Addressing Systemic Barriers in Abortion Care Across Southern Africa: A Call for Reform

A situational analysis by Rhodes University, WHO, and UNFPA highlights systemic barriers, gender inequities, and inadequate healthcare infrastructure in abortion care across Botswana, Eswatini, Lesotho, and Namibia. The study calls for comprehensive policy reforms, better resource allocation, and public education to address reproductive health inequities and reduce maternal mortality​

A detailed situational analysis of comprehensive abortion care (CAC) in Botswana, Eswatini, Lesotho, and Namibia conducted by researchers from Rhodes University, the World Health Organization (WHO), and the United Nations Population Fund (UNFPA) reveals critical gaps in reproductive health services. Despite these nations’ commitments to the Sustainable Development Goals (SDGs), abortion-related complications contribute significantly to maternal mortality, accounting for nearly one-fifth of pregnancy-related deaths. The findings highlight systemic barriers, societal stigma, and insufficient healthcare infrastructure, all of which hinder access to safe and legal abortion. This research underscores the pressing need for robust policy interventions and resource allocation to address these reproductive health inequities.

Legal Frameworks and Systemic Barriers

Abortion laws in these countries allow the procedure under specific conditions, including cases of rape, incest, or fetal abnormalities. However, restrictive implementation processes create significant barriers. Survivors of sexual violence often face cumbersome requirements, such as police reports or magistrate certification, which discourage them from accessing legal abortion services. In Botswana, fewer than five percent of healthcare providers have been trained in post-abortion care, while Namibia’s healthcare system is plagued by severe staff shortages, particularly in rural areas. Eswatini’s dependence on donor funding for sexual and reproductive health (SRH) programs further exacerbates the problem, raising sustainability concerns. Meanwhile, Lesotho’s healthcare infrastructure struggles to provide safe abortion services, with only a small percentage of health facilities equipped to offer comprehensive care. These systemic weaknesses leave women vulnerable, particularly in underserved rural areas.

The Impact of Gender Inequities and Societal Stigma

Gender-based violence (GBV), high HIV prevalence, and entrenched gender inequities further complicate the reproductive health landscape in these countries. Women in rural areas, economically disadvantaged groups, and adolescents bear the brunt of these challenges. Unmet contraceptive needs range between 15% and 17.5%, while stigma against abortion and early pregnancies creates significant barriers to healthcare. For instance, societal attitudes in Namibia and Botswana view abortion as immoral and women seeking it as irresponsible. Young people requesting abortion services often face judgmental attitudes from healthcare providers and inadequate privacy. This stigma pushes many women to resort to unsafe abortions, risking severe complications or death. Moreover, the lack of youth-friendly reproductive health services, coupled with discomfort in clinic environments, further deters adolescents from seeking safe healthcare options.

Policy and Knowledge Gaps

The absence of comprehensive national guidelines for CAC across the four countries is a major obstacle. Botswana is the only country with some form of post-abortion care manuals, yet these do not comprehensively address the full scope of CAC. Other countries lack specific CAC guidelines, and existing policies often focus on managing unsafe abortions rather than preventing them through access to safe and legal services. Public awareness campaigns about abortion rights are virtually non-existent. For example, in Namibia, many women incorrectly believe that abortion is entirely illegal. Additionally, healthcare providers often lack clear guidance on legal abortion protocols, further compounding the challenges for women seeking services. Inconsistent and insufficient health data collection systems also hinder effective policy-making. Demographic and health surveys in these countries often exclude questions about abortion, making it difficult to assess the scale of unsafe procedures and their impact on maternal health.

Resource Inequities and Healthcare Disparities

Inadequate healthcare funding and uneven resource distribution add to the challenges. Botswana and Eswatini’s healthcare expenditures are below the global average, with no clear budget allocations for SRH services. Over-reliance on donor funding in Eswatini and Lesotho makes SRH programs vulnerable to financial instability. Data collection and management systems are outdated and poorly integrated, with limited capacity to analyze and interpret health information. Rural areas face the most significant disparities, with a severe shortage of trained healthcare professionals and limited access to facilities offering safe abortion services. For instance, Namibia reports that fewer than 40% of national hospitals maintain abortion care registers, and post-abortion care is often substandard, characterized by long wait times and insufficient resources.

A Roadmap for Transformative Change

The study calls for a multi-sectoral approach to address these systemic challenges. Key recommendations include developing national CAC guidelines aligned with existing legislation, ensuring adequate training for healthcare providers, and improving the equitable distribution of resources. Strengthening data collection systems to monitor abortion services and maternal health outcomes is also essential. Public education campaigns must aim to reduce stigma and increase awareness of legal abortion rights. Addressing gender inequities through coordinated government efforts is crucial, as higher levels of gender equality are linked to reduced rates of unsafe abortions. Botswana’s multi-sectoral mechanism to combat GBV provides a promising model, showcasing the potential of targeted interventions.

Improving access to comprehensive abortion care requires strong political will, sustained funding, and a commitment to reproductive justice. Such reforms align with the SDG target of reducing maternal mortality and have broader implications for gender equality, education, and economic development. Framing reproductive health as a human rights issue offers a pathway for transformative policy and practice changes. The reparative health justice framework employed in this analysis provides a valuable tool for identifying and addressing these barriers, offering actionable insights for policymakers in southern Africa and beyond. By prioritizing the reproductive rights and health of women, these nations can advance toward more equitable and inclusive healthcare systems.