This study aimed to explore the decision-making process of patients with pregnancies affected by serious congenital abnormalities. The study design was an exploratory qualitative study. The sample for this study was pregnant individuals who had a prenatal diagnosis of a serious congenital abnormality and were offered termination of pregnancy. Semi-structured face-to-face interviews with closed and open-ended questions, recorded and transcribed verbatim, were used to collect the data; this was then analyzed using a thematic data analysis approach. Five topics were developed: “Health care services”, “Home”, “Being a mother”, “Finding meaning”, and “The aftermath”. The first four topics describe the decision-making process where the participants filtered through multiple factors to reach their final decision. Although the participants consulted with their families, partners, and community, they made the final decision themselves. The final topics describes activities which were necessary for closure and coping. This study has provided valuable insight into the decision-making process, which can be used to improve services offered to patients. Information should be communicated clearly with follow-up appointments to discuss further. Healthcare professional should show empathy and assure the participants that their decision is supported. •There are limited qualitative data on termination of pregnancy decision-making for serious congenital abnormalities in the African setting.•This paper provides insight into the decision-making process of pregnant individuals from the Western Cape, South Africa.•Decision-making for terminating pregnancy affected by congenital abnormality is multifaceted but with one deciding factor.•Contrary to what is anecdotally expected, in this study the participants made the final decision.•Tragic optimism was necessary for the participants to carry on with their lives.