Accessing abortion services in rural areas under conditions of liberal abortion legislation is neither straightforward nor simple. As the South African example shows, the liberalisation of abortion legislation was the first step in granting pregnant persons access to abortion care. Despite this and some progress in implementation, many challenges persist resulting in a lack of services, especially in areas where distances and transport costs are a factor. Drawing on the findings of a study conducted in three rural districts of the Eastern Cape, the authors highlight the complexities involved in understanding problematic or unwanted pregnancies and abortion services within these communities; the reported barriers to, and facilitators of, access to abortion services among rural populations; and preferences for types of abortion services. A key finding is the conundrum of costs versus confidentiality: lack of confidentiality involves additional costs to access services outside the area; high costs mean that confidentiality may have to be foregone, which leads to stigma. The authors place the findings within a reparative reproductive justice framework and present a comprehensive set of recommendations. Abortion Services and Reproductive Justice in Rural South Africa is an insightful and informative resource – the first of its kind – for scholars in health and sociology, reproductive health policy makers, national planners, health facility managers and providers, and activists.