Abortion Attitudes in South Africa and the United States: Implications for Abortion Stigma and Health Equity

Abstract

Background: Unsafe abortion and abortion-related health inequities are important global public health issues, even in legal settings like South Africa and the United States (U.S.) because of abortion stigma and unequal access to safe services. In this dissertation, I compared abortion attitudes in South Africa and the U.S. asking: 1) in what ways do the socio-demographic patterns of abortion attitudes mirror the socio-demographic patterns of abortion-related health inequities; 2) how is moral acceptability of abortion co-constructed with social ideologies of gender and socioeconomic stratification; and 3) how do those relationships vary by race/ethnicity and socioeconomic status (SES)?

Methods: I analyzed data from the South African Social Attitudes Surveys and the U.S. General Social Surveys, which recorded if respondents think abortion is “always wrong”/“almost always wrong”/“wrong only sometimes”/“not wrong at all” in the case of fetal anomaly and in the case of poverty. First, I estimated the cross-sectional distribution and socio-demographic predictors of abortion attitudes (“always wrong” vs. other responses) in South Africa using multivariable logistic regression, then I analyzed national and subgroup trends over recent years. Next, I compared moral acceptability of abortion (all four response categories) in South Africa and the U.S. using ordinal regression to measure the effects of social welfare and gender role attitudes. Finally, I explored differences by race/ethnicity and education using stratification and post-estimation interaction tests.

Results: Over half of South Africans think abortion is “always wrong” in the case of fetal anomaly and over three-quarters in the case of poverty, compared to one-quarter and one-half of Americans, respectively. South Africans were more likely to feel abortion is wrong in both cases if they were non-Xhosa African or Coloured, less educated, over 45, living in Gauteng or Limpopo, or less accepting of premarital sex. Americans were more likely to feel abortion is wrong if they were male, less educated, younger, less accepting of premarital sex, Christian, or more conservative. There was no relationship between social welfare attitudes and abortion attitudes in the U.S., but greater support for social welfare among South Africans predicted lower acceptability of abortion in the case of poverty. This effect significantly interacted with race/ethnicity and with levels of education (support for social welfare was only significant for Afrikaner, Zulu, and less educated South Africans). In the U.S., more egalitarian attitudes toward gender roles in the family predicted higher abortion acceptability in both cases. In South Africa, attitudes toward gender roles in the family predicted abortion acceptability in the case of fetal anomaly (but not poverty), and these effects were only significant among the less educated.

Conclusions: These results suggest that differences in abortion attitudes might be contributing to racial/ethnic, socioeconomic, and geographic abortion-related health disparities in South Africa and to disparities by SES in the U.S. Moral acceptability of abortion does not seem to be related to socioeconomic ideology in the U.S., while poverty-related abortion acceptability is inversely related to support for social welfare among Zulu, Afrikaner, and less educated South Africans. Egalitarian gender attitudes are associated with higher abortion acceptability for fetal anomaly in South Africa and for both cases in the U.S. The relationship between abortion acceptability and gender attitudes varied by race/ethnicity and SES in South Africa, and by race/ethnicity in the U.S. Successful abortion destigmatization efforts will likely need to be community-specific, gender transformative, and intersectional.