Termination of Pregnancy Act Implementation: hearings

Meeting report

HEALTH PORTFOLIO COMMITTEE
6 June 2000
IMPLEMENTATION OF CHOICE OF TERMINATION OF PREGNANCY ACT: HEARINGS

Documents handed out:
None

SUMMARY
The hearings were held to assess the implementation of the Act, specifically avoiding the moral debates around the question of termination. The Reproductive Rights Alliance organised these public hearings in partnership with the Portfolio Committee. The speakers outlined the problems experienced with regard to access to terminations and victimisation of staff and women.

MINUTES
Womens' Health Project
The submission by the Women's' Health Project was based on two pieces of work: a national literature review of work done after the Act was published and an ongoing health systems project. The implementation of the Act has been accompanied by ongoing research. Their work shows that about 114 501 terminations (TOPs) have been reported in three years.

Three provisions of the Act render TOPs accessible to women:
- Midwives can perform first trimester TOPs
- No restriction is placed on first trimester TOPs
- Women of all ages have access to terminations.

What is the extent of implementation in the health services?
Ninety percent of terminations are provided at hospitals whereas they should also be provided at primary health care units. Some hospitals have been designated as TOP facilities but are not providing the service. There are few trained midwives to perform terminations. The Project is of the view that the SA Nursing Council needs to heed this and change regulations to enable the training of midwives. Among the fully trained midwives some have left for the private sector or do not work in TOP clinics. This affects women who do not have access to private facilities.

Regarding second trimester terminations, figures show a reduction in these. This reduction is positive if women are presenting earlier for the procedure but negative if the delay is due to women being obstructed. Women often present late because they do not have basic biological information and do not identify their pregnancy immediately.

Regarding interaction between clients and health care workers, insufficient attention has been paid to this aspect of terminations. Women report that health care workers at referral centres shun them. Judgmental attitudes affect both workers and clients. Health care workers involved in terminations report that they feel unsupported and alienated by those of their colleagues who are opposed to the procedure. Workers could become more directly involved by giving correct information and guidance to clients.

What interventions are being done to change the attitudes of service providers?
A Values Clarification Workshop is currently being held at which health care workers can express their difficulties and increase the information and knowledge on terminations.

Discussion
Dr Rabinowitz (IFP) asked the presenter which aspects of TOPs are most objectionable to staff. Was it the lateness at which a termination is possible?
Ms Sanjani agreed that lateness was a reason but staff also objected to terminations for personal reasons.

Dr Rabinowitz noted that they were asking for more TOPs to be performed at primary health care clinics. What about the dangers of complications especially where Misoprostal was being used to induce the termination?
Ms Sanjani said that there is a range of different protocols. Some women can take Misoprostal and leave while others would have to come back for after-care. This should not prevent decentralisation.

Ms Dudley (ACDP) asked why doctors are so unwilling to perform the terminations. What is the emotional impact of TOPs on staff?

Ms Sinjana said that the refusal to perform terminations stemmed from personal opinion. It was also attributed to health care fatigue. Health services are burdened by the numerous new service policies caused by the rapid transformation of the health care system. An option that had to be considered was referrals.
The emotional impact is due to there still being an non-supportive environment and also because health care workers are generally overburdened. This might manifest itself in alcohol dependence or burnout or a desire to leave the service.

Ms Mnumzana (ANC) asked whether the integration of services with general services is the viewpoint of the Department or of service providers. Dr Mbulawa (ANC) asked whether staff who performed terminations were experiencing stigmatisation.

Ms Sinjana said that the integration of services was an attempt at de-stigmatising services. There was a need for more anonymity for the termination service and to integrate it with general services. She stated that people are now being labelled 'TOP staff'.

Dr Nsengani (Northern Province)
Dr Nsengani made a number of general observations about terminations in the Northern Province.
- Attitudes are getting better among younger people but there is still opposition to the service by priests and older people.
- Women who need TOPs are under emotional stress. They therefore need a non-judgemental attitude from staff.
- A huge stigma is still attached to TOPs therefore they should not be provided by a particular facility or particular staff. Health care workers also need to be informed of the facilities that provide the service in their area.
- There should be a single protocol at clinics.
- General practitioners need to be more involved in the termination service.
- Patients need counselling and information. For instance, they need to be informed that fertility resumes immediately after the termination.
- There needs to be continuous community education and family planning.
- Services must be provided in a respectful, accessible, user friendly manner.
- Cost effectiveness of the service must be managed.
- TOPs should not be a stand-alone service.
- The management protocol for TOP facilities should be consumer friendly.
- Academic institutions must train health care providers, monitor and improve on the protocol and the implementation of the Act.
- Partnerships with NGOs should be encouraged to facilitate the implementation of the Act.

Discussion
Ms Njobe (ANC) asked whether training would change the attitudes of health care workers or whether volunteers should be trained and used.

Dr Nsengani acknowledged that training is important because some health care workers are not educated on the after effects of abortion and often infertility may arise from complications. He advocates a system where general practitioners are more involved. TOP services must be integrated and if general practitioners could perform the service privately, it would improve the service.

Dr Mbulawa (ANC) asked what they were doing to change the attitudes of traditional leaders and religious leaders as the Northern Province was predominantly rural.

Dr Nsengani said that elderly persons and traditional leaders mostly do not believe in contraception. An organisation has been started and it is calling on all men to educate themselves on contraception and terminations but older men still have a negative attitude towards terminations. He feels there should be more discussion of these issues.

Dr Rabinowitz (IFP) asked what happens if someone has a termination in a close-minded community and this fact is then revealed. What about a girl who uses Misoprostal but later changes her mind and then gives birth to an abnormal baby?
Dr Nsengani said that in cases where the community came to know of a termination, even a spontaneous one, the woman is isolated for at least six months to avoid her infecting her husband.

In naswer to Dr Jassat's question on whether traditional leaders condone premarital sexual activity, Dr Nsengani said that in general the community is opposed to it.

Ms Dudley (ACDP) asked whether it is imperative that people's minds be changed. Dr Nsengani said that personally he does not perform TOPs although he refers people to a practitioner who does. But his refusal is only based on the fact that he is already well known as an expert on infertility and there would be some conflict.

Dr Nsengani did not have sufficient time to address the following questions:
Ms Dudley (ACDP) asked whether the community did not feel disempowered seeing as their views on terminations were not respected.
Ms Marshoff (ANC) asked whether general practitioners were reluctant to perform TOPs in the public sector but were willing to perform them in the private sector where they could charge a high fee.
Ms Mnumzana (ANC) asked whether they had a component in their programme to make clients more aware of their services. Do they work with the private sector?

Reproductive Health Forum- Northern Province
Ms Sophie Magwala said that it is important to look into whether women can access termination facilities in a province with a population of 5.5 million people. In the Northern region 7 hospitals and 700 clinics offer TOPs. Because of the problems with distance in the region access to service points is a problem. Affordability is also a problem because people require transport to and from facilities.

Ms Magwala felt that people have 'mixed feelings' about terminations. She suggested that community and health care providers have mixed feelings while those who receive the termination service are happy to be able to exercise their choice. Knowledge, practice and attitudes are the main barriers in the province and compound the access problems.

Figures show that more persons are now accessing TOPs. In 1998, 895 persons accessed the service (already an increase from the first 12 months after promulgation of the Act) and 1615 persons accessed the service in 1999. The service is largely provided by trained midwives and more are now being trained.

Ms Magwala identified a number of strategies which would facilitate the implementation of the Act. Community volunteers need to be trained as counsellors. Strategies of poverty alleviation have to be reinforced. Public transport and rural roads should become a focus, as women have to cover long distances to access services.

Ms Nonyani added that as a health care worker at Groothoek Hospital in the Northern Province she faces many difficulties in the provision of a termination service. She has no physical structure from which to work and most are done in a ward. The designated, trained midwife does not perform her duties. She herself is victimised and the effect is that she provides a poor quality service to the client.

Discussion
Dr Mbulawa (ANC) asked Ms Magwala why people have to cover such distances. Are there no clinics in the area?

Ms Magwala said the identified institutions for the terminations are hospitals but they are very far. The province is working on the question of decentralisation.

Mrs Dudley (ACDP) asked whether women are using abortion as a form of contraception.

Ms Magwala said that a most important part of pre-counselling is information on family planning to inform women that abortion is not a form of contraception.

Ms Njobe (ANC) asked whether women are only using the service when necessary, as the Act stipulates. She commented that there were disparities in the last two presentations seeing as they are both from the Northern Province. Are figures not expected to decline after some time, especially where counselling and other services are provided to women? She also asked if there has ever been a problem with backstreet abortions in the Northern Province. Do conservatives prefer women to have unseen backstreet abortions instead of openly?

Ms Baloyi (ANC) thought that the disparities in the presentations were understandable. The Northern Province is very large and the speakers obviously came from different regions.

Ms Magwala responded to the comments on the disparities in the presentations. She reiterated her earlier comment saying that they had probed the question of 'mixed feeling' as part of a forum and realised that these were being experienced not only by health care workers but also by managers of institutions.

Dr Mogoba (PAC) expressed sympathy with the second speaker especially in respect of the threats she has to deal with. The Northern Province is still very rural and education is needed.

Empangeni Hospital - Kwazulu Natal
Ms Thandi Pewa said that the advantages of the Act is that it helps to reduce backstreet abortions and in this way saves the lives of women.

The problems that they identified in respect of implementation:
- Accessibility of the service is not ideal. Empangeni Hospital is the only facility and they have a long waiting list.
- It is hard to advertise the service in rural areas.
- They were experiencing a staff shortage. Only two nursing sisters were available to perform TOPs. Doctors have a problem with procuring abortions in the second trimester while first trimesters are done as outpatients. It does help that the hospital is in town because it prevents stigmatisation. People from the rural areas can get away from their communities to have the termination done.
-There are clients who return for a second time although these cases are isolated. The law does not stipulate how many times they can have a termination done.
- Clients who receive Misoprostal at the hospital but then change their mind about the termination do not always return the tablets.
- Referrals are problematic because women are usually only referred in their second trimester.
- There is no safety or security for TOP staff who experience threats from violent boyfriends. Clients who are turned away because they are too far into the pregnancy are also dissatisfied.

Due to a serious staffing problem they recommend that family planning be accessible to all youth of diverse cultural backgrounds with special attention being paid to rural areas. They recommend the provision of one-stop services and female police for rape victims and the provision of more efficient and sympathetic services. In-service training is needed to sensitise health care workers.

Discussion
Ms Marshoff (ANC) asked what criteria is used to put persons on a waiting list. Is it not an added burden for persons in rural areas to return to the hospital?
Ms Pewa said that the criterion for the waiting list is the time at which the woman reports. Space is always left for those are too far into their pregnancy who cannot wait.

Dr Mbulawa (ANC) asked whether violence against staff has ever resulted in death. Ms Pewa replied that staff members have not been physically assaulted yet.

Ms Njobe (ANC) asked whether they are aware of any programmes to change attitudes in the rural areas. Do women generally find it difficult to communicate with their husbands? Would it help to involve religious communities in counselling?
Ms Pewa replied that religious groups in town are generally not that hostile and some do offer to do counselling.

Ms Dudley (ACDP) asked whether violent reactions are not being provoked by denying fathers their rights.
Ms Pewa replied that wives often request terminations where there are marital problems.

Institute for Pastoral Studies - Eastern Cape
Ms Plaatje explained that unplanned pregnancies are prevalent among Black disadvantaged women although government has tried to institute family planning facilities. Women used to die of back street abortions and they are still happening although they have declined. Women are traumatised by negative statements and attitudes, which sometimes block people from accessing these services. These attitudes are displayed by community and staff at facilities who need to be conscientised along with men.

The Institute made suggestions about the implementation of the Act:
- Communities should be educated against gender stereotypes.
- TOPs should be made more accessible.
-Clinics need to be staffed with trained persons. In Albany there is only one doctor to cover a large population.
- Women need to be counselled.
- There should be a community training programme in addition to existing initiatives.
- Information centres should provide advice to people when faced with negative attitudes.
- Religious stereotypes must be addressed.
- Funds should be made available for all these programmes.
- Staff should know where to refer people and should be able to counsel even the families of clients.

Discussion
Ms Njobe (ANC) said that an important tool for education is the local Member of Parliament. Does the organisation not get any co-operation or have they not approached the Member?
Ms Plaatje said that they do use the Members of Parliament on various occasions. She emphasised that education is needed across the board - for both men and women.

Dr Mbulawa (ANC) asked whether farmworkers attend workshops and discuss their problems, seeing as there are many farms in the Albany district?
Ms Plaatje said that as far as she knew farmers have never been reported although they are aware of their attitudes.

Dr Jassat (ANC) asked whether the organisation is affiliated to any faith.
Ms Plaatje said that although Ministers do attend their meetings they do not give support back to their congregation.

Ms Dudley (ACDP) asked whether women are given detailed options to make an informed choice on termination. Are they informed about adoption or exposed to scans of the baby? [Ms Marshoff (ANC) asked that Ms Dudley be ruled out of order. The presenter is a lay person and at her level of intervention there is no provision for scans.] Ms Plaatje responded to Mrs Dudley's question, saying that women are given options but choose termination. Adoption does not work especially in the Black community where women already have large families.

Dr Schoon - Free State
Dr Schoon gave a brief historical perspective of termination in the province. When the Termination Act became law a large proportion of practitioners in the Free State were opposed to terminations and there was a limited budget for implementation. Specialists did terminations for health reasons only and still do.

There were no beds available and the question arose as to whether it was safe to manage people as outpatients. Staff were willing to do terminations but not after eleven weeks of pregnancy. The province chose to follow the outpatient model and induce pregnancies and closely monitor the patient. They have built centres that offered TOP services but also a comprehensive family planning and sterilisation service for women. This had a positive effect on morbidity and mortality in respect of unsafe abortions in the province. There has been no death related to an unsafe abortion and no morbidity since this approach was adopted.

The Free State did experience some problems:
- A fair number of persons in the advanced stage of pregnancy still demand abortions.
- Ninety percent of women decide they will never go through with termination again. Depression is experienced and a need has been shown for support groups for women. At the moment there is no psychological support for staff who often experience burnout.
- Staff experience opposition from middle management and other administrative problems such as how to acquire MVA syringes.
- Misoprostal is not currently listed as an essential drug.
- The frequent demand for second trimester terminations is linked to the interpretation of the Act. If the practitioner favours a liberal interpretation of the Act more clients are likely to go to that particular centre.

Discussion
Ms Marshoff (ANC) asked whether there was sufficient support for health professionals. Should a comprehensive programme be put in place as part of the overall employment package?

Ms Marshoff asked if more terminations are performed in private or public facilities.

Dr Schoon said that input from the private sector is very limited. A large proportion of the staff said that working at these facilities for a long time had a negative effect on their personal lives.

Dr Mbulawa (ANC) commented that often when a doctor is doing sessions at a public hospital he will refuse to do a termination on the basis of conscientious objection but will be willing to charge a client for a termination in his private practice.
Dr Schoon said this may be happening in the Free State but he had no figures to prove it.

Ms Dudley (ACDP) asked how the emotional problems caused by terminations are manifested by patients. Would it help to walk the patient through the process?

Dr Schoon said that there are insufficient support mechanisms for women in the long-term. Even for women who have had a spontaneous abortion [as opposed to an induced abortion] there is very little support.

Ms Dudley said that even as early on as eight weeks the foetus responds to touch because their nervous system is already developing. Are clients given medication for the baby's pain?

Dr Schoon said that no painkillers are given unless the patient suffers abnormal pain.

The hearings continue on Wednesday, 7 May 2000.