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Assignment: In one file submit all of the following?
1. Your broad category
2. A narrowed topic
3. A list of at least 10 questions within the topic that you would like answered
4. The research question you would like to pursue
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6. A one-page summary of what you have discovered so far and how you think you will proceed in your research toward developing the final essay.
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International Perspectives on Sexual and Reproductive Health
154
Stephanie B. Wheeler
is assistant professor,
Leah L. Zullig is a
predoctoral fellow
and Bryce B. Reeve
is associate professor,
all at the Department
of Health Policy and
Management, Gillings
School of Global Pub-
lic Health, University
of North Carolina at
Chapel Hill, Chapel
Hill. Geoffrey A. Buga
is professor, Depart-
ment of Obstetrics
and Gynaecology,
Walter Sisulu Uni-
versity, Mthatha,
South Africa. Chelsea
Morroni is senior
lecturer, Women?s
Health Research
Unit, School of Public
Health and Family
Medicine, University
of Cape Town, Cape
Town, South Africa,
and academic doctor,
Research Depart-
ment of Reproductive
Health, Institute for
Women?s Health,
University College
London, London,
United Kingdom.
Voluntary induced termination of pregnancy is a common
medical procedure worldwide. An estimated 42 million
abortions are performed annually; nearly 20 million are
considered medically unsafe.
1?4
Estimates suggest that
97% of unsafe abortions occur in the developing world,
and that unsafe abortion is the leading cause of maternal
deaths in Africa, which has the world?s highest case-fatality
rates.
2,3,5,6
After a 1994 study found that an estimated 45,000
South African women per year were admitted to public
hospitals as a result of incomplete or unsafe abortion,
7,8
the country legalized abortion in 1996. Prior to this change
in the law, abortion had been legal in very limited circum-
stances under the Sterilization Act of 1975, requiring the
approval of three physicians. The 1996 law speci?es that a
woman can obtain an abortion on request within the ?rst
12 weeks of pregnancy.
9
Between 13 and 20 weeks? gesta-
tion, a woman can obtain an abortion if at least one of four
criteria is satis?ed: continuing the pregnancy would pose
a risk to the woman?s mental or physical health; there is
signi?cant risk that the unborn child would have a men-
tal or physical handicap; the pregnancy was the result of
rape or incest; or having the child would be detrimental to
the woman?s socioeconomic condition.
9
Beyond 20 weeks,
abortion is sanctioned only when the woman?s life is en-
dangered. In addition, although medical providers can
conscientiously object to performing abortions, providers
who are unwilling or unable to offer abortion services are
legally obligated to inform women of their rights and to
refer them to other providers.
As part of a series of progressive human rights initia-
tives undertaken by the postapartheid government, the
1996 law extended abortion provision to all provinces in
South Africa, and free abortion services were provided in
public clinics and hospitals.
9
Although the legalization of
abortion often leads to a considerable decrease in maternal
morbidity and mortality through the resulting decline in
unsafe abortions,
10
it does not necessarily ensure effective
implementation of and access to medically safe abortion
services. One global survey estimated that approximately
60% of the world?s population lives in countries where
abortion is of?cially legal but considerable barriers to get-
ting an abortion remain, despite high demand.
11
In South
Africa, one national survey of 15?24-year-olds found that
65% of women who had ever been pregnant reported
having had at least one unwanted pregnancy, but only
CONTEXT:
Although South Africa liberalized its abortion law in 1996, signi?cant barriers still impede service provi-
sion, including the lack of trained and willing providers. A better understanding is needed of medical students?
attitudes, beliefs and intentions regarding abortion provision.
METHODS:
Surveys about abortion attitudes, beliefs and practice intentions were conducted in 2005 and 2007
among 1,308 medical school students attending the University of Cape Town and Walter Sisulu University in South
Africa. Bivariate and multivariate analyses identi?ed associations between students? characteristics and their gen-
eral and conditional support for abortion provision, as well as their intention to act according to personal attitudes
and beliefs.
RESULTS:
Seventy percent of medical students believed that women should have the right to decide whether to
have an abortion, and large majorities thought that abortion should be legal in a variety of medical circumstances.
Nearly one-quarter of students intended to perform abortions once they were quali?ed, and 72% said that consci-
entiously objecting clinicians should be required to refer women for such services. However, one-?fth of students
believed that abortion should not be allowed for any reason. Advanced medical students were more likely than
others to support abortion provision. In multivariate analyses, year in medical school, race or ethnicity, religious af-
?liation, relationship status and sexual experience were associated with attitudes, beliefs and intentions regarding
provision.
CONCLUSIONS:
Academic medical institutions must ensure that students understand their responsibilities with
respect to abortion care?regardless of their personal views?and must provide appropriate abortion training to
those who are willing to offer these services in the future.
International Perspectives on Sexual and Reproductive Health, 2012, 38(3):154?163,
doi: 10.1363/3815412
By Stephanie B.
Wheeler,
Leah L. Zullig,
Bryce B. Reeve,
Geoffrey A. Buga
and Chelsea
Morroni
Attitudes and Intentions Regarding Abortion Provision
Among Medical School Students in South Africa
View the Answer
Volume 38, Number 3, September 2012
155
METHODS
Sampling and Data Collection
We developed a self-administered questionnaire for all stu-
dents enrolled in the medical training programs at the Uni-
versity of Cape Town (UCT; years 1?6) and Walter Sisulu
University (WSU; years 1?5)* in 2005 and 2007, respec-
tively. These settings were selected to capture the racial,
ethnic, geographic, cultural and socioeconomic diversity
of South African medical students and the communities
served by these medical centers. UCT and WSU are in an
urban and a rural area, respectively, on opposite sides of
the country. The former school is located in one of the two
wealthiest South African provinces, where annual per cap-
ita disposable income is US$3,282, with 32% of the popu-
lation living in poverty; the latter school is in one of the
poorest provinces, where per capita income is US$1,081,
with 72% of the population living in poverty. In South Af-
rica, most medical students attend medical school within
their home province. Regarding race and ethnicity, UCT is
a historically white university, whose student population
re?ects the greater number of whites living in the Western
Cape, whereas WSU is a historically black university, re-
?ecting the greater number of Africans or blacks living in
the Eastern Cape.
36,37
We believe these schools encompass
South Africa?s diverse medical student population.
Arrangements were made with faculty members and lec-
turers to designate an appropriate time to administer the
questionnaire. Following an explanation of the purpose
and intention of the study, informed consent was obtained
from students. The questionnaire was administered dur-
ing a required course for each year cohort and took ap-
proximately 20 minutes; responses were anonymous. We
excluded students if they were absent when the question-
naire was disseminated. Class rosters were used to deter-
mine the underlying population size and overall survey
response rate.
Survey Development and Measures
The survey consisted of ?ve domains: social and demo-
graphic characteristics; knowledge of the country?s abor-
tion law; attitudes and beliefs about abortion provision;
medical curriculum and training in abortion services; and
future intentions pertaining to abortion provision. This
study focuses primarily on students? attitudes, beliefs and
practice intentions. The instrument was based on litera-
ture on the knowledge, attitudes, beliefs and practice in-
tentions regarding abortion care of medical providers and
medical students worldwide.
32?35,38?47
According to Cook
et al.,
39
the wording of questionnaires designed to capture
knowledge, attitudes and beliefs about abortion is of criti-
cal importance. In their analysis of several types of survey
questions from abortion polls in the United States, they
found that when questions were too general, responses
?overstate the strength of sentiments for positions at either
3% had received an abortion in a medical facility.
12
In one
major city, only one-third of all abortions requested over a
two-year period had actually been performed.
13
Estimates
suggest that as many as 125,000 unsafe abortions (out of
approximately 200,000 total abortions) are performed an-
nually in South Africa, and that 26% of maternal deaths
result from unsafe abortion.
3,14?17
There is also concern
that barriers in access to abortion services have led to an
elevated rate of second-trimester abortions (about 20%
of all procedures),
18,19
and these later abortions are inher-
ently more dangerous.
Barriers to access lead to a signi?cant public health
burden, in terms of both cost and poor health outcomes
associated with medically unsafe abortions, as well as the
strain placed on providers to meet the high demand for
abortion without compromising quality of care. Evidence
that midwives and nurses can safely provide ?rst-trimester
abortions has increased the use of such providers in South
Africa, which has shifted some of the burden from doctors
in hospitals to midlevel providers in community health
centers.
20?23
In addition, the increased use of medication
abortion has helped to relieve the bottleneck of abortion
service provision.
24,25
However, in spite of South Africa?s
policy-making efforts, staff, infrastructure and budgetary
constraints have limited the effectiveness and timeliness
of the rollout of abortion services in the country.
26,27
Yet
the greatest barrier to implementing the abortion law has
been the lack of health personnel willing to train to be-
come abortion providers.
28,29
Data from present and future health care providers
regarding their abortion attitudes, beliefs and practice in-
tentions can yield insight about the potential supply of
the abortion providers and can point to opportunities for
training, values clari?cation and recruitment of practition-
ers. As the next generation of health care providers, medi-
cal students are a critical component of service provision,
and a better understanding of their attitudes, beliefs and
intentions regarding abortion may help inform the devel-
opment of training programs and policies regarding abor-
tion care.
Studies in the United States and the United Kingdom
have shown associations between medical students? atti-
tudes toward abortion and a number of individual char-
acteristics, including religious beliefs, gender, age, sexual
experience, exposure to abortion, extent of medical train-
ing in abortion services and future practice intentions.
30?34
However, these ?ndings may not be generalizable to South
Africa or other African nations, and may not accurately re-
?ect the nuances of African health systems and cultures.
Furthermore, little research has been conducted on abor-
tion in developing nations, and to help address this gap
in the literature, the current study assessed attitudes and
beliefs about abortion provision and future practice inten-
tions of South African medical students. This research ex-
pands the scope of an earlier study that assessed attitudes
and beliefs about abortion among students at a small med-
ical school in rural South Africa.
35
*The University of Cape Town has a six-year academic program, whereas
Walter Sisulu University has a ?ve-year program.
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