Dr Dusi, Dr Google, stigma and all the other reasons pregnant women are risking their lives

There are piles of R100 notes, a hand holding a tinted vial, a small plastic bag of brown herbs and a bloody sanitary pad with a message in green type: “Thank you Dr Dusi. Now I’m Free.” There is also a phone number where, presumably, you’ll find someone at the other end of the line eager to help. 

If Dr Dusi doesn’t pick up, or, more likely, has changed his number, don’t worry. There are plenty of others to call. Dozens of them.

On a Friday afternoon in late April this year, the comments stream in a local Facebook group with over 2,800 members was flowing. 

Along with an unending scroll of images advertising “abortion pills” with “hand to hand” delivery, “womb cleaning”, “surgical abortions with same day service” and “pain free” terminations, the comments were packed with offers to pregnant women from Gugulethu to Germiston and all points in between. 

Just a call and you, too, could be free.

The group has the name of a well-respected legal abortion provider. But it isn’t. It’s just parading as one. 

That’s just one way virtual platforms are serving up very real, and often very dangerous, ways for women to end their pregnancies — even though abortion, when done correctly, is a safe, and legal, medical procedure that many government hospitals and clinics do for free.

So why would anyone call Dr Dusi instead? 

Heartbreakingly simple

Sometimes it is heartbreakingly simple: some people don't even know that legal abortion clinics exist.

Elna McIntosh, who founded the Disa Clinic in Johannesburg, a private clinic which offers safe abortions for a fee, recently counselled a woman who had been misled by a dodgy clinic in Sandton.

“So she went there, and they told her she was 26 weeks pregnant but they offered her a termination. [They told her] ‘It's all right, we're gonna sort everything out ... don't cry, don't cry.’ But she then wanted a second opinion,” McIntosh told Bhekisisa’s monthly TV show Health Beat in April, when our team visited the facility.

Abortions in South Africa are legal up until 20 weeks — five months — of pregnancy. After 20 weeks the woman’s or foetus’s life must be in danger for a legal abortion to happen — and it is extremely dangerous. By the time the woman arrived in McIntosh’s rooms, she was 31 weeks pregnant. 

“She ended up going on to have the baby as she was already in her third trimester [a pregnancy has three trimesters]. But women don't always end up at safe clinics. They're frequently at the mercy of scammers trying to sell them non-existent meds.” 

McIntosh told Health Beat one of the most popular of the non-existent medications flogged online and through flyers plastered on street poles, are sonar (medical imagery that can show the foetus in the womb) pills.

“You can't do a sonar with a pill. It's not like the pill is going to go and ... look around [the womb]. But people say, I must have a sonar. Ya, no, [they say], ‘We’re giving you the sonar pills and a ‘womb cleaning’.”

And that’s where things go bad.

Making choices

The World Health Organization estimates that, globally, six out of 10 unintended pregnancies end in women choosing to have an abortion. Nearly half of all abortions are unsafe, with most of the unsafe terminations happening in developing countries. 

Because they happen “underground”, it’s close to impossible to accurately track how many illegal abortions happen each year in South Africa. But the health department’s 2020-22 report into maternal deaths shows that deaths due to miscarriage (the loss of a pregnancy in the first 23 weeks, which is also called spontaneous abortion) are evidence that illegal abortion businesses are thriving. 

Sixteen percent of deaths from miscarriage were attributed to unsafe abortion, a number that dropped from 25% in 2017—19. But those numbers are likely underestimated, the report noted, because women often conceal the fact that they had had an illegal abortion. 

The report also stated that, “there is no doubt that lack of access to a department of health termination of pregnancy service was an important administrative factor” in some of the maternal deaths.

But, the authors noted, there’s no reason, at least in theory, those deaths had to happen.

In 1996, President Nelson Mandela signed abortion into law, giving women the right to choose whether they would carry their pregnancies to term. After that, abortion-related complications deaths — close to 45,000 women were admitted to public hospitals in 1994 for incomplete abortions, of which 425 died — plummeted. A scientific letter in a 2005 edition of the South African Medical Journal found that, by 2001, maternal deaths due to unsafe abortions decreased by 91%.

While abortion is free at government hospitals, at private clinics, medical abortions, which are done in the first trimester of pregnancy, cost about R2,000, phone calls to providers by our Health Beat team showed. Surgical ones, which are more expensive because they involve a more complicated procedure for abortions in later stages of pregnancy, cost anywhere from about R2,000 and R6,500. 

But medical aids are legally required to cover the procedure for members choosing to have one; abortions are a prescribed minimum benefit by the Council for Medical Schemes.

Our choice on termination of pregnancy law says that up to the 12th week of pregnancy, getting an abortion is up to the pregnant person to decide. Between 13 and 20 weeks, the pregnancy may be terminated if it’s the result of rape or incest, if the person can’t afford to have a child or if their or the foetus’s health is in danger. After 20 weeks, it’s only possible if the woman’s or baby’s life is in danger.

The fewer weeks along in the pregnancy, the lower the risk of complications from abortion procedures. For the first three months, a medical abortion is normally what’s used. A combination of two types of pills, mifepristone and misoprostol, are taken at intervals prescribed by the healthcare provider to help the lining of the uterus break down, resulting in cramping and bleeding to end the pregnancy. 

For surgical abortion procedures, which are usually done after 12 weeks of pregnancy, suction devices are used to help extract the foetus out of the womb.

Abortion is considered very safe — in fact, safer than childbirth — when performed under the right conditions, using the prescribed methods and done by a trained healthcare provider. 

Botched

The problem with illegal abortion providers is that they’re unregistered providers and have therefore not been checked out by the health department to make sure they have trained health professionals who perform procedures and they do so in clean environments.

This often results in unsafe procedures with dangerous complications    

Those complications haunt McIntosh. Before she founded Disa, which was one of the first legal abortion clinics in the country, she was a hospital nurse. She saw first-hand what happened to women forced to go the illegal route. 

“We worked in emergency rooms and we saw the botched [abortions], the bled-out woman, which was tragic,” she told Health Beat.

Emergency rooms are often the places where health workers see what happens when abortions go bad; when pregnancy tissue is left in the uterus, or there are infections, or something pierces the uterus, or damages internal organs or results in dangerous levels of heavy bleeding and any combination of these.

Tlaleng Mofokeng, the medical director at Disa and the UN special rapporteur on the right to health, better known as Dr T, says sometimes the outcomes of a failed medical abortion are even passed to the next generation.

“Some people will, unfortunately, [have a child] that has abnormalities because of medication that was given at the wrong time, in the wrong way, in the wrong quantity, and even mixed with other things that are not even abortion pills.” 

Some of these problems come from consulting Dr Google.

Abortion infodemic

Mis and disinformation about abortion proliferate online — from social media to search engines. Some researchers are worried we are on the precipice of an abortion infodemic.

In 2022, after abortion rights were overturned in the US, Amnesty International reported that posts with information about abortion and how to access them were being removed or marked as “sensitive content” on social media.

That’s also what the 2024 report by the Centre for Countering Digital Hate, a UK-based nonprofit research and advocacy group, and MSI Reproductive Choices, which provides contraception and abortion services in 36 countries, including South Africa, found. They looked at how social media platforms dealt with MSI’s educational reproductive health content alongside ads claiming abortions are high risk or conspiracies about how nefarious groups are promoting abortions.

That’s backed up by a report from the global nonprofit media group Open Democracy. Its investigation across 18 countries looked into “crisis pregnancy centres” funded by a US-based Christian conservative organisation, Heartbeat International. The centres position themselves as reproductive healthcare clinics, manipulating key search terms so that when people are looking for abortion care, its clinics pop up as an option — even though they don’t provide them. 

The researchers found that once the patients were lured into the clinic, staff told women, falsely, that abortion increases the risks of cancer and mental illness; encouraged them to delay abortion or emergency contraception; and offered ultrasounds without medical qualifications.

In South Africa, Open Democracy found affiliates of the group Heartbeat International, provided biased counselling — our law requires non-directive counselling — as well as illegal ultrasounds. The health department promised a crackdown. Still, the organisation continues to operate 70 “pregnancy help centres” across South Africa.

Bhekisisa asked the health department what actions have been taken, but had not received a response by the time of publication. We will update once we do.

But misinformation is far from the only problem.

‘The woman who had the abortion’

Dr T told Health Beat what leads women to have unsafe abortions is systemic.

“There are still many administrative barriers. You need to have proof of address, [you] need an ID. You need a whole lot of other co-payments in some facilities that people are not simply prepared for. There's also a lot of delays in getting people to the hospitals because to even get a diagnosis of a pregnancy [you have to] be referred, most often to another facility, where you can then get the process done.” 

These delays, she says, mean that — even when women do come in early in their pregnancy for testing — they can wait weeks to get the procedure done, taking them even further along in their pregnancy, resulting in surgical abortion as opposed to medical abortion.

“The other important thing is that, you know, women are working. We are in the informal economy. We have jobs that don't have labour protection, so to take time off to attend a clinic repeatedly, where you are also met with stigma, means that your chances of going back to those clinics are very low.”

Dr T says health workers sometimes see patients through the lens of the “woman that had an abortion”. So even if that person comes in later with a headache or a toothache, “everything now becomes about the fact that she had an abortion”.

Finding particularly state clinics and hospitals that offer safe abortions has been notoriously difficult. In 2017 Bhekisisa attempted to map government facilities that provide abortion services. But it was outdated before it was even published. That’s because facilities that do provide abortions might have a single health worker willing to do the job (health workers are allowed to conscientiously object to performing abortions in South Africa). When that person leaves, the service goes as well.

In 2022, we worked with the Triad trust to create the Where to Care map, that is now run by a consortium of nonprofit partners, which regularly updates information and locations.

Health workers providing abortions also have to brace themselves. They are harassed and verbally attacked for their work. One provider from South Africa told researchers in a 2023 report from Amnesty International they had been called a “murderer” and “Lucifer”, one of the many forms of harassment that hit abortion providers.

But oftentimes the reasons that people go to unsafe abortion providers come back to the simplest issue: a lack of information about sexual and reproductive health.

What to expect

The younger the patient — of the estimated 365 girls that give birth every day in South Africa, 10 are under 15 — the more complicated it gets to deliver the right information.

Zozo Nene, a reproductive health specialist at the Steve Biko Academic Hospital in Tshwane, leads a national project tackling teenage pregnancies by trying to get them science-based, non-judgmental help. With puberty starting as early as eight, it’s difficult. She told Health Beat girls don’t know what to expect, or even what is happening to their bodies.

“So while they are trying to understand their own development ... the development of breasts, the starting of the menstruation early, you can imagine, for an 8-year-old, that must be very uncomfortable. Even for the parents of the 8-year-old, it is actually very uncomfortable. So now they engage in sexual intercourse for whatever reason, and they didn't know that was going to result in a pregnancy.”

With money from private sponsors such as small businesses and large chain stores, Nene and her team travel to different provinces to train nurses, doctors, teachers and religious leaders on how to deal with teen pregnancies. They also learn more about how and where girls get their information about pregnancy and abortion. That usually comes through friends, TV and, of course, the misinformation streaming right onto their screens.

Nene knows how dangerous that can be, but she says it’s a way to meet kids where they are.

“We can turn [social media] into a positive if we have to give them free Wi-Fi, right? And then throw in some adverts ... We need to find a way of making that work to our advantage.”

The right stuff

Marie Stopes South Africa has a TikTok channel that shows how well it can be done. It posts videos like “how to put on a condom” and “how to avoid getting scammed” by illegal abortion providers, mixed with a good dose of the kind of amusing greenscreen memes that make scrolling so addictive.

Women are also going public with their own abortion stories which can help take some of the stigma of abortion away and, sometimes, even teach people along the way.

Take, for example, TikTokker Jessica Welz with her more than 330,000 followers. She’s made over 40 videos of educational content about her experience taking the medical abortion route, which have gotten millions of views. 

Even better, though, are the doctor-influencers who are helping to demystify sexual and reproductive health. 

Well-known US-based obstetrician and gynaecologist Jennifer Lincoln has over 2.8-million followers on TikTok and churns out a weekly education programme on sexual and reproductive health on YouTube. Closer to home, Lethukwenama Letsoalo, a South African medical doctor working on her master’s in public health at the London School of Hygiene and Tropical Medicine, speaks about the topic to her more than 125,000 followers on TikTok, mainly in isiZulu.

Getting Dr Dusi offline and Dr Google to clean up what they are serving up would also help.

But, says Dr T, it's not just a virtual problem. It is a very real one, operating with impunity, easily available for anyone who’s asking — if only the right people were asking, and doing something to stop it.

“If you go to Gandhi Square now in Johannesburg, everyone knows who's selling the pills. And so the question is, why is there no political will to actually fix this problem?”

This story is based on our Health Beat TV programme, “Why are thousands of babies dumped each year in SA instead of being safely aborted?,” which was broadcast on March 29 on eNCA. View the full programme on our YouTube channel. It also includes reporting from our previous stories, including “Hell is 16 ,000 unanswered telephones”; “When all else fails: Why people opt for backstreet abortions”, “Here’s how abortion works after 13 weeks”; and “Abortions 101”. 

— Additional reporting by Tanya Pampalone

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.