A critical review of sanctioned knowledge production concerning abortion in Africa: Implications for feminist health psychology

Abstract

Taking a feminist health psychology approach, we conducted a systematic review of published research on abortion featured in PsycINFO over a 7-year period. We analysed the 39 articles included in the review in terms of countries in which the research was conducted, types of research, issues covered, the way the research was framed and main findings. Despite 97 per cent of abortions performed in Africa being classifiable as unsafe, there has been no engagement in knowledge production about abortion in Africa from psychologists, outside of South Africa. Given this, we outline the implications of the current knowledge base for feminism, psychology and feminist health psychology in Africa.

Keywords

abortion Africa feminist health psychology health psychology reproduction

Introduction

In this article, we present the results of a systematic review of the published literature on abortion in Africa using the PsycINFO database. The purpose of this review is to unpack the implications of the knowledge produced about abortion in Africa for health psychology research and practice. Given the centrality of gender in abortion and its key place in feminist work (Braam and Hessini, 2004), we home in on the possibilities and gaps in relation to feminist health psychology.

In 2008, an estimated 13 per cent of all pregnancies (including live births, miscarriage and abortions) ended in abortion in Africa, a minor increase from the 12 per cent estimated in 1995 and 2003. Of these, 97 per cent could be classified as unsafe abortions, with unsafe abortions being defined as a procedure performed by people lacking the necessary skills or in an environment not meeting minimal medical standards, or both. The rates of unsafe abortion are somewhat lower in Southern Africa (58%) owing to the liberal abortion law, and the implementation thereof, in South Africa (Sedgh et al., 2012).

In their review of the status of abortion in Africa (as part of the United Nations Development Programme (UNDP)/United Nations Population Fund (UNFPA)/World Health Organization (WHO)/World Bank assessment of the global status of unsafe abortion), Hord et al. (2006) indicate that low contraceptive use, restrictive abortion laws, lack of access to safe, elective abortion and post-abortion care and poor quality services contribute significantly to the morbidity and mortality associated with unsafe abortion. They note that the issue is complicated by high rates of HIV/AIDS and other sexually transmitted diseases, high rates of poverty, the low status of women and the numbers of refugees and internally displaced people resulting from ongoing regional wars.

As this review will show, and as already indicated by Macleod (2012), much of the work on abortion in Africa has taken a specifically public health perspective, with attention being on epidemiological issues and the factors leading to morbidity and mortality. As noted by Macleod (2012) and confirmed by our dataset, there are no psychologists, outside of South Africa, who are involved in sanctioned knowledge production, in the form of peer-reviewed publications featuring in journals, concerning abortion. Given this, we outline the implications of the current knowledge base with regard to abortion in Africa for feminism, psychology and feminist health psychology.

Background

Abortion is a complex issue due to various reasons. Other than the obvious fact that it is a bio-medical procedure and hence bound up with healthcare provision and health systems of a country, it is also a procedure governed, first, by varying legislation around the globe, and, second, by deep-rooted cultural and social understandings of the status of women and the foetus, gender relations, mothering, morality and embodiment (Ferree, 2003). These various facets intertwine to create an intricate web of possibilities within which abortion may be experienced. For example, liberal legislation does not necessarily imply social acceptance and lack of stigma, as is demonstrated in South Africa (Trueman and Magwentshu, 2013).

While we cannot, in this article, hope to capture the full intricacies of the social and cultural settings across Africa, Table 1 outlines the legal status of abortion in the countries in which the studies referred to in this article were conducted. We excluded all other African countries that did not have articles featured in our database. As can be noted, other than South Africa, most of the countries featured in this review have restrictive laws, while one has very restrictive laws, allowing abortion only in the case of a threat to the woman’s life. (Overall, 11 countries in Africa have very restrictive legislation, 39 have restrictive legislation and only 3 have liberal legislation.)

Table 1.

Legal status of abortion in the countries featured in the articles under review.

Country	1 Permitted to save life of woman	2. Physical health grounds	3 Rape, incest and foetal impairment	4. Mental health grounds	5. Socioeconomic grounds	6. Without restriction (on demand)	Other indications
Liberal legislation
South Africa	Yes	Yes	Yes	Yes	Yes	Yes	Any woman of any age can request an abortion if she is less than 13 weeks pregnant. If she is between 13 and 20 weeks pregnant, she can obtain the abortion under specified conditions including on socioeconomic grounds. Abortions may be performed after 20 weeks gestation if the woman’s or the foetus’s life is in danger or there are likely to be serious birth defects. Minors do not require the permission of their parents/guardians.
Restrictive legislation
Burkina Faso	Yes	Yes	Yes	Yes	No	No	Two physicians must attest to danger to woman’s life or that the unborn child will be afflicted with a condition of exceptional and incurable seriousness. Rape or incest to be established by the State prosecutor. Abortion must be performed during the first 10 weeks of pregnancy.
Cameroon	Yes	Yes	Yes/yes/no	Yes^a	No	No	In the case of rape, the prosecution or the public prosecutor’s office must certify a ‘good case’.
Ethiopia	Yes	Yes	Yes	Yes	No	No	An abortion also permitted for minors who are physically or psychologically unprepared to raise a child and in the case of grave and imminent danger that can be averted only through immediate pregnancy termination.
Ghana	Yes	Yes	Yes	Yes	No	No	The abortion must be performed in a government hospital or a private hospital or clinic registered under the Private Hospitals or Maternity Homes Act of 1958 (No. 9) or in a place approved for the purpose.
Kenya	Yes	Yes	No	Yes	No	No	An abortion must be performed by a certified physician, with the consent of the woman and her spouse. Two medical opinions, one of which must be from the physician who has treated the woman and the other from a psychiatrist, are required before the abortion is performed. The abortion must also be performed in a hospital.
Mozambique	Yes	Yes	No	Yes	No	No	Abortions are also allowed in cases of contraceptive failure.
Nigeria	Yes	Yes^b	No	Yes^b	No	No	Two physicians are required to certify that the pregnancy poses a serious threat to the life of the woman.
Rwanda	Yes	Yes	No	Yes	No	No	An abortion must be performed by a physician in a public hospital or other authorised healthcare facility. Two physicians must confirm in writing that continuation of the pregnancy would seriously endanger the woman’s health.
Tanzania	Yes	Yes	No	Yes	No	No	Two physicians must certify that the abortion is necessary in order to preserve the life of the pregnant woman.
Uganda	Yes	Yes	No	Yes	No	No	A legal abortion must be performed by a registered physician. Although the law does not require the approval of a committee, the consent of two physicians is usually sought before a legal abortion can be performed.
Zambia	Yes	Yes	Yes/no/yes	Yes	Yes	No	Abortion requires the consent of three physicians, one of whom must be a specialist in the branch of medicine related to the woman’s reason for seeking an abortion. The requirement may be waived if the abortion is immediately necessary to save the life or prevent grave permanent injury to the physical or mental health of the woman.
Very restrictive legislation
Gabon	Yes	No	No	No	No	No	The physician performing the abortion must obtain the advice of two consulting physicians, one of whom must be taken from a list of experts provided by the court. The physician must attest to the fact that the life of the woman cannot be saved by any means other than the intervention contemplated.

The law does not specify whether health includes physical and mental health.

Nigeria has two abortion laws: one for the northern states and one for the southern states. Both laws specifically allow abortions to be performed to save the life of the woman. In addition, in the southern states, Rex v. Bourne is applied, which allows abortions to be performed for physical and mental health reasons.

As shown in the table, there has been a trend towards liberalisation of laws in some countries, specifically in Burkina Faso in 1996 (previously, abortion was prohibited without any explicit exceptions), Ethiopia in 2004 and 2006 (previously, abortion was permitted to preserve a woman’s life or health); Ghana in 2006 and 2012 (previously abortion was permitted to save a woman’s life, preserve her physical or mental health or in cases of rape, incest or foetal impairment), Kenya in 2010 (previously, abortion was only permitted to save a woman’s life) and South Africa in 1996 and 2008 (the former law permitted abortion only to save a woman’s life, preserve her physical or mental health or in cases of rape, incest or foetal impairment). A number of these countries have also developed guidelines to make access easier (e.g. in Ghana women who become pregnant as a result of rape are not required to provide evidence of the assault to access abortion services).

Our study

We conducted a systematic review of the literature on abortion in Africa abstracted in PsycINFO from the period January 2007 to November 2014. The rationale for choosing this period was that we were interested in investigating recent developments in scholarship on abortion in Africa and we reasoned that a 7-year period provided a reasonable timeframe for this. PsycINFO was chosen as the data source as it ‘is the largest resource devoted to peer-reviewed literature in behavioural science and mental health, with 99 per cent of the covered material peer-reviewed’ (http://www.ebscohost.com/academic/psycinfo). Our search terms were ‘abortion AND Africa’ and then ‘abortion AND [name of each country in Africa]’. So, for example, we searched for ‘abortion AND South Africa’, ‘abortion AND Zimbabwe’ and so forth.

Our inclusion criteria were as follows: articles written in, or translated into, English, published in peer-reviewed journals; main problematic of the article is abortion and article about induced abortion. Exclusion criteria were as follows: dissertations/theses, editorials/commentaries/opinion pieces that are not full-length articles, and books; abortion mentioned in relation to another reproductive health issue (i.e. not the main problematic of the article); abortion in Africa mentioned in relation to a global perspective on abortion; and article about spontaneous abortion (miscarriage). The search and the application of the inclusion and exclusion criteria were conducted by two researchers. The process resulted in 39 articles being included in the review.

We analysed the data in terms of affiliations of authors, countries in which the research was conducted, types of research conducted, main issues focussed on, framing of the article and main findings. For the types of research, main issues and framing, we created an initial code book based on our understanding of the field. We then independently coded the articles. This resulted in a refinement of the code book. Thereafter, the articles were coded by two of the researchers independently and checked by the third. Disagreements over the categorising of the article were resolved through dialogue. A narrative approach to describing the main findings was adopted.

In terms of the framing of the article, we drew on the notion of communication frames in which an author uses particular words, images, phrases and presentation styles to relay information about an issue or event to an audience (in this case, academic readers) thereby defining the underlying premises of what the author sees as relevant to the topic at hand (Chong and Druckman, 2007). As a result of the refinement of the codes described above, the following framing codes were agreed upon:

Medical: these articles concentrate on the medical procedures involved in abortion or on the medical treatment required after abortion. The emphasis is on physical treatment rather than psychiatric or psychological issues.

Public health: these articles speak to the population effects of abortion, including issues such as the incidence of abortion and of mortality and morbidity associated with abortion, the provision of abortion or post-abortion services and factors associated with abortions.

Clinical psychological/psychological: these articles consider the experiences of abortion, the psychological effects of abortion, the decision-making process that the women went through and the treatment of psychological fall-out as a result of abortion.

Human rights/reproductive rights: these articles use the language of rights to argue for or against various aspects relating to abortion (legislation, implementation of services, treatment).

Ethical/moral: these articles frame abortion within some ethical or moral framework; ethics or morals are the central focus.

Contextual social/cultural/gendered understandings: these articles conduct research that attempts to understand abortion within context. They speak to issues such as social stigma, social and cultural attitudes to abortion, public discourses about abortion and gendered issues involved in abortion.

Reproductive justice: these articles use a social justice framework to argue for liberal abortion legislation and access to abortion services. Drawing on notions of justice that recognise social, economic, gender and colonial inequalities, the framework goes beyond a rights approach.

Our description of the main findings was underpinned by the feminist health psychology approach to abortion outlined by Macleod (2012). Noting, first, the lack of engagement by feminist health psychologists with abortion; second, the significant and fractious engagement of psychologists with abortion in the global North and third, the absence of psychological discourse concerning abortion in the global South, Macleod (2012) argues that feminist health psychologists need to avoid the pitfalls implicit in both the ‘choice’ rhetoric that underpins much feminist work on abortion, especially in the global North, and the problematic psychologisation of abortion that has occurred in some countries, most notably the United States (which has seen a dovetailing of anti-abortion rhetoric with the proposal of post-abortion syndrome (PAS)). She advocates a transnational feminist approach, using a framework of ‘reproductive justice’ that takes context and differences into account while at the same time considering universal principles of justice in relation to reproduction. Given overarching socioeconomic inequalities, racism and sexism that shape many women’s lives, a reproductive justice approach locates abortion within the social dynamics surrounding the occurrence of an unwanted pregnancy and focuses on achieving conditions that are necessary for comprehensive reproductive and sexual freedom. To do this in countries where the most unsafe abortions occur means, according to Macleod (2012), joining a critical public health debate concerning abortion in these spaces and supplementing this with understandings of the psychological consequences of unsafe abortion.

Results

Author affiliations (which exceed the number of articles as each author affiliation on each article was counted) showed a dominance of medical departments (39); abortion-related or reproductive health institutes or non-governmental organisations such as Guttmacher Institute, Ipas, Ibis, Pathfinder International, African Population and Health Research Centre (38) and public health departments (20). Other affiliations are as follows: psychology departments (14), general research units (7), anthropology/sociology departments (7), demography departments (7), independent researchers (3), development studies (2), nursing (2) and Ministry of Health (1). All 14 psychology department author affiliations were in South Africa. Seven of these are for the first author and her co-authors.

The countries in which the research was conducted were as follows: South Africa (11 articles), Nigeria (7 articles), Ghana (6 articles), Kenya (3 articles), Cameroon (2 articles), Ethiopia (2 articles), Burkina Faso (1 article), Gabon (1 article), Mozambique (1 article), Rwanda (1 article), Tanzania (1 article), Uganda (1 article), Zambia (1 article) and multi-country (Nigeria and Zambia) (1 article). Three countries thus dominate: South Africa, Nigeria and Ghana.

In terms of the type of research conducted, methodological triangulation was the most popular method (14 articles). This consisted of many cases of data collection from women accessing abortion or post-abortion care, health service providers and health facility records. Triangulation was particularly popular in research on abortion services. Surveys were the next most used method (11 articles), followed by interviews with women who have undergone an abortion, with health service providers or with people in general (6 articles). Textual analysis, case studies, focus group discussions and analysis of health facility data were each used in two articles.

In Table 2, we see the main issues that were researched in the studies under review, as well as the countries in which the research was conducted. Attitudes towards abortion, abortion services, abortion decision-making, narratives/discourses of abortion, the incidence of abortion and unsafe abortion emerge as the most researched issues, indicating a reasonable spread of interest in research questions regarding abortion. Broadly speaking, thus, health and public health issues (abortion services, the incidence of abortion, unsafe abortion), social issues in relation to abortion (attitudes and public discourses) and abortion decision-making are the main areas of interest in the research. Interestingly, PAS and medical abortion each featured in one article only. Table 2 also indicates that there is no discernible pattern in terms of the countries in which the various issues are being researched.

Table 2.

Main issues researched in particular countries.

Issues researched	No. of articles	Article number^a (and country)
Attitudes towards abortion	8	14 (Nigeria/Zambia), 16 (Ghana), 23 (Ghana), 30 (South Africa), 31 (South Africa), 32 (Tanzania), 38 (Cameroon), 39 (Cameroon)
Abortion services	7	1 (Ethiopia), 6 (Ghana), 8 (Kenya), 11 (South Africa), 26 (Nigeria), 35 (Kenya), 36 (South Africa)
Abortion decision-making	7	11 (Gabon), 15 (Ethiopia), 17 (Nigeria), 22 (Mozambique), 24 (Ghana), 28 (Nigeria), 29 (South Africa)
Narratives/discourses of abortion	4	13 (Kenya), 18 (South Africa), 19 (South Africa), 20 (South Africa)
Incidence of abortion	5	3 (Nigeria), 4 (Rwanda), 25 (Nigeria), 27 (Nigeria), 33 (Burkina Faso)
Unsafe abortion	4	2 (Nigeria), 7 (Zambia), 12 (Ghana), 37 (Ghana)
Factors associated with abortion	2	21 (South Africa), 34 (Ghana)
Medical abortion	1	9 (South Africa)
Post-abortion syndrome	1	5 (South Africa)

Refer to reference list for article number.

Table 3 outlines the framing of the articles. Unsurprisingly, public health emerges as the most utilised framework, with just under half the articles being framed in this way. This approach is counterbalanced by many articles taking a contextual approach in which social, cultural and gendered issues relating to abortion are highlighted. Few articles take a clinical psychological/psychological, human/reproductive rights, reproductive justice or medical approach. No articles take an explicitly ethical or moral framing. Although there is a spread of framings across countries, it is interesting to note that only articles from South Africa take a human/reproductive rights or reproductive justice approach. In addition, more articles from South Africa take a contextual approach (5) than a public health approach (2). This is reversed in the case of Nigeria: Four articles are framed in a public health approach and two in a contextual approach.

Table 3.

Framing of the articles in relation to particular countries.

Framing	No. of articles	Article number^a (and country)
Public health	17	1 (Ethiopia), 3 (Nigeria), 4 (Rwanda), 6 (Ghana), 7 (Zambia), 8 (Kenya), 9 (South Africa), 16 (Ghana), 21 (South Africa), 22 (Mozambique), 25 (Nigeria), 26 (Nigeria), 27 (Nigeria), 33 (Burkina Faso), 34 (Ghana), 35 (Kenya), 38 (Cameroon)
Contextual social/cultural/gendered	14	12 (Ghana), 13 (Kenya),14 (Nigeria/Zambia), 15 (Ethiopia), 18 (South Africa), 20 (South Africa), 23 (Uganda), 28 (Nigeria), 29 (South Africa), 30 (South Africa), 31 (South Africa), 32 (Tanzania), 37 (Ghana),39 (Cameroon)
Clinical psychology/psychology	4	5 (South Africa), 11 (Gabon),17 (Nigeria), 24 (Ghana)
Human rights/reproductive rights	2	10 (South Africa), 36 (South Africa)
Reproductive justice	1	19 (South Africa)
Medical	1	2 (Nigeria)

Refer to reference list for article number.

In the following sections, we summarise some of the main findings of the research. The discussion cannot hope to do justice to the nuance and complexity of argument evidenced in the 39 articles. Therefore, we home in on particular issues in order to draw out the implications of this work for feminism, psychology and finally feminist health psychology.

Main findings: implications for feminism

Advocacy for the liberalisation of abortion legislation is a key aspect of feminist work concerning abortion (Braam and Hessini, 2004). In the African context, the use of a public health frame to emphasise the incidence of unsafe abortion as well as the morbidity and mortality associated with unsafe abortion has shown promise (as demonstrated in South Africa). Estimating both the incidence of unsafe abortion and the associated morbidity and mortality is, however, not a simple matter as alluded to by Oliveras et al.’s (2008) discussion of the preceding birth technique and Sedgh et al.’s (2011) comparison of the abortion incidence complications method and the anonymous third-party reporting method. In addition, comparing estimates is not always possible as the denominator differs. For example, Oliveras et al. (2008) use abortions per 100 pregnancies, Sedgh et al. (2012) and Basinga et al. (2012) estimate abortions per 1000 women, and Okereke (2010) report abortions per adolescents who had ever been pregnant. Nevertheless, estimates of the incidence of unsafe abortion and the associated morbidity and mortality are important in feminist advocacy work.

These data need to be nuanced with an indication of why women decide to terminate a pregnancy. Studies that investigated factors associated with abortion showed some similarity across countries. For example, in Nigeria (Bankole et al., 2008),¹ South Africa (Mdleleni-Bookholane, 2007)² and Ghana (Sundaram et al., 2012),³ being unmarried and young were key factors. Other factors, however, diverged. For example, Mdleleni-Bookholane (2007) found, in South Africa, that lack of financial resources and support were associated with seeking abortion, while in Ghana Sundaram et al. (2012) report that it is women of a higher socioeconomic status who are more likely (and possibly able) to resort to abortion in the event of an unwanted pregnancy.

Nuanced explanations of these noted factors are also important. Bankole et al. (2008) argue that the trends noted in Nigeria have to do with young women increasingly delaying marriage and childbearing in order to obtain more education and better job prospects. Koster (2010),⁴ on the other hand, argues that for a growing number of young women in Nigeria, fear of infertility as a result of contraception usage as well as the need to prove fertility prior to marriage are significant factors in the occurrence of unwanted pregnancies that lead to abortion. In South Africa, Orner et al. (2011)⁵ indicate that, apart from health, the reasons provided by HIV+ women for abortion are similar to women in general: lack of preparedness for childbearing, already having the desired number of children and poverty.

Advocacy for accessible abortion care takes centre stage in feminist work, along with advocacy for liberal legislation. Our dataset revealed mixed findings with regard to abortion services. On one hand, abortion services and post-abortion care remain woefully inadequate as indicated by Abdella et al. (2013)⁶ in Ethiopia, Clark et al. (2010)⁷ in Ghana and Harries et al. (2012)⁸ in South Africa with respect to second trimester abortion. This is despite the scaling up of abortion services in Ethiopian health facilities in 2005 following the reform of abortion legislation and health workers obtaining obstetric care training in Ghana. Barriers to service provision include those trained in post-abortion care not actually delivering the services (Clark et al., 2010) and practitioners resisting second trimester techniques that require more active service provider involvement (Harries et al., 2012). On the other hand, more positive results were found by Evens et al. (2014)⁹ whose research shows favourable attitudes to post-abortion care among health service providers in Kenya, as well as high client satisfaction. However, there was a discrepancy between what health service providers indicated was routinely done in post-abortion care and the reports of clients of this care.

The above-mentioned studies were all framed within a public health approach. While this is important in terms of viewing abortion services, critical analysis is also needed from a feminist perspective. Vincent’s (2012)¹⁰ article illustrates the importance of this. She argues that the pre-termination of pregnancy counselling routinely provided in South Africa is in fact normative and directive. This, she indicates, potentially undermines women’s rights and autonomy.

Main findings: implications for psychology

While a public health framing is useful to feminism as indicated above, what is missing from the discussion of the incidence of morbidity and mortality associated with unsafe abortion, in this dataset and elsewhere, is the incidence of psychological trauma experienced by women (and their families) in procuring an unsafe abortion and in the possible resultant physical complications. This glossing over of psychological trauma is evident in other research too. For example, Akaba et al. (2013)¹¹ present a case study of unsafe abortion which resulted in uterine perforation, bowel injury and gangrene. The study speaks to the medical aspects of the case, with no mention of the woman’s subjective experiences of these severe complications or of the medical procedures applied.

Nevertheless, despite there being no psychologists addressing the issue of unsafe abortion in the dataset, there are studies that highlight psychological issues. For example, Webster (2013)¹² speaks to the desperation implicit in seeking an unsafe abortion in Ghana. She argues that abortion is a desperate act not only because of the risk to physical health but also because these women step outside of the boundaries of cultural ideologies concerning womanhood as well as what are considered acceptable practices by the ancestors.

The processes of procuring an abortion under illegal conditions are referred to by a number of authors, although the full psychological implications are not drawn out. Unsafe abortion ranges from self-induction to consulting backstreet abortionists, traditional healers, chemist shops and health professionals operating on the side (Dahlbäck et al., 2010;¹³ Koster, 2010; Okonofua et al., 2011¹⁴). Studies alert us to the difficulties encountered by women in accessing illegal services. Bankole et al. (2008) indicate that 10 per cent of their sample of women in Nigeria who had successfully terminated a pregnancy had to make two or more attempts to do so, and Plummer et al. (2008)¹⁵ indicate that some women in their Tanzanian study reported sexual and financial exploitation by the informal practitioners of abortion.

Research shows careful consideration on the part of women in deciding on the abortion options. Hill et al. (2009)¹⁶ report that women in Ghana generally weigh up methods and self-apply cheaper, milder forms first. In gathering information about methods, women choose their confidantes very carefully. Mitchell et al. (2010)¹⁷ conclude that women in Mozambique are motivated to find early pregnancy termination techniques that they deem socially acceptable and clinically low risk.

How women deal with the after-effects of unsafe abortion has also received attention. Hill et al. (2009) indicate the complications that arise from unsafe abortion in Ghana are usually dealt with at home. As a result of the shame and secrecy, the abortion is seldom disclosed when the women do eventually present at a health facility. Plummer et al. (2008) found in Tanzania that women who underwent unsafe abortion felt physical pain and discomfort, as well as social ostracism, but not regret. Hess (2007),¹⁸ however, indicates that of the five women interviewed in her study in Gabon, four experienced regret, guilt and remorse.

Boulind and Edwards (2008) are the only authors who deploy the controversial term PAS in their report of a psychotherapy case study conducted in South Africa in which it emerged during the course of the therapy that the client had undergone an abortion (under safe conditions). PAS, proposed as a diagnostic category similar to post-traumatic stress disorder, has attracted significant debate, particularly in terms of its use in anti-abortion activism in the American context (for a full critique, see Macleod, 2009).

Main findings: implications for psychology and reproductive justice

While the psychological aspects of unsafe abortion are important for feminist health psychology, a reproductive justice approach requires situating these experiences within the contexts of partner relations, service provision and social/cultural understandings of reproduction and abortion. A number of studies indicate that a poor relationship with, and lack of support from, sexual partner is a factor in women’s decision-making around terminating a pregnancy (Bankole et al., 2008; Mdleleni-Bookholane, 2007; Orner et al., 2011). Partner denial of paternity is a particular form of lack of support mentioned by some women in Gabon (Hess, 2007). On the other hand, partners may encourage abortions, even under unsafe conditions as found in Zambia (Dahlbäck et al., 2010), which could be related to a lack of readiness to take on a father role as indicated by Omideyi et al. (2011)¹⁹ in Nigeria. Other than the gender relations that cohere around abortion decision-making, the inequitable gender norms that lead to unwanted pregnancies, such as the inability to refuse sex as alluded to by Orner et al. (2011), is an important question for feminist health psychologists.

Turning to social and cultural contexts, a number of the studies under review sought to understand attitudes to abortion or public discourses concerning abortion. The research generally revealed negative social attitudes to abortion. Kavanaugh et al. (2013)²⁰ show that respondents in both Nigeria and Zambia favoured childbearing over abortion for HIV+ women, although support for abortion was slightly higher in instances where antiretroviral drugs were not available. In Uganda, Moore et al. (2011)²¹ report that male respondents indicated that an abortion is a sign of infidelity. They were generally not supportive of abortion in light of the potential value of the ‘unborn child’, risk to health and fear of arrest. In South Africa, where abortion is legal, Patel and Myeni (2008)²² found that, among their university student sample, attitudes to abortion were complex and multifaceted. While abortion was seen as acceptable in particular contexts (rape, incest, health concerns such as being HIV+), the majority of students disapproved of abortion, with 55 per cent identifying specifically as pro-life. In a similar sample, Patel and Kooverjee (2009)²³ found that there was greater support among women respondents for the availability of termination of pregnancy services and for women’s autonomy in decision-making.

While the above research investigates general public attitudes to abortion, some research has focussed on the attitudes of specific people. Wonkam and Hurst (2007)²⁴ found that there was low acceptance of voluntary abortion among doctors and medical students in Cameroon when the reason for the abortion was financial or economic, but that this increased when there were medical reasons. Also in Cameroon, Wonkam et al. (2014)²⁵ report that a ‘remarkably high’ number of adults living with sickle cell disease (SCD) approved of terminating a pregnancy based on the diagnosis of SCD on the basis of their assessment of the future well-being of the child.

A number of articles used qualitative methods to understand social constructions of abortion. Macleod and Hansjee (2013),²⁶ Macleod and Feltham-King (2012)²⁷ and Macleod et al. (2011)²⁸ outline some of the public discourses concerning abortion emerging in focus group discussions and newspaper articles in South Africa. Their research shows the subtleties of public discourse concerning abortion, where a ‘cultural’ discourse can be used to oppose abortion, and men may use equality and rights discourses to perpetuate gendered power relations that undermine women’s autonomy over abortion decision-making. Macleod and Feltham-King (2012) show how the ways in which women are named in relation to abortion are used in contradictory ways to advocate for, or oppose, access to abortion (e.g. ‘the innocent mother’ subject position is used to promote abortion under medical conditions while ‘the dangerous mother’ subject position is used to oppose abortion). Izugbara et al.’s (2009)²⁹ research shows how Kenyan women’s and men’s narratives concerning abortion differ. While the women in their study saw abortion as shielding women against the shame, and negative socioeconomic consequences, of mistimed or socially unviable entry into motherhood, the men were condemnatory, viewing abortion as women’s strategy for concealing their deviation from culturally acceptable gender and motherhood standards.

Conclusion: implications for feminist health psychology

There are number of glaring absences in the recent research conducted on abortion in Africa. No psychologists, outside of South Africa, have published on abortion in journals featured on PsycINFO over the 7-year period under review. The dominance of studies conducted in three countries, one with liberal abortion legislation and two with restrictive legislation, means that recent knowledge about a great number of countries is missing. Research framed within clinical psychological/psychological, human rights/reproductive rights, ethical/moral and reproductive justice approaches is either absent or in short supply.

The research that has been conducted spans a range of topics, most notably concerning public health (abortion services, incidence of abortion, unsafe abortion), social issues (attitudes and public discourses) and abortion decision-making. Despite the absence of psychologists in conducting these studies, much of the work has implications for feminism, psychology and finally feminist health psychology.

Given this, what can we glean from this research that could be of use in articulating a feminist health psychology understanding of abortion? Much of the work has been framed within a public health approach. This can be of use to feminist health psychology in using the incidence of morbidity and mortality associated with unsafe abortion to advocate for the liberalisation of legislation and accessible abortion care. These arguments, need, however, to be supplemented by insights concerning the potential psychological trauma associated with procuring an unsafe abortion and with the possible physical outcomes thereof.

Gender issues are alluded to in the research in relation to partner relations in abortion decision-making and the occurrence of unwanted pregnancies. Social aspects such as (mostly negative) attitudes and subtle discursive constructions that undermine abortion access, as well as questions around abortion services, have also received attention. Feminist health psychology needs to highlight these gendered and social conditions that lead women to seek abortions and that underpin the stigma and shame associated with abortion.

Some of the work conducted on abortion in Africa gives us insight into the desperation women feel in seeking unsafe abortion, their emotional and cognitive processes in procuring the abortion, and how they deal with the physical and psychological aftermath of an unsafe abortion. In talking to specifically psychological issues, feminist health psychologists can highlight the simultaneous vulnerability and resilience of women, as well as how stigma translates into shame that prevents women from seeking the help that they need.

Finally, while utilising a public health frame that outlines epidemiological issues and speaks to the successes and barriers to service delivery, it is vital that a critical voice that speaks to reproductive justice is inserted into the feminist health psychology discussion of abortion in Africa. Although research on health and public health issues is balanced by studies investigating social issues in relation to abortion, the lack of studies that frame the issue from a reproductive rights or reproductive justice approach is a gap that feminist health psychologists need to explore.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work is based on research supported by the South African Research Chairs initiative of the Department of Science and Technology and National Research Foundation of South Africa (grant no. 87582).

Notes

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