Women who have been forced to go without their usual birth control shot are now facing the consequences of months-long shortages.
For many women in Rustenburg's Bojanala Platinum District, Kgaladi Mphahlele is the first person they see after an abortion.
And one of the things they speak about is how to avoid seeing each other again.
Mphahlele works for the international humanitarian organisation Doctors Without Borders' (MSF) and manages their termination of pregnancy programme in North West. There, he counsels women who have had abortions about ways to prevent unwanted pregnancies in the future by using contraception.
But for most of last year, Mphahlele couldn't give women much of anything to avoid falling pregnant again - there were no contraceptives in the five clinics he manages.
Under South African law, a person can terminate a pregnancy for whatever reason up to 12 weeks. A woman can also request an abortion between 13 and 20 weeks of pregnancy if it poses a threat to her physical, mental or socioeconomic health.
"When you sit down with the patients, some explain that they had to [resort to] using condoms, and their husbands don't want to use condoms," Mphahlele says. "But if there were contraceptives available at that time, it would actually have made an impact."
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Mphahlele's patients were not the only ones who went without their usual birth control. A national shortage of the bimonthly injectable contraceptive Nur-Isterate is now entering its second year.
Bhekisisa first received reports about contraceptive shortages from women in January 2018. The health department alerted clinics about stockouts four months later in April. At the time, the country was also short of the birth control tablets Oralcon, Trigestrel and Famynor.
Oral contraception is now back on clinic shelves. But health facilities in at least five provinces - Gauteng, Free State, KwaZulu-Natal, North West and Mpumalanga - are still out of the popular bi-monthly birth control shot Nur-Isterate, the civil society coalition Stop Stockouts Project found.
Mphahlele says women have paid the price. He's seen an increase in patients seeking abortions, which he argues is because of the shortages.
He explains: "Women would say, 'I asked for contraceptives at the clinic, but there weren't any'."
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In South Africa, two types of injectable contraceptives are available in the public sector: Nur-Isterate and Depo-Provera. Both use hormones to stop women's ovaries from releasing eggs each month and thus prevent them from becoming pregnant.
To avert shortages, South Africa usually gets injectable contraceptives from three pharmaceutical companies: Bayer, Pfizer and Fresenius Kabi.
But in October 2017, both Pfizer and Fresenius Kabi did not bid for the national tender for these drugs. To cut costs, Fresenius Kabi had pulled its version of Depo-Provera from the South African market but later agreed to manufacture the contraceptive until April 2018, Mikko Tiitinen, managing director at the company's local branch, says.
Pfizer - which had repeatedly vied for the country's Depo-Provera contract and lost - also decided not to submit a bid, national health department director for affordable medicines Khadija Jamaloodien explains.
"At the time, Pfizer was unable to meet the requirements for the tender," the company's communications manager, Charmaine Motloung, says.
In response to 2018 shortages, the health department obtained a quote from Pfizer for the drugs. Jamaloodien says provincial health departments are now ordering directly from the international pharmaceutical company.
Bayer is the only company registered to supply Nur-Isterate in South Africa. But tough price negotiations between the firm and national treasury delayed the finalisation of its contract to provide the country with the shot by five months, triggering national shortages, national treasury told Bhekisisa last year.
While negotiations with Treasury dragged on, Bayer's production plant in Germany was forced to allocate machines that would usually churn out Nur-Isterate to other medicines, the company's spokesperson, Tasniem Patel, told Bhekisisa last week.
When it became clear the company's German production plant would not be able to fill the backlog caused by the delayed contract, Patel says Bayer asked for special permission from Sahpra to start importing the Nur-Isterate from its factory in Pakistan. Before then, only the plant in Germany had gone through safety checks by South Africa's drug regulator, Sahpra.
Bayer's Pakistani plant has already produced 24 000 doses of Nur-Isterate, but the shots cannot be released to South Africans until Bayer resolves manufacturing issues raised by Sahpra, the department wrote in an update (which Bhekisisa has seen) to Stop Stockouts Project administrator Kopano Klaas.
Although Bayer rushed to address Sahpra's concerns, the company is still waiting for the regulator's report on its latest inspection of its Pakistani plant, Patel says.
The health department's update to Klaas explains that once Sahpra gives the go-ahead, stockouts of these contraceptives will likely go back to normal in March. Sahpra did not respond to requests for comment.
In Germany, Bayer's production of NurIsterate is also catching up and about 100 000 doses of the injection have already reached South African shores. Another shipment of similar size is expected by the end of this week.
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South Africa has not researched the impact of contraceptive stockouts so it's impossible to say whether the year-long shortage has caused a spike in unwanted pregnancies. Globally, how the availability of contraception affects the number of children women have is hotly debated, Yana van der Meulen argues in a recent book, The Global Gag Rule and Women's Reproductive Health. But 2002 research from Ghana published in the journal Genus and later studies in Bangladesh found that women who had access to family planning services were able to reduce their fertility by about 15%.
A small 2016 study published in the journal International Perspectives on Sexual and Reproductive Health did look at the impact of stockouts on women in two Ugandan health districts. Researchers surveyed 50 women and about 30 healthcare workers - they found that shortages lead to unwanted pregnancies, increased stress among women and made them more vulnerable to domestic violence.
Health workers reported feeling overwhelmed by the stockouts and often faced blame from their patients.
South African research shows unplanned pregnancy rates are already high. A 2017 national survey, published in the South African Medical Journal, found that close to two-thirds of women surveyed reported an unintended pregnancy in the past five years. The country's national HIV plan aims to get 74% of women between 15 and 49 on to contraception methods such as the shot or the pill by 2022.
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Stockouts are challenging to track, and just because medicine is in the country doesn't mean it's available at clinics.
"The medicine supply chain is complex," the health department's Khadija Jamaloodien admits.
Indira Govender is a doctor working in rural KwaZulu-Natal and a member of the Stop Stockouts steering committee.
"So many things can go wrong - from manufacturing to transport logistics from the warehouses [to facilities], and clinics don't always report shortages early enough," she says.
Govender warns that the department's response to stockouts - usually in the form of circulars sent to health facilities alerting them to shortages - also falls short.
"What's missing is advice that will help health workers counsel their patients properly during a stockout," she says, "especially because some healthcare workers have not been trained to advise patients about contraception."
In the case of the recent shortages, a lack of this type of information put patients at a higher risk of unwanted pregnancies, Govender argues.
She explains: "If a patient who usually gets the shot now has to start taking the pill, that patient should be told about the possible side effects they could experience, and that they should use a condom for the first couple of days until the pill takes full effect."
Jamaloodien says it remains up to provincial health departments to update local clinics and to make sure patients are informed about switching contraceptives. The department is working with the Stop Stockouts Project and the Southern African HIV Clinicians Society on a new strategy to get messages like these to clinics, she says.
Back in North West, Mphahlele says he has seen a steady increase in patients coming from Johannesburg to get abortions at MSF's clinics. The influx has strained the few health workers willing to provide terminations in the area. Abortion remains stigmatised, even among nurses and doctors, and those who do offer it often face difficult working conditions in health facilities, including harassment from coworkers.
Last year, one North West clinic manager changed the locks to the room where abortions were provided to prevent nurses from performing the procedure, Manala Makua, national health department director for women's health and reproductive health and genetics, told Bhekisisa.
One major hospital in the Rustenburg area now relies on a single doctor to perform second-trimester abortions.
"Women say there's nothing available in Johannesburg, but they'd heard they could get help in Rustenberg," Mphahlele says.
"The nurses can't cope."