	0.646 (medium)	195	3.3

^a Total number of children that would be born to each woman if she were to live to the end of her child-bearing years and give birth to children in alignment with the prevailing age-specific fertility rates.

All four countries follow the Primary Health Care (PHC) approach: referral systems between community outreach points, mobile units, health clinics, health centres, district or regional hospitals and primary or national referral hospitals.

Background: legislative frameworks

Abortion is legislated through various Acts in the four countries:

• In Botswana, abortion is covered by Sections 160–162 of the Penal Code (Amendment) Act, 1991 within the category of ‘Offenses against Morality’.

• In Eswatini, Section 15 of The Constitution of the Kingdom of Swaziland Act, 2005 criminalises abortion together with providing the conditions under which abortions may be provided.

• In Lesotho, induced abortion is criminalised by Section 45 of the Penal Code Act, 2010 but is permitted under specific circumstances under a ‘defence to a charge’.

• In Namibia, The Abortion and Sterilisation Act (Republic of Namibia, 1975) stipulates the conditions under which abortion may be performed.

The legislative conditions for providing or procuring an abortion in each of the countries is laid out in Table 2.

Table 2. Legislative conditions for providing or procuring abortions.

	Botswana	Eswatini	Lesotho	Namibia
Abortion permitted on the basis of
Woman’s life	Yes	Yes	Women’s health	Yes
Woman’s health (physical)	Yes	Yes		Yes
Woman’s health (mental)	Yes	Yes		Yes
Foetal abnormalities	Yes	Yes	Yes	Yes
Rape or incest	Yes	Yes	Yes	Yes
Unlawful sexual intercourse with a woman with intellectual disabilities	Yes (considered defilement)	On other grounds determined by parliament		Yes
Woman is deemed mentally incapacitated to become a parent				Yes
Other stipulations in law
Gestation limits	Yes – 16 weeks
Police report in the case of rape/incest				Yes
Local magistrate certificate in the case of rape/incest				Yes
Medical certification for medical or therapeutic grounds or foetal impairment	Yes (from two healthcare practitioners)	Yes	Yes (from two healthcare practitioners)	Yes (from two healthcare practitioners not from the same partnership or employer)
Abortions may only be provided in designated state health facilities or registered private facilities	Yes			Yes

In all four countries, abortion performed outside of the legal frameworks is criminalised, carrying prison sentences or fines. With this as background, we now turn to the comparative analysis.

Method

Between 2019 and 2022, the Ministries of Health in Botswana, Lesotho, Namibia and Eswatini, with the support of UNFPA and WHO, embarked on country-specific Strategic Assessments. The initial stage consisted of background papers on current data and research (written and developed by the authors). This article is based on these background papers.²

For each background paper, we obtained information through desk-based searches and documentation supplied by UNFPA and WHO Country Offices, and by members of relevant Ministries, NGOs, statutory bodies and educational institutions (the first author conducted country visits, except in the case of Namibia owing to COVID restrictions). We accessed peer reviewed research via searches of the following databases: Academic Search Premier; ERIC (Education Resource Information Centre); Health Source: Nursing/Academic Edition; Medline; PsyArticles; PsyINFO; SocIndex; Sabinet; Web of Science and Google scholar. Grey literature was accessed through desk-based searches and references made by key informants and references within reports already obtained. The search was restricted to the last decade to ensure that the information is current. As the background papers were based on public documents, no ethics approval was necessary for this segment of the programme.

For this paper, we used the background papers to perform a comparative analysis. To do so, we used a reparative health justice approach, based on Verdeja’s (2008) work and used in other analyses on abortion (Macleod & Reynolds, 2021) and early reproduction (Macleod & Feltham-King, 2020). The approach is broadly located within a reproductive justice stance in which the impact of multiple interweaving forms of oppression is recognised and rights and the ability to exercise rights are viewed in context (Morison, 2023; Ross & Solinger, 2017). To our knowledge, this is the first time that the reparative health justice approach is being used for comparative purposes.

In general, reparative justice implies recompense or restitution for an injustice in which a person’s rights (in this case health rights) have been harmed. Applied to reproductive health, the approach advocates interlinked multi-sectoral remedies or recompenses when pregnant people’s rights to reproductive healthcare are jeopardised. Drawing on the interweaving of the politics of (re)distribution (just and fair distribution of material resources, especially in cases of material inequities) and of recognition (the right to ethical self-definition or identity), the model involves analyses of two conditions: material/objective conditions and symbolic/subjective, identity-based conditions. These are analysed at two levels: individual and collective. The combination of conditions and levels allows for four ‘ideal-typical’ dimensions to be analysed: individual material; collective material; individual symbolic, and collective symbolic. These dimensions are described in relation to comprehensive abortion care in Figure 1 (adapted from Macleod 2019).

Figure 1. Reparative justice in relation to CAC.

The first two authors went through the background papers, using the dimensions as templates in which to categorise the information contained in the background papers, as these papers were not written using the reparative justice dimensions. The categorisation was checked by the other authors for accuracy. There were no disagreements regarding the categorisation.

The limitations of this comparative study are as follows. The documents accessed for the background papers do not necessarily refer to the same indicators in each country. Where the same indicators are referred to, they may vary across the countries in terms of the years in which they were gathered. The concentration on contraceptive prevalence as an indicator of public health success has been questioned. Senderowicz (2019, 2020), for example, highlights contraceptive coercion and argues, instead, for the measurement of contraceptive autonomy. Finally, the recompenses or remedies suggested are ideal; some may require the allocation of fiscal and human resources beyond the countries’ current governance capacities. We, nevertheless, outline these ideal remedies, with an indication at the end of the initial processes that could be taken on the road to these ideal remedies.

Findings

In the tables that follow, we outline the indicators, data and information available for each country within the various dimensions. Injustices are highlighted in grey. These injustices are identified on the basis of the reparative health justice principles outlined above. The column on the right suggests the remedy to be put in place to overcome the highlighted injustices.

Individual material dimension

The individual material dimension is outlined in Table 3.

Table 3. Individual material dimension.

Botswana	Eswatini	Lesotho	Namibia	Remedy
Employment to population ratio (number of workers – general, women, men – currently employed against the total working-age population) (World Bank, 2022b)
2020: General: 52.4%; Women: 42%; Men: 58.5%	2016: General: 39.5%; Women: 36%; Men: 44.1%	2019: General: 47.9%; Women: 45%; Men: 56%	2018: General: 47.2%; Women 45%; Men 49.5%	Reduce gender inequities in employment
Country performance on 72 SDG gender indicators (high performance: > 66th percentile; medium performance: 33rd to 66th percentile; low performance: < 33rd percentile) (UN Women, 2022)
% performance that is: High: 20.5% Medium: 11.5% Low: 3.3% Missing data: 64.7%	% performance that is: High: 21.3% Medium: 6.6% Low: 8.2% Missing data: 63.9%	% performance that is: High: 16.4% Medium: 13.1% Low: 4.1% Missing data: 66.4%	% performance that is: High: 11.5% Medium: 9% Low: 13.9% Missing data: 65.6%	Reduce missing data to improve gender equity planning; improve performance on gender indicators
Contraceptive use prevalence (any method) 15–49 years (2009–2019)^a (United Nations, 2020)
67.4%.	66.1%.	64.9%	56.1%	Continue – global average 49%
Unmet need for contraception (2009–2019) (United Nations, 2020)
17.3%	15.2%	16%	17.5%	Improve contraception services in disadvantaged areas; improve youth friendly services
More likely amongst women residing in rural areas, poorer women, women aged 15–19 and 45 + years
Unintended pregnancies
No national data; 43% in one study (Doherty et al., 2018); 44% in another (Mayondi et al., 2015).	No national data. 70% in one study (Niemeyer Hultstrand et al., 2019) conducted in a disadvantaged community. 69.2% in another study (Warren et al., 2013) amongst postpartum women	30% mistimed, 22% unwanted (Lesotho Ministry of Health, 2016)	10% unintended; 41% mistimed (Namibia Ministry of Health and Social Services, 2014).	Collect national data. Improve youth friendly and contraceptive services
Rape survivors’ access to legal abortions
One study: of rape survivors who had an abortion, 49% had an illegal abortion (Ministry of Nationality Immigration and Gender Affairs, 2018)	Researchers note ‘The new law … [makes] it difficult for women to know their rights and obtain legal abortion, and for healthcare professionals to know their obligations’ (Mavundla & Ngwena, 2014, p. 69)	Nothing specific, but there is reluctance amongst Basotho women to talk about experiences of date and marital rape (Khau, 2007).	The Combating Rape Act (Act No. 8 of 2000) is seen as one of the world’s most progressive rape laws; but there are onerous conditions for obtaining a legal abortion – district surgeon agreement; police and magistrate’s certification.	Remove barriers to rape survivors accessing legal abortion
Gender-based violence (GBV)
Life-time prevalence: 67% in 2012 (Department of Women’s Affairs and GenderLinks, 2012) reduced to 37% in 2018 (Ministry of Nationality Immigration and Gender Affairs, 2018) after institution of various GBV prevention programmes	Data difficult to obtain. One study: 48% of girls and women between the ages of 13–24 reported having experienced some form of sexual violence (Centers for Disease Contol and Prevention (CDC), 2018)	86% of women experienced some form of GBV; 40% of men admitted to perpetrating GBV at least once (Lesotho Ministry of Development Planning, 2018)	One in three (32%) women aged 15–49 experienced physical violence since age 15; 7.2% experienced sexual violence (Namibia Ministry of Health and Social Services, 2014)	Reduce GBV through a range of programmes, including ones targeted at reducing harmful forms of masculinities and gender norms.
HIV prevalence (2020)(UNAIDS, 2021)
19.9%	26.8%	21.1%	11.6%	Reduce HIV rate
Post-abortion care received
Evidence of delayed patient care and prolonged hospital stay (Melese et al., 2017).	No research	No research	Long waiting periods; shortage of anaesthetists and theatre rooms in State hospitals (HEARD, 2016). Women presenting at healthcare facilities with abortion-related complications are unlikely to receive the required quality of post-abortion care needed (Owolabi et al., 2019)	Conduct research on post-abortion care. Increase quality of care; implement recommendations outlined in the WHO abortion guideline (World Health Organization (WHO), 2022)

^a The concentration on contraceptive prevalence as an indicator of public health success has been questioned. Senderowicz (2019, 2020), for example, highlights contraceptive coercion and argues, instead, for the measurement of contraceptive autonomy.

There are clear material gender injustices across all four countries. Employment is lower for women than men in all countries bar Namibia and performance on the SDG gender indicators are low in all four. Unmet need for contraception affects just below 1 in 5 women, with many marginalised women being worse affected. Unintended or mistimed pregnancies hover around 50% in the two countries where data are available (Lesotho and Namibia). Legal abortion appears to be difficult to obtain, especially for rape survivors. Gender-based violence and HIV prevalence are high. Where data are available, post-abortion care has been found to be suboptimal.

Collective material dimension

The collective material dimension is outlined in Table 4.

Table 4. Collective material dimension.

Botswana	Eswatini	Lesotho	Namibia	Remedy
Healthcare fees
Primary public healthcare services free of charge	Fees structured around level of service (post-abortion care is charged for)	Primary public healthcare services free of charge	Primary public healthcare services free of charge	Make all contraception- and abortion-related services free of charge for users
Overall health expenditure as a percentage of GDP (2019) (World Bank, 2022a)
6%	6.7%	11.2%	8.5%	Increase healthcare expenditure to approximate world average: 9.83%
SRH health budget
No clear health budget allocated to SRH services (Government of Botswana, 2019).	Data on the financing of SRH are difficult to obtain. Where a budget line for SRH is shown, it hides the allocation across functional activities and mixes government and development partner funds (Eswatini Ministry of Health, 2018)	Specific budget allocations for family and reproductive health (Kingdom of Lesotho, 2019)	Reproductive healthcare expenditure clear, but declining (38% in 2012/2013 compared to 14% in 2016/2017) (The World Bank, 2019)	Develop clear and sustainable budget line items for SRH care, and within this for abortion services
Donor funding in SRH
Reduced donor funding based on Human Development Index (HDI) – focused on HIV (Botswana Ministry of Finance and Economic Development, 2017)	Over-reliance on donor funds; only salaries and procurement paid by government; lack of government capacity to utilise funds optimally (National Emergency Response Council on HIV and AIDS (NERCHA), 2018)	Over reliance on donor funds (Lesotho Ministry of Health, 2019)	Reduced donor funding based on HDI – focused on HIV (The World Bank, 2019)	Create sustainability across donor and government funding.
N/A	N/A	CHAL^a operates 38% of health centres and some district hospitals – mainly in rural and remote areas (Lesotho Ministry of Health, 2019)	N/A	Ensure contraception and CAC are offered in areas covered by CHAL
Data collection and management
Poor integration across data management systems and collection methods; manually collected data; data not aligning with protocols or policy; insufficient technical capacity to analyse or interpret data; Demographic and Health Surveys (DHS) performed infrequently; DHS not including questions on abortion (Botswana Ministry of Health, 2019; Eswatini Ministry of Health, 2019a; Lesotho Ministry of Health, 2018; Titus et al., 2015)				Improve data collection and management capacities; conduct frequent DHSs with appropriate abortion questions
Health data on abortion difficult to obtain	Data collected on: spontaneous abortion; unspecified abortion; complications of abortion; failed attempted abortions; missed abortions; other (Kingdom of Eswatini, 2015)	Health data on abortion difficult to obtain	Abortion care registers available in fewer than 40% of national hospitals, 37% of district hospitals and 2% of health centres (HEARD, 2016)	Improve data collection on incidence of abortions; understand the limitations of data collection (stigma; fear of criminal liability).
Pregnancy-related death reviews
Yes	Yes	Yes	Not properly recorded in health facilities with only intermediate and district hospitals conducting the reviews (Namibia Ministry of Health and Social Services, 2016)	Ensure reviews are conducted in all facilities
Health staffing
Health workers most densely concentrated in the urban areas (Botswana Ministry of Health, 2018a).	2019: Doctors: 17 per 100,000 people (up from 13); Nurses: 127 per 100,000 people (down from 150)(Eswatini Ministry of Health, 2019a)	Acute shortages – six nurses, one physician and one pharmacist for every 1000 (Government of Lesotho, 2018)	Understaffed and overstretched, especially doctors and pharmacists; regional distribution (Titus et al., 2015)	Improve health staffing and distribution through careful fiscal and human resource planning.
Legal abortion services
No information found	11% of facilities provide manual removal of placenta; 40% of facilities provide post-abortion care (Eswatini Ministry of Health, 2019b)	10% of facilities provide full range of safe abortion care; medical abortion provided in 18% of hospitals, 14% of health centres, and 25% of filter clinics. No guidelines for induced abortion (Lesotho Ministry of Health, 2015b).	Majority of abortions performed in State hospitals only (HEARD, 2016). Abortion care registers available in < 40% of national hospitals, 37% of district hospitals, and 2% of health centres (Namibia Ministry of Health and Social Services, 2016)	Increase facilities and staff able to offer safe abortion through fiscal and human resource planning, and up-skilling of current reproductive healthcare staff. Keep up-to-date abortion registers.
Post-abortion services
Pain management and antibiotics use not standardised (Melese et al., 2017)	40% of health facilities provide post-abortion care; guidelines, standard operating procedures and jobs aids for post-abortion care inadequate, not up-to-date and poorly disseminated (Eswatini Ministry of Health, 2019b)	15% of hospitals and health centres provide post-abortion care (Lesotho Ministry of Health, 2015b)	In a multi-country study (Owolabi et al., 2019) using eight key signal functions to managing post-abortion care, found that Namibia was one of the worst performing countries.	Improve post-abortion care using the WHO abortion guideline (World Health Organization (WHO), 2022)
Availability of emergency contraception
Yes. No further information	Yes. No further information	Yes, but in 2012, 25–30% of facilities did not stock emergency contraception (Lesotho Ministry of Development Planning, 2012)	Yes. Emergency contraception was previously available to survivors of sexual violence only. The National Guidelines on Family Planning (2019) (Namibia Ministry of Health and Social Services, 2019) make emergency contraception more widely available.	Ensure emergency contraception is stocked in all facilities.
Youth friendly services
Despite a number of initiatives, challenges include, inter alia, weak coordination structures, low prioritisation of services, and lack of funding (Botswana Ministry of Health, 2018a)	80% of facilities provide youth-friendly services (Eswatini Ministry of Health, 2018). However, fewer than half of youth utilise SRH services. The SRH service providers accessed most are pharmacies, followed by hospitals and shops (Eswatini Ministry of Health & UNFPA, 2016)	Policy commitment, but no information on actual services	Over half of the adolescents who accessed youth friendly services were not provided with the sufficient and correct SRH information. Respondents also reported poor treatment by healthcare workers and discomfort with having to share clinic spaces with adults (Namibia Ministry of Health and Social Services, 2018)	Improve youth friendly services through implementing recommendations from the WHO guidelines, Making health services adolescent friendly(World Health Organization, 2012)
GBV services
Government’s multi-sectoral mechanism to enhance prevention of GBV holds promise (Botswana Ministry of Nationality Immigration and Gender Affairs, 2018). Bottlenecks include limited financial and human resources, limited capacity building, weak facility readiness, insufficient data, and inadequate shelter for survivors of GBV (Botswana Ministry of Health, 2018a; Botswana Ministry of Nationality Immigration and Gender Affairs, 2018)	Multi-sectoral regional referral networks of responders to gender-based violence have been piloted. Poor resourcing of the Department of Gender and Family Issues, limited institutionalisation of gender focal points, geographically skewed civil society initiatives, limited numbers of social workers and a reliance on volunteerism limit the reach and effectiveness of responses (Eswatini Deputy Prime Minister’s Office and Department of Gender and Family Affairs, 2017).	Policy commitment and initiatives in place, but no information on effectiveness or challenges.	Progress has been made, but challenges remain: weak coordination, lack of sustainability, lack of conceptual understanding of GBV, over reliance on donor funding, and a lack of standard tools and guidelines for case management and data collection (Gawaya, 2016).	Improve GBV services through, inter alia, fiscal and human resource capacitation, suitable provider training, improving facility readiness, increasing the number of shelters, strengthening civil society dealing with GBV, improving data collection, creation of standard guidelines.

^a CHAL stands for Christian Health Association of Lesotho, which forms part of the Roman Catholic Church. CHAL does not provide contraceptive services, legal abortion or post-abortion services.

In two countries (Botswana and Eswatini) health expenditure is lower than the world average, and there is no clear SRH health budget. Over-reliance on donor funding creates a challenge for sustainability in Eswatini and Lesotho. Health data collection and management is poor across all countries, with data on abortion being difficult to obtain in Botswana, Lesotho and Namibia. In all countries, health staffing is a problem (shortages and inequitable distribution across rural and urban areas). Legal abortion and post-abortion care services are suboptimal, as are youth friendly services. Emergency contraception is available, but there is little information on its distribution. Although some progress has been made in relation to GBV services in all four countries, significant challenges remain.

Individual symbolic dimension

The individual symbolic dimension is outlined in Table 5.

Table 5. Individual symbolic dimension.

Botswana	Eswatini	Lesotho	Namibia	Remedy
Discriminatory gender norms
42.9% of women and 55.4% of men believe that a woman should obey her husband (Ministry of Nationality Immigration and Gender Affairs, 2018).	29% of men and a third of women felt that a husband was justified^iv in hitting his wife (Eswatini Central Statistical Office and UNICEF, 2016).	A third of women and 40% of men agreed that a husband is justified^a in hitting or beating his wife (Lesotho Ministry of Health, 2016)	28% of women and 22% of men aged 15–49 justified beating as an acceptable way for a husband to discipline his wife (Namibia Ministry of Health and Social Services, 2014)	Active social campaigns to undermine discriminatory gender norms
Stigma attached to abortion and/or non-marital/early pregnancies
Abortion is seen as shameful, immoral, and as conflicting with the role of women. Unwanted pregnancies are viewed as the result of irresponsible sexual behaviour (Smith, 2012; Smith, 2013)	Sexually active adolescents often do not go to the clinic for fear of health care worker attitude and the condemnation (Eswatini Ministry of Health & UNFPA, 2016)	Young people requesting abortions are less likely to receive services; youth experience judgemental attitudes from healthcare providers, and inadequate confidentiality and privacy (Lesotho Ministry of Health, 2012)	General attitudes towards abortion are negative, and religious groups strongly oppose it (HEARD, 2016)	Active social campaigns to de-stigmatise early or unwed pregnancies, and to normalise abortion as a standard healthcare procedure
Knowledge of abortion law
Rape survivors who access illegal services cite lack of knowledge of the law (Ministry of Nationality Immigration and Gender Affairs, 2018)	No information	No information	An NGO group, Sister Namibia, maintains that women do not know their abortion rights and many believe that abortion is illegal in all circumstances (Billings & Mallett, 2009).	Conduct research on the population’s knowledge of the stipulations under which legal abortion may be obtained; active social campaigns to increase knowledge of legal abortion
Knowledge of emergency contraception
Only 53% of University of Botswana students had good knowledge of emergency contraception (Kgosiemang & Blitz, 2018)	No recent information	No information	No information	Conduct research on the population’s knowledge of emergency contraception; active social campaigns to increase knowledge of EC

^a Under the following circumstances: burns the food, argues with him, goes out without telling him, neglects the children, refuses to have sexual intercourse with him.

Significant injustices are highlighted in Table 5. These include, across all four countries, discriminatory gender norms, and stigma attached to abortion and/or non-marital or early pregnancies. These norms and stigma potentially form barriers to healthcare seeking as women fear judgemental attitudes from staff and others. Where data are available, women’s knowledge of the respective countries abortion laws appears to be poor (Botswana and Namibia). Information on women’s knowledge of emergency contraception is lacking, except for in Botswana where it appears to be poor.

Collective symbolic dimension

The collective symbolic dimension is outlined in Table 6.

Table 6. Collective symbolic dimension.

Botswana	Eswatini	Lesotho	Namibia	Remedy
National abortion and post-abortion guidelines
Yes. Comprehensive Post Abortion Care Reference Manual (Botswana Ministry of Health, 2013); and Comprehensive Post Abortion Care Trainer’s Manual (Botswana Ministry of Health, 2016) [includes legal abortions]	No. Brief guidance on abortions and post-abortion care included Essential Health Care Package for Swaziland (Eswatini Ministry of Health, 2010) and Standard Treatment Guidelines & Medicines List (Eswatini Ministry of Health, 2012).	No. Post-abortion care outlined in Integrated Management of Pregnancy and Childbirth. Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice (Lesotho Ministry of Health, 2014)	No	Develop national CAC guidelines in line with legislation
Access to legal abortion services referenced in other policies/protocols/guidelines See tables below for details of how abortion is referenced
Contradictions in abortion legislation
Abortion may be legally performed for foetal abnormality prior to 16 weeks gestation; screening for many foetal abnormalities possible 15–20 weeks	N/A	N/A	N/A	Resolve legislative contradiction
Research on abortion and post-abortion care
No	No	No	No	Increase relevant research; improve monitoring and evaluation capacity in all areas of CAC
Adequate training of health service providers in CAC
Fewer than 5% of health care providers working in health facilities have undergone training in post-abortion care (Botswana Ministry of Health, 2018b).	No information	21% of emergency obstetric staff trained on MVA. and 16% on D&C (Lesotho Ministry of Health, 2015a)	Outdated information	Provide training. Update or collect information on training. Monitor and evaluate training.
Public health campaigns on conditions and procedures for accessing legal abortion
No. Comprehensive post-abortion guidelines do not mention referral mechanisms for legal abortion	Policies that do speak to abortion are not specific on mechanisms for procuring a legal abortion	Policies that do speak to abortion are not specific on mechanisms for procuring a legal abortion	Policies that do speak to abortion are not specific on mechanisms for procuring a legal abortion	Information and education about accessing legal abortion through various communication channels, including at local clinic level.

The only country with any abortion guidelines is Botswana, although these are focussed on post-abortion care. No research specifically focussing on legal abortion services or post-abortion care could be located in any of the countries. Where information is available, training of health service providers in CAC is suboptimal. The procedures whereby legal abortions may be obtained are not addressed in policy or protocols in any of the countries.

In the tables below (Tables 7–10), we outline how national and health sector policies in the four countries address abortion. All countries acknowledge that unsafe abortion is an issue that needs to be addressed in reducing pregnancy-related mortality. Notably, for all countries, except Botswana, policies do not provide specific details and guidelines for providing safe abortions within the ambit of their respective legislative frameworks. Policies across all four countries speak to managing unsafe abortions by preventing abortion, clinical management of incomplete abortion, and providing post-abortion care and counselling.

Table 7. Botswana government policies and guidelines.

Policy	Reference to related issues (where obvious in the title the cell is left blank)	Reference to abortion
National Policy
National Development Plan 11 (NDP 11) (2017c)	Acknowledges that pregnancy-related mortality and high levels of GBV are areas of concern.	None
Health Sector Policies
The National Health Policy: Towards a Healthier Botswana, December 2011 (2012)	Mentions pregnancy-related mortality targets, but not contraception or SRH	None
The Essential Health Service Package for Botswana (EHSP)	SRH is mentioned as one of the four components of care.	Outlines staff competencies for post-abortion care and counselling. Procedures for legal abortions are not covered.
Botswana Integrated Sexual, Reproductive, Maternal, Newborn, Child and Adolescent Health & Nutrition (RMNCAH&N) Strategy (2018–2022)		Includes the scale up and provision of post-abortion care. Procedures for legal abortions are not covered.
Policy Guidelines and Service Standards: Sexual and Reproductive Health		Provides details on post abortion care and counselling. Procedures for legal abortions are not covered.
Comprehensive Post Abortion Care Reference Manual^60 and Comprehensive Post Abortion Care Trainer’s Manual^61.		Provides comprehensive post-abortion guidelines; addresses circumstances under which induced abortion may be legally performed; covers various types of abortions; addresses contextual issues in relation to abortion

Table 8. Eswatini government policies and guidelines.

Policy	Reference to related issues (where obvious in the title the cell is left blank)	Reference to abortion
National Policy
National Development Strategy (NDS), Vision 2022 (1997)	Addresses reproductive healthcare service delivery, gender disparities, strengthening the ‘fight against HIV’, and establishing shelters for women who experience abuse.	Aims to prevent abortion and improve the management of unsafe abortions. No reference to legal abortion.
Health sector policies
The Standard Treatment Guidelines and Essential Medicines List of Common Medical Conditions in the Kingdom of Swaziland of 2012 (2012)	Includes section on gynaecology and obstetrics, including ‘sexual assault’ and family planning.	Guidance on post-abortion care, including non-pharmacological and pharmacological treatment and referrals. No guidance on inducing (legal) abortion.
The Pocket Book Guidelines and Protocols for Common Obstetric Emergencies and Clinical Conditions for Doctors and Midwives: Swaziland EmONC Services (2016)		Miscarriage mentioned, but not induced abortion or complications from abortion. No specific guidelines for emergency care following induced abortions or for the provision of legal termination of pregnancy services.
The National Policy on Sexual and Reproductive Health 2013		Acknowledges legal conditions for abortion. Commits to providing comprehensive information and quality health services to reduce incidence, manage abortions, and prevent complications of abortion.
Eswatini Ministry of Health Guidelines for Health Sector Response to Sexual Violence – Clinical Management (2018)		Legal provision of abortion as per the constitution mentioned.
The draft SRMNCAH&N Strategic Plan 2019–2023 (2019)	Strategic plan for a range of SRH issues. Flags septic abortion as a leading cause of pregnancy-related mortality.	Strategic aims are to improve post abortion care and contraceptive services post abortion. Acknowledges inadequate and poorly disseminated guidelines for post abortion care. Legal abortion not mentioned.
The National Multisectoral HIV and AIDS Strategic Framework 2018–2023(2009)	HIV/AIDS plan. Refers to the prevention of GBV and the care of those exposed to such violence.	Silent on abortion.

Table 9. Lesotho government policies and guidelines.

Policy	Reference to related issues (where obvious in the title the cell is left blank)	Reference to abortion
National Policy
National Strategy Development Plan (NSDP) 2012/13–2016/17 (2012)	Places emphasis on the promotion of gender equality and the empowerment of women.	No direct mention of abortion
Health Sector Policies
The National Health Strategic Plan (NHSP) 2017–2022(2016d)	Developed to meet SDG3. A number of SRH action areas are identified.	Acknowledges that abortion is one of the top causes of female hospital admissions.
The Essential Service Package	Sexual and reproductive health is one of the five components of care.	Lists providing vacuum aspiration of incomplete abortions at the hospital level. Legal induced abortion not mentioned
National Addis Ababa Declaration on Population and Development (AADPD) Plus Five Review Report: Final Report (2018)	A SRH health policy	Includes management of unsafe abortion as a priority health area. Legal abortion not mentioned.
National Quality Standards for Young People Friendly Health Services in Lesotho		Outcomes include reducing unsafe abortions among young people aged 18–24. Calls for: screening for complications of unsafe abortions, the availability of post-abortion care, and for safe abortion services on medical grounds being available
Lesotho National Family Planning Guidelines for Health Service Providers		Mentions reducing abortions but legal abortions and post-abortion care is not mentioned as part of this package.
Health care for people subjected to intimate partner violence or sexual violence: A Clinical Handbook		Provision of emergency contraception and referral for abortion are covered. Counselling for these procedures is explained and informed consent for examination, treatment and for the release of information to third parties, such as the police and the courts, is emphasised.
National guidelines for medico-legal care for survivors of sexual violence 2018		Includes pregnancy prevention (i.e. emergency contraception) and abortion services
Integrated Management of Pregnancy and Childbirth. Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice		Guidelines for post-abortion care are provided. Guidance on treatment and advice is given for complicated abortion, threatened abortion, complete abortion, and ectopic pregnancy.
Standard Treatment Guidelines for Lesotho 2017.	Has section on Gynaecology and Obstetrics	No guidelines for performing induced abortions, but rather the treatment of threatened abortion, inevitable abortion, complete abortion, incomplete abortion, missed abortion or septic abortion

Table 10. Namibian government policies and guidelines.

Policy	Reference to related issues (where obvious in the title, the cell is left blank)	Reference to abortion
National policy
Namibia’s Fifth National Development Plan	Speaks to gender equality, pregnancy and antenatal care	No reference to abortion
Health Sector Policies
National Health Policy Framework 2010–2020 (2010)	Addresses HIV/AIDS, reproductive and adolescent health issues	Mentions unsafe abortion only once (in relation to adolescent health)
National Policy on Reproductive and Child Health (2012)		Briefly mentions providing abortion within the ambit of legislation, and post-abortion care
Guidelines on Essential and Emergency Obstetric Care (2009)		Acknowledges unsafe abortion but does not provide information on clinical management of post-abortion care
Namibia Standard Treatment Guidelines (2011)	Contains a section on Obstetrics and Gynaecology	Provides guidelines for performing different types of abortion but post-abortion care and counselling are not included
Operation Theatre Manual (2015)	Specifies major drapes for ectopic pregnancy operations	Details provision and recording of legal abortions
Clinical Handbook on the Health Care of Survivors Subjected to Intimate Partner Violence and/or Sexual Violence (2016)		Provides advice on when abortion may be legally performed
Namibia National Strategy for Women, Children, Adolescents – Health and Nutrition 2018–2022 (2018)	Covers a range of SRH issues	Identifies post-abortion care as a key strategic priority. Legal abortion not mentioned.
National Guideline on Antenatal Care for a Positive Pregnancy Experience (2020)		Explains how to perform different types of abortions

Discussion

Despite the fact that abortion is legal under specific circumstances in all four countries, health data collection and management is sub-optimal. This indicates a need for health information systems to keep accurate data to assist with CAC planning and implementation. The implementation and monitoring of quality of care abortion service indicators as developed by Darney et al. (2019) for low- and middle-income countries as well as recommendations from the WHO Abortion care guideline (World Health Organization, 2022) could assist in overcoming some of the challenges noted.

There is little research on post-abortion care in all four countries. Where studies have been conducted, the quality of post-abortion care appears to be substandard, including delayed care and prolonged hospital stays (Botswana and Namibia), inadequate standard operating procedures (Eswatini), few facilities offering post-abortion care (Lesotho), and signal functions of quality post-abortion care not being instituted (Namibia). Ongoing research should be funded, and poor areas of CAC functioning addressed in country-specific CAC Guidelines.

Access to legal abortion is minimal (e.g. few rape survivors are able to or do claim their legal right to abortion). Botswana is the only country with guidelines on post-abortion care. While the reduction of unsafe abortion and the provision of post-abortion care appear in a number of policies in all countries, information on the legal procedures for procuring an abortion is limited within policies and protocols and for the general population. Such information should be inserted into relevant policies and protocols and a range of health communication channels; and Comprehensive Abortion Care Guidelines should be developed.

Insufficient mention is made in policies regarding accessing, referring for, and conducting legal and safe abortion. Where research is available (Botswana and Lesotho), healthcare provider training in CAC has been shown to be suboptimal. To rectify this, CAC guidelines should be developed to ensure that providers are trained in CAC.

It is important that the needs of particular pregnant people are noted in the CAC Guidelines. For example, given the high prevalence of HIV in the region, the needs of pregnant people living with HIV for information and options concerning both safe pregnancies (e.g. prevention of mother to child transmission) and safe abortions (Orner et al., 2011) should be considered in devising policy and implementing CAC services. The needs of young people in relation to abortion, including privacy, non-coerced decision-making (in particular in relation to parents) and non-judgmental service provision (Macleod, 2017) should also be considered.

It is clear that gender inequities continue to plague all four countries, including gender-based violence, inequitable material conditions, and negative gender norms. Given that higher gender equality is linked with reduced rates of induced abortion (Dema Moreno et al., 2020; Uzoigwe, 2017), careful programming to reduce gender inequities is indicated. This is a cross-cutting issue for all Ministries and should not be delegated solely to Ministries dedicated to gender issues. An example of where such an interdisciplinary approach has been successful is the Botswana government’s implementation of a multi-sectoral mechanism to enhance prevention of GBV, which appears to have led to a decrease in GBV.

Health expenditure in Botswana and Eswatini is below the global average. In three of the countries (Botswana, Eswatini and Namibia), SRH services do not have a clear budget allocation. This should be rectified. There is an over reliance on donor funding in Eswatini and Lesotho, which threatens the sustainability of programmes. Where donor funding sets up programmes, these should be sustained through internal funding.

The health workforce is understaffed, and inequitably distributed. Given the topographical challenges of the four countries, the staffing of rural health facilities is essential for proper service delivery, including CAC, in these areas.

Although the contraceptive use prevalence is higher than the global average and emergency contraception is stocked in all four countries, unmet need for contraception persists – especially amongst poorer, rurally-based, younger and older women. Careful supply chain management is needed to avoid stock-outs, and contraceptive support through public health clinics and community services strengthened.

Conclusion

Abortion (unspecified) accounts for about one in five pregnancy-related deaths in the four countries in which we conducted this situational analysis. Using a reparative health justice approach, we showed that there are several injustices – across individual material, individual symbolic, collective material, and collective symbolic dimensions – associated with women’s agentic decision-making regarding whether and under what circumstances to have children. The conditions needed to prevent unwanted pregnancies, both economic and health-related, require further work. This applies particularly to gender inequities, and requires cooperation across a range of Ministries tasked with governing education, economic development, labour, health and gender.

Access to safe, legal abortion appears to be minimal, and post-abortion care suboptimal. Policy guidance from relevant ministries and programme managers as well as service implementation to reach CAC are much needed.

All four countries are committed to the SDGs. Women’s access to sexual and reproductive health and rights and services, including CAC, are directly linked to reductions in pregnancy-related mortality (SDG 3). However, the benefits do not end there. Women’s and girls’ lack of autonomy over their health can limit their outcomes on education (SDG 4), sanitation and hygiene (SDG 6), employment (SDG 8) and political participation (SDG 10). Where inequities have been addressed through reparative justice, empowered women and girls contribute to promoting peaceful and inclusive societies (SDG 16), creating opportunities for decent work and employment (SDG 8), therefore also to poverty reduction (SDG 1) (Leone et al., 2017).

While this paper focusses on four countries in southern Africa, this type of analysis, and the lessons learnt from this analysis may be of use to other regional or international policy-makers. The reparative health justice framework is a relatively new addition to the analytical possibilities in reproductive health, in particular a gender transformative approach. The analysis conducted above illustrates its usefulness in highlighting cross-cutting, as well as specific policy and practice implications, across multiple countries.

Acknowledgements

The authors thank the Ministeries of Health, and the UNFPA and WHO country offices in each of the four countries, as well as colleagues in the UNFPA/WHO 2gether4srhr initiative for the information shared and for comments on the background papers that formed the basis of this paper.

Disclosure statement

The named authors alone are responsible for the views expressed in this publication and do not necessarily represent the decisions or the policies of the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) or the World Health Organization (WHO).

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This work is based on research supported by the United Nations Population Unit (UNFPA) through the UNFPA/WHO 2gether4srhr initiative, and the South African Research Chairs initiative of the Department of Science and Technology and National Research Foundation of South Africa [grant number 87582].

Notes

1 The terms maternal mortality and maternal near misses assume that pregnant people are cisgender women and that they are or will be mothers. We opt for the ‘pregnancy-related deaths’ where feasible but use maternal mortality where that term is used in various documents (e.g. SDGs). We are aware that the use of the word ‘women’ creates a gender binary that does not acknowledge the existence of queer and non-binary people. We use the word in line with current data.

2 Lesotho did not go beyond the background paper.