Clinical overview
Termination of pregnancy (TOP) in South Africa operates under the Choice on Termination of Pregnancy Act (Act 92 of 1996, amended 2008), one of the most progressive abortion laws globally. The Act permits TOP on request up to 12 weeks of gestation, on broader grounds (medical, fetal abnormality, mental/social, rape/incest) from 13 to 20 weeks, and on restricted grounds (serious fetal abnormality, threat to maternal life) after 20 weeks. Despite this legal framework, access in practice is uneven — many designated facilities are not functional, conscientious objection is widespread, and the result is that unsafe abortion remains a leading cause of maternal mortality in South Africa, particularly among adolescents and women living in rural areas.
The registrar must be able to: (1) understand the legal framework and ethical considerations; (2) counsel a woman seeking TOP without bias; (3) describe medical and surgical methods by gestational age; (4) recognise and manage complications of safe and unsafe abortion; (5) provide post-abortion contraception. The chapter integrates with SA O&G law (the Act details) and Spontaneous miscarriage (since incomplete TOP and incomplete miscarriage are managed similarly).
Core knowledge
The Choice on Termination of Pregnancy Act in summary
- Up to and including 12 weeks: TOP on request of the woman. No spousal/parental consent required. Minors must be advised to consult parents but cannot be refused if they do not.
- 13–20 weeks: TOP on grounds of risk to maternal physical or mental health, substantial risk of serious fetal abnormality, pregnancy from rape/incest, or socioeconomic circumstances.
- >20 weeks: TOP only on grounds of serious fetal abnormality, threat to maternal life, or severe fetal malformation. Two doctors must agree.
- Service must be provided in a designated facility.
- The Act has a conscience clause — clinicians may decline to perform TOP but must refer to a non-objecting provider; refusing to refer is unlawful.
Methods — by gestational age
First trimester (≤12 weeks)
Medical TOP (regimen aligned with WHO 2022, FIGO, and SA NDoH).
First-trimester medical TOP: mifepristone and misoprostol with the gestational sac, uterus, and cervix labelled.
- Mifepristone 200 mg PO, followed by misoprostol 800 mcg vaginally/buccally/sublingually 24–48 hours later.
- If mifepristone unavailable: misoprostol-only regimen — 800 mcg vaginally/sublingually every 3 hours for up to 3 doses; less effective than combination (~85% vs ~95–98%).
- Effectiveness: ~95–98% with combined regimen up to 9 weeks; ~90% at 10–12 weeks.
- Pain control: paracetamol, ibuprofen, opioids if needed.
- Provided as outpatient/home where appropriate; safer for the patient than waiting for surgical access.
- Follow-up: at 2 weeks with urine pregnancy test or ultrasound to confirm completion. A persistent positive urine test at 2 weeks → exclude ongoing pregnancy or retained products.