The research team, led by Rebaone Petlele and Maureen Joffe of the University of the Witwatersrand, drew on the South African Breast Cancer and HIV Outcomes (SABCHO) cohort, a longitudinal study initiated in 2015. They analyzed data from two large academic hospitals affiliated with the university: Chris Hani Baragwanath Academic Hospital in Soweto, referred to as Site 1, and Charlotte Maxeke Johannesburg Academic Hospital in central Johannesburg, referred to as Site 2. Of 3,778 women diagnosed with invasive breast malignancies across the study windows, 2,623 consented to participate, and after excluding cases of ductal carcinoma in situ, phyllodes tumours, breast sarcoma, and patients lost to follow-up, 2,522 women with confirmed invasive breast carcinomas formed the analytical cohort, 1,641 at Site 1 and 881 at Site 2.

The investigators divided enrolment into three roughly two-year periods designed to minimize temporal spillover: a pre-Covid-19 window from April 2017 to March 2019, a pandemic window from April 2020 to March 2022, and a post-pandemic window from July 2022 to June 2024. This design captured two additional disruptions that complicate interpretation. In April 2021, a fire at Charlotte Maxeke hospital shut down treatment services for six months, while in June 2021 a new chemotherapy unit opened at Baragwanath, potentially improving treatment access there. Guided by the Model of Pathways to Treatment, the team measured three intervals: the pre-contact interval from symptom recognition to first healthcare access, the diagnostic interval from first contact to pathology-confirmed diagnosis, and the treatment interval from confirmed diagnosis to initiation of surgery, chemotherapy, or endocrine therapy.

The headline finding concerns stage at diagnosis. Late-stage disease, defined as stage III or IV, was already disturbingly common before the pandemic, affecting 50 percent of patients at Site 1 and 63 percent at Site 2. During Covid-19, those proportions climbed to 60 percent and 69 percent respectively, and then partially recovered to 53 percent and 55 percent in the post-pandemic period, differences that were statistically significant at both sites. The World Health Organization’s Global Breast Cancer Initiative, launched in 2021, calls for at least 60 percent of breast cancers to be diagnosed at stage I or II. Johannesburg’s public hospitals never came close to that benchmark in any period, meaning that even after recovery, the majority of women still arrived with advanced disease.

The timing analysis exposed where the system broke down. At Site 1, the median pre-contact interval, the time women waited after noticing symptoms before seeking care, rose from 0.8 months before the pandemic to 1.0 month during it and 2.0 months afterward, a statistically significant deterioration that never reversed. At Site 2, pre-contact intervals did not change significantly. The most commonly reported reason for delay at both hospitals was the belief that breast symptoms were not serious, cited by 75 to 89 percent of women depending on site and period, with the highest proportions during the pandemic. Fear of contracting Covid-19 on public transport and in clinics likely compounded this hesitancy. Fewer than 70 percent of women reached the health system within three months of symptom onset in any period, ranging from 45 to 58 percent at Site 2 and 58 to 64 percent at Site 1.

Diagnostic intervals, by contrast, proved relatively resilient. At Site 1 the median diagnostic interval held constant at 1.8 months across all three periods, and at Site 2 a rise to 2.0 months during the pandemic was not statistically significant. Remarkably, at Site 1 the proportion of women diagnosed within the Global Breast Cancer Initiative’s 60-day target was actually higher during the pandemic, reaching between 60 and 80 percent, because surgeons personally triaged patients for both breast and Covid-19 symptoms at the tertiary surgical breast unit, a function normally delegated to triage nurses. Still, between 27 and 41 percent of women at the two sites required more than two months from first contact to a pathology-confirmed diagnosis, and the study confirmed that delays longer than three months in the combined diagnostic journey were associated with late-stage disease.

Treatment initiation told a grimmer story. At Site 1, the median treatment interval lengthened from 1.6 months before the pandemic to 2.0 months during it and remained at 2.0 months afterward. The national suspension of elective surgical procedures and restricted theatre availability slashed the proportion of women receiving surgery, a decline that worsened in the post-pandemic period regardless of disease stage. At no point did either hospital meet the European Society of Breast Cancer Specialists benchmark of initiating first treatment within eight weeks of diagnostic workup in 80 percent of patients. The pandemic also accelerated a therapeutic shift: neoadjuvant chemotherapy rose from 35 percent of patients before Covid-19 to 54 percent afterward at Site 1, and from 52 to 62 percent at Site 2, while endocrine therapy served as a bridging strategy for hormone-responsive tumours when operating theatres were unavailable.

The stakes of these delays are not abstract. Prior analyses of the same SABCHO cohort showed that women who underwent surgery within three months of diagnosis had three-year overall survival of 85 percent, compared with 79 percent for those delayed beyond three months, with mortality risk climbing 11 percent for every additional month of delay. The authors also note that patient volumes at both hospitals increased by more than 20 percent after the pandemic compared with pre-pandemic levels, without any corresponding increase in staff or infrastructure, meaning the system is now treating more women with fewer resources per patient. Simulation-based sensitivity analyses supported the robustness of the pre-contact and treatment interval findings, though the study relied on self-reported recall for the pre-contact interval, an unavoidable source of bias.

The authors argue that their findings point to interventions at two levels. In communities, aggressive education campaigns are needed to encourage breast self-examination and dispel the perception that small or painless lumps can be ignored, since pre-contact delays were long and never recovered after the pandemic. Within the health system, they recommend streamlining referrals so that suspected breast cancer cases bypass secondary hospitals, a route previously linked to later-stage diagnosis, and they call for public-private partnerships to finance expanded surgical and chemotherapy capacity. Without substantial investment in human resources and infrastructure, they conclude, neither Johannesburg hospital is likely to meet international standards or cope with the steadily rising burden of breast cancer in South Africa, a country where no formal public screening programme exists and mammography remains reserved for symptomatic women.

Subject of Research: The impact of and recovery after the Covid-19 pandemic on breast cancer stage at diagnosis, diagnostic intervals, and treatment initiation at two public academic hospitals in Johannesburg, South Africa.

Article Title: Impact of and recovery after Covid-19 on breast cancer diagnosis and care in Johannesburg, South Africa

Article References: Petlele, R., Chikwati, R. P., Ojoniyi, O. O., Akokuwebe, M. E., Chen, W. C., Murugan, N., Ndwambi, P., Kumirayi, L., Jassat, F., Nietz, S., Mathiba, R. M., Singh, K., Ohene-Agyei, P., McCormack, V., Norris, S. A., & Joffe, M. (2026). Impact of and recovery after Covid-19 on breast cancer diagnosis and care in Johannesburg, South Africa. BMC Cancer, 26(1), Article 1182. https://doi.org/10.1186/s12885-026-17068-x

Image Credits: AI Generated

DOI: 10.1186/s12885-026-17068-x

Keywords: breast cancer, Covid-19, South Africa, Johannesburg, late-stage diagnosis, diagnostic delays, treatment delays, Global Breast Cancer Initiative, EUSOMA, public health system, neoadjuvant chemotherapy, health services research

The study was conducted by Bayla Ostrach, a medical anthropologist and family medicine researcher at Boston University School of Medicine, who carried out fieldwork at the only clinic then contracted with the Catalan public health system to provide full-spectrum abortion care. That single-clinic arrangement is itself a telling detail. Although abortion is, by policy, available through the public system in Catalunya, the actual delivery of services depends on a small network of contracted providers, meaning that patients in much of the region must travel to one facility to exercise a right that the law nominally guarantees everywhere. Using opportunistic and convenience sampling, Ostrach documented patient experiences directly within this setting, capturing the practical texture of access in a way that surveys and administrative data cannot.

Ethnographic methods of this kind are particularly well suited to studying abortion access because the barriers patients encounter are rarely formal or visible in policy documents. A waiting list that adds two weeks, a phone line that is difficult to reach, a health worker who implies that a medication regimen is the only appropriate option, or a comment that carries judgment—these are the frictions that accumulate into delay, and delay is the single most consequential variable in abortion care, since gestational age limits determine whether a patient can be treated at all. By embedding observation in the clinic and talking with patients as they moved through the system, the study was able to record these frictions as they occurred, rather than reconstructing them retrospectively.

The results converge on a central conclusion: years after liberalization, delays and obstacles persisted throughout the public health system. Participants described waiting periods and scheduling difficulties that pushed their care later into pregnancy, misinformation about what services were available and how to obtain them, and the continuing weight of abortion stigma, which manifested both in interactions with the health system and in patients’ own accounts of their decisions. Stigma, in this context, is not merely an emotional burden; it operates as a structural barrier, discouraging patients from asking questions, delaying their presentation for care, and shaping how providers communicate about options.

One of the study’s most striking findings concerns the form that stigma took within the publicly funded pathway itself. Participants reported pressure to undergo pharmacologic abortion—that is, medication-based termination rather than an aspiration or procedural method. Medication abortion is safe, effective, and appropriate for many patients, and its availability is an unambiguous good. The concern raised by the study is different: when patients are steered toward one method regardless of their clinical circumstances, gestational age, or personal preference, the pressure itself becomes a form of obstruction. Method choice in abortion care should reflect informed patient preference within clinical guidelines, and reports of systematic steering suggest that the public system’s delivery model, whatever its logistical rationale, was not consistently centering patient autonomy.

The study also documented the socioeconomic motivations that participants described for seeking abortion, particularly in the context of existing child-rearing responsibilities. Many patients were already parents, and their decisions were framed explicitly around the material realities of raising children—income, housing, work schedules, and the absence of adequate support. This finding aligns with a long line of research showing that the most common reasons women give for seeking abortion are financial and caregiving constraints rather than health complications or fetal indications. It also underscores a point that abortion access researchers have made repeatedly: the people most affected by delays and obstacles in publicly funded systems are those with the fewest private alternatives, and the most marginalized patients bear the brunt of every added barrier.

That distributional point is central to the study’s significance. The abstract notes that delays and obstacles appear to especially impact the most marginalized, and the single-contractor structure of Catalan abortion provision illustrates why. A patient with a car, flexible employment, and private resources can absorb travel costs, take time off, and, if necessary, pay for private care. A patient working hourly shifts, caring for children, or lacking documentation or funds cannot. When the public pathway is slow or opaque, the system effectively sorts patients by their capacity to navigate it, converting administrative friction into inequity. In this sense, the Catalan case is a warning for any health system that treats legal availability as equivalent to realized access.

The research also carries methodological and ethical weight. The study protocol was reviewed by the human subjects research board at Boston University School of Medicine and, under United States federal research regulations codified at 45 CFR 46, was determined exempt from further review, while still being conducted in accordance with those federal guidelines; all participants provided informed consent. The research was unfunded, and the author declares no competing interests. The article is published open access under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International license, and the version shared ahead of final publication is citable and carries a permanent digital object identifier, a practice that journals increasingly use to speed the dissemination of peer-reviewed findings.

For public health, the implications reach well beyond Catalunya. The global health community has long identified access to safe, high-quality abortion as a priority, and the study’s central lesson is that liberalization is a beginning, not an endpoint. A law changes what is permitted; a health system determines what is possible. Between the two lie waiting times, referral pathways, provider training, method availability, information quality, and the informal norms that shape clinical encounters. The Catalan experience shows that even where all of these operate within a framework of legality and public funding, they can still function as obstacles—and that closing the gap requires monitoring not just whether services exist, but how patients actually experience them.

The study’s conclusion is deliberately restrained but pointed: years after abortion liberalization, overall health system delays and obstacles persisted, even in an ostensibly ideal setting of legality and public funding. That phrase—ostensibly ideal—is the finding’s sharpest edge. If a wealthy European region with a universal health system, a liberalized law, and public financing still produces the delays, misinformation, and stigma documented here, then no jurisdiction can assume that legal reform alone delivers equitable access. What remains to be studied, and what the Catalan case now demands, is the systematic measurement of patient experience as a core indicator of abortion service quality, treated with the same seriousness as clinical outcomes. Until then, the gap between the law on the books and the care patients receive will continue to fall hardest on those with the least capacity to bridge it.

Subject of Research: Patient experiences navigating publicly funded abortion care in the Catalan public health system years after Spain's 2010 abortion liberalization

Article Title: Patient experiences in the Catalan public health system years after abortion liberalization

Article References: Ostrach, B. (2026). Patient experiences in the Catalan public health system years after abortion liberalization. Discover Social Science and Health. https://doi.org/10.1007/s44155-026-00486-4

Image Credits: AI Generated

DOI: 10.1007/s44155-026-00486-4

Keywords: abortion access, abortion delays, abortion stigma, Catalonia, Catalunya, public health system, publicly funded healthcare, Spain abortion law, medication abortion, health equity, medical anthropology, reproductive health