Choice on termination of pregnancy (CTOP) is one of the least accessible services of sexual and reproductive health. This limited accessibility is often attributed to nursing-related factors such as negative attitudes, inadequate training and the influence of individual religious or cultural beliefs.^1,2 Termination of pregnancy (TOP) refers to the deliberate separation and expulsion of the contents of the uterus of a pregnant woman through either medical or surgical means.³ Medical TOP uses pharmacological means to induce uterine contractions and expel the uterine contents, whereas surgical TOP involves transcervical procedures, such as vacuum aspiration or dilatation and evacuation.⁴ Both methods are safe and effective and may be provided when continuation of the pregnancy would substantially affect the woman’s social or economic circumstances, pose a risk to her physical or mental health or for other reasons considered clinically or legally appropriate. Notably, over 260 000 nurses are registered with the South African Nursing Council (SANC), making them the most accessible healthcare providers in the country.⁵ Despite this nursing manpower, access to CTOP services remains constrained. Equally important, these constraints on CTOP access are further perpetuated by existing legal frameworks.

According to the National Clinical Guideline for Implementation of the Choice on Termination of Pregnancy (CTOP) Act, only registered medical practitioners or trained nurses and midwives are permitted to perform terminations.⁴ In line with this guideline, nurses are allowed to terminate pregnancies up to 12 weeks and 6 days at a woman’s request, without requiring a stated reason.⁴ This restriction is based on the understanding that early TOP procedures carry fewer health risks, are less complex to perform and are more cost-effective for health facilities. Furthermore, nurses involved in CTOP services play a vital role in providing pre- and post-counselling and educating clients on contraceptive methods to prevent future unintended pregnancies.^6,7 While the South African context presents unique legal and professional dynamics, the accessibility and implementation of CTOP services remain a global public health and social challenge. In Ireland, the main challenges related to CTOP have been identified as a lack of education and training, a shortage of staff and a lack of resources.⁸ Similarly, in Thailand, it has been found that nurses lack knowledge and do not have favourable attitudes towards CTOP.⁹ Evidently, religion, cultural beliefs and attitudes of nurses play a crucial role in the accessibility of TOP services.¹⁰

Sub-Saharan Africa has made great progress in addressing unsafe CTOP since 2000 through legalisations, regulations and policies.¹¹ However, that does not equate to the progress of accessibility of the CTOP service. Evidently, TOP services in countries like Zimbabwe and Kenya remain an option only under exceptional circumstances.^12,13 Furthermore, countries like Nigeria report a rate of more than 50% of unsafe TOP to date, with most of the women coming from disadvantaged backgrounds.¹⁴ In Ethiopia, recognised barriers to the access of safe TOP care include costs of services, lack of privacy and fear of judgement from providers. Women who had had negative experiences with providers were more likely to seek unsafe CTOP the second time around.¹⁵ Equally important, restrictive religious beliefs and deeply rooted social norms across many countries further limit women’s access to safe CTOP services.¹⁶ From a socio-ecological perspective, social norms at interpersonal and community levels serve as significant barriers to women’s access to safe CTOP services by perpetuating stigma and limiting supportive social environments.

The CTOP Act 92 of 1996 replaced the restrictive Sterilization Act of 1975, providing safe, early and legal access to termination services. Under the CTOP Act, a pregnancy may be terminated if it poses a risk to the woman’s physical or mental health, results from rape or incest or would significantly impact her social or economic circumstances. Despite this legislative advancement and broader efforts to improve women’s sexual and reproductive health, unsafe and informal terminations continue to present significant public health and social challenges. It is estimated that annually, between 52% and 58% of terminations of pregnancy are performed outside the legal framework and are therefore unsafe.¹⁷ Equally important, fewer than 7% of public health facilities in South Africa are reported to provide CTOP services.¹⁸ The limited availability of CTOP services in public facilities increases the likelihood that women may resort to unsafe ‘backstreet’ terminations, which pose serious health risks and can lead to severe complications or even death.¹⁸ This persistent gap between policy and practice underscores the urgent need to interrogate the structural, institutional and professional barriers that hinder the full realisation of reproductive rights.

Nurses are often the first and, sometimes, the only point of contact for women seeking reproductive health services. The barriers mentioned directly undermine access to safe CTOP care, perpetuating the cycle of unsafe TOP despite the enabling legal framework. Examination of the literature affirms that nurses encounter challenges when they want to improve their knowledge and skills through training.⁶ Furthermore, there is a lack of integration of CTOP in current nursing curricula and education, and this delineates a gap in the provision of sexual reproductive health services in South Africa. Choice on termination of pregnancy is a crucial service that requires urgent attention to achieve Sustainable Development Goal (SDG) 3. This review aims to systematically explore and synthesise the literature on nurses’ roles, experiences and challenges in providing CTOP services in South Africa. Using the Socio-Ecological Framework, the review seeks to identify and map factors that influence the delivery and accessibility of safe CTOP care, at individual, interpersonal, organisational, community and policy levels. Equally, this review highlights key areas for intervention and policy improvement to better support nurses, reduce stigma and enhance access to safe CTOP care, ultimately contributing to improved reproductive health outcomes and informing future research, practice and policy development.

This scoping review began with an initial pool of 2295 studies, which was systematically narrowed to 21 that met the inclusion criteria, as shown in Figure 1. In the preliminary phase, titles and abstracts were screened to assess their relevance to the study’s scope, resulting in 39 records selected for full-text evaluation. Of these, 22 were excluded for reasons such as being beyond the study’s scope, focusing on healthcare professionals other than nurses, examining patients receiving CTOP services or being conducted outside South Africa. Additionally, 29 further studies were identified through reference harvesting, including both backward and forward searches. The studies included in this review, published between 1998 and 2023, provided diverse and in-depth insights into the multifaceted experiences of nurses involved in CTOP services, highlighting emotional and moral challenges, interpersonal dynamics, organisational constraints, sociocultural influences and legal gaps. As shown in Figure 2, most of the studies (66.7%) employed qualitative methods, reflecting a strong emphasis on obtaining in-depth, contextually rich insights. Quantitative studies accounted for 28.5%, while a single report-based source represented 4.8% of the total. This distribution underscores the predominance of qualitative approaches in exploring the topic. To the best of the researchers’ knowledge, this is the first review to specifically examine these dimensions of nurses’ roles and challenges in CTOP since the implementation of the CTOP Act 92 of 1996. Guided by the Socio-Ecological Framework, six themes emerged from the analysis as presented in Table 2.

This article aimed to examine and map the existing evidence regarding the roles and challenges faced by nurses in the CTOP services in South Africa, utilising a socio-ecological framework. The study reveals that the involvement of nurses in CTOP services is shaped by a variety of factors. On a personal level, the review underscores the fact that nurses frequently confront emotional distress and trauma, as well as moral, ethical and religious dilemmas. These findings are consistent with those observed in other regions of Africa. For example, a study conducted in Nigeria found that some healthcare professionals strongly oppose the practice of CTOP, expressing that their role is to heal rather than to take life.⁴¹ These healthcare professionals contend that providing CTOP services equates to the act of taking a life. The moral obligations and religious dilemmas are consistent across other healthcare professionals involved in the provision of CTOP services. Another study conducted in South Africa indicates that healthcare professionals, on a personal and religious level, view CTOP as murder, the destruction of human life and a sin.⁴² Recent literature in South Africa reports that healthcare professionals have little knowledge of CTOP services and still deem CTOP as an unacceptable practice.² Drawing from trends of studies published in South Africa since the introduction of the Choice of Termination Pregnancy Act 92 of 1996, it seems that the duty of TOP was imposed on clinical practice without proper consultation with healthcare providers. This is supported by the notable trends that healthcare professionals felt that their personal and religious beliefs were not considered, as they were expected to provide the CTOP services as part of their scope of practice. This results in their feeling antagonistic towards and dissatisfied with their jobs. Consequently, this compromises the provision of quality CTOP services.^31,42 However, inconsistencies in CTOP views are noted globally in the North and South. Nicholson, Slade and Fletcher indicate that nurses were unconditionally accepting of the CTOP, but that they felt that CTOP was used as a form of contraception.⁴³ This results in their feeling frustrated and having difficulty in supporting women’s decisions. Despite the inconsistencies in the global North and South, similarities were noted among the healthcare professionals. All healthcare professionals were accepting of CTOP and displayed empathy, particularly to the women whose pregnancy resulted from incest or rape or whose termination was necessitated by medical indications.^{6,24,41,42,44} Overall, despite the moral and religious dilemma, the existing literature illuminates how various reasons for CTOP shape the perception and attitude of nurses.

In addition to the internal conflicts faced by nurses with regard to the provision of CTOP services, the review findings are consonant with the Socio-Ecological Framework that the behaviour of nurses towards CTOP is anchored in other problems at multiple levels, not only at the individual level but also at organisation, policy and community levels. Scholars have affirmed that the negative attitudes towards and unacceptable practice of CTOP services are influenced by external factors such as a shortage of resources and equipment and a lack of training and professional development.^2,36 This is similar to the review findings that reveal that the practices of CTOP services among nurses are negatively impacted by factors at organisational, community and policy levels. Among the factors are lack of support, community and societal stigma and inadequate infrastructure.^27,29,37,39 The review identifies the profound weight the external factors at community, organisational and policy levels have on shaping the behaviour and attitudes of nurses towards CTOP. Drawing from both the review findings and the Socio-Ecological Framework, the current study underscores that the professional integrity and agency of nurses regarding the acceptability and provision of quality CTOP services in South Africa is embedded within networks of personal beliefs, institutional barriers and broader societal and community influences. The nurses attempt to navigate these dynamics and to maintain respect towards their religious and moral obligations. Despite the identified challenges, these findings advocate for the need to prioritise the provision of reproductive healthcare services such as CTOP. This could be achieved by the provision of adequate resources and training for nurses to optimise the quality of CTOP care. Moreover, nurses and community stakeholders should be included in policy development on CTOP services to mitigate the community stigma towards CTOP and to enhance community and society awareness and understanding of CTOP. As reflected in the findings, CTOP services are sometimes provided in an attempt to save women’s lives. Therefore, the active participation of nurses and community members in psychologically focused awareness campaigns on the CTOP is essential, as it may contribute to reducing mortality associated with backstreet and self-induced abortions in South African communities. Existing research emphasises the influence of community and nurse power dynamics on women’s decisions regarding pregnancy termination.¹⁷ These dynamics often lead women to choose unsafe methods, thereby exposing themselves to serious risks such as sepsis or even death.

The study elucidates the interplay of individual, interpersonal, community, institutional and policy factors in shaping nurses’ behaviour towards the provision of CTOP services to women in South Africa. Religion, moral obligation, community stigma, insufficient resources and lack of support negatively impact nurses in the provision of quality CTOP services. Efforts to combat community stigma and improve awareness and understanding of CTOP services at the community level should be implemented. This calls for the development of customised, sensitive community-based and workplace initiatives to improve and support nurses in the provision of CTOP services.