Termination of Pregnancy Act Implementation: hearings

Meeting report

HEALTH PORTFOLIO COMMITTEE
7 June 2000
REVIEW OF IMPEMENTATION OF CHOICE OF TERMINATION OF PREGNANCY ACT: HEARINGS

Submissions handed out
Democratic Nursing Organisation of South Africa (DENOSA)
Dr R Jewkes of the Medical Research Council (MRC)
Dr L Denny of Groote Schuur Hospital
Department of Psychology, University of Stellenbosch
Women's Legal Centre submission
National Youth Commission Submission
Choices Crisis Pregnancy Centre

SUMMARY
Choices Crisis Pregnancy Centre spoke on the necessity of counselling for women seeking terminations in order for them to make an informed choice.

A clinically-based study by a researcher at the University of Stellenbosch's Department of Psychology presented her findings on the anxiety of those facing abortion and drew various conclusions about the need for counselling, before and after the abortion.

Dr Newbury, on behalf of Pro-Life, spoke on conscientious objection of health workers. Committee members stopped him from reintroducing the moral debate which had gone on before the Act was promulgated He then gave recommendations that should be considered in implementing this Act.
Health workers and a client from Odi and Dora Nginza Hospitals in the Northern Province spoke of their experiences with regard to implementation of the Act
A researcher from the Baragwanath Hospital recommended that there be further investigation as to why 69% of services nation-wide are not functional. There needs to be a determination of the factors which contribute to long waiting lists and the difference between number of terminations requested and the number actually performed.
Doctors for Life requested that there be no mandatory referrals, that is, a doctor who consciously objects to terminations should not be forced to refer a patient seeking a termination to another doctor. They hold the view that such a doctor is as morally culpable as the one who performs the termination. They also hold the view that the effect of terminations on doctors is grave, leading them to suffer from alcoholism and depression.

The Women's Legal Centre made a detailed submission on the constitutional and legal framework within which terminations are currently located.
A National Youth Commission presenter spoke on problems which youth experience with respect to the implementation of the Act.

A private health clinic spoke from its perspective on implementation of the Act.

DENOSA proposed that midwifery training should be accelerated because well-trained midwives and nurses were needed to deliver termination of pregnancy services. They noted that staff involved in TOP procedures suffer from burnout and need counselling almost as much as the client does. They also indicated that a conscience clause should be inserted into the Act to protect staff who did not want to perform terminations.

The Medical Research Council discussed a study showing that the drug, Misoprostal, was effective if used two to four hours before a TOP procedure and was a safe drug if used properly. It was being abused in backstreet abortions which women still resorted to. Reasons for this is ignorance on how to access TOP facilties and the attitude of health care professionals toward women asking for the TOP procedure. Further, there is a difficulty in securing second trimester abortions. Efforts are needed to end abuse by staff who infringe patients rights. People need to be educated about TOP facilities and seeking early terminations.

Groote Schuur Hospital made recommendations to increase the availability of the TOP procedure to women. She noted that one half of the women who applied for the procedure last year were unable to be accommodated by the hospital. One reason was health professionals refusing to perform the procedure. She recommended introducing a quota system in respect of the number of nurses employed in an institution who are prepared to perform the TOP procedure. Only after this quota has been filled should other nurses be hired.

MINUTES
Choices Crisis Pregnancy Centre
Ms Dene Moschoff presented on aspects of counselling and in particular the options faced by women with an unwanted pregnancy.

In general, Ms Moschoff feels that termination is often used by women as a form of contraception. While the Act requires counselling, women are often ill informed and resources are poor. Women need to be informed on all options available to them such as single parenting, adoption and so forth. The Choices Crisis Pregnancy Centre, started in 1996, believes that by allowing women to choose, they will be able to make informed choices. In the past the Centre was polarised between pro-choice and pro-life. Now they are "pro-women" and have adopted a no-pressure approach. They feel that women face pressure and the decision whether or not to have a termination is often a panicked one. Women benefit from counselling.

The Choice Centre provides counselling and support for women in the choice they make. The Centre is funded privately. The Centre is staffed by a multi-therapeutic team comprised of five registered nurses and midwives, two social workers and one psychologist. They offer additional services such as abstinence-based sex education to schools and a home for pregnant women.

Statistics show that after counselling, the majority of women chose to continue with the pregnancy.

Discussion
Ms Dudley (ACDP) asked whether there are enough people willing to adopt babies?
Ms Moschoff said that their programme also has an adoption arm and they are currently setting up international adoptions. In Gauteng they go around to Black communities to encourage adoptions. They do find that there is a cultural problem but think there is hope.

Ms Baloyi (ANC) asked whether the organisation is interdenominational. What is the response of the Christian community to the programme?
Ms Moschoff said that the programme is made up of various Christian groups but they do not exclusively serve Christians. They serve the entire community.

Dr Mbulawa (ANC) asked whether the Churches around the centre support the programme. Does the work have a psychological effect on the counsellors?
Ms Moschoff said that they receive referrals from all communities, even from those opposed to abortion. Regarding the psychological impact on counsellors, Ms Moschoff said that they are carefully screened and supervised. There is also a lot of interaction between counsellors, which allows them to "offload on each other".

Ms Saramenyena (a Northern Province delegate) asked how the Centre follows up on clients if they do not have telephones.
Ms Moschoff assured her that the Centre is very accessible by public transport and because they build up a relationship of trust with women, they usually find that women do come back to the centre.

Mrs Njobe (ANC) asked whether women are counselled in a non-directive way. Are they looking at the psychological effects of international adoptions?
Ms Moschoff said that the Centre offers women information and from then on a decision is made. These women are therefore making informed decisions. She felt that she was not qualified to answer the questions on adoption.

Ms Dudley (ACDP) noted that after counselling 80% of women choose not to have the termination. What changes for these women?
Ms Moschoff speculated that sometimes these women just need time. Counsellors help the woman work through the situation until she cannot delay the decision any longer.

Department of Psychology, University of Stellenbosch
Ms Faure said she had conducted a research study into the implementation of the Act. The aims of her research were to examine pre-and post levels of anxiety, depression and perceived coping levels. The participants were 76 pre-abortion and 43 post-abortion subjects. Their average age was 26 years, 54% were single, 58% held a tertiary qualification, 33% held a grade 12 diploma and 92% had never had an abortion previously.

The study found that women experienced a high level of anxiety before the abortion, which suggests it is a stressful event for women. Of these subjects 55% expected to cope well, none expected not to be able to cope at all. In general a higher level of education was related to the woman coping better. The study confirmed that women seem to cope with abortion in the long run but it is very stressful.

Regarding pre-abortion counselling the circumstances under which the woman fell pregnant should be explored. Her fears, anxieties and concerns should be explored as well as her conflicting maternal desires. High risk factors for the woman are emotional, social, moral and religious conflicts.

An inherent paradox which the study revealed is the woman's ambivalence - the conflict between a mother's freedom of choice versus infanticide, the power to create versus the power to destroy. Rarely is a woman sure of her choice to terminate. Counsellors should help her become more confident in her choice.

Opinions may change but attitudes and values are harder to change. This makes the process difficult for nurses as well. They often experience anger with clients and show callousness or resentment towards them at having to cope with late abortions without their own feelings being taken into consideration. Common emotions experienced are depression, fear and anxiety, sadness and inadequacy. They often feel overwhelmed at the need to educate women on good sexual behaviour and the appreciation of life. Ms Faure emphasised that nursing staff deserves understanding and empathy and need to be affirmed. They also need counselling. Policy makers are removed from the cutting edge at which nurses operate.

Discussion
Ms Kalyan (DP) asked whether the counselling which is provided is free of pressure.
Ms Faure said that during counselling women only need to be validated and listened to. Counselling does not require any formal qualifications, people can be trained.

Ms Kalyan asked whether it was easier for the client to accept the abortion if it was for clinical reasons rather than when it was for personal reasons?
Ms Fare could not comment because the study had not included women who had terminations for medical reasons.

Ms Kalyan commented that the study had only used a sample of 73 women.
Ms Faure acknowledged that her study had been a very modest one. Often questioning was not completed because women were too upset to go on. Women of language groups other than English and Afrikaans were not involved because she had wanted to maintain the international viability of her study and had only used English and Afrikaans translations.

Dr Jassat (ANC) asked whether Ms Faure had ever seen cases of post-abortion psychosis.
Ms Faure said she had not seen any cases of psychosis only depression and anxiety.

Ms Dudley (ACDP) noted that the study done was short-term. What was to be done about women who need long-term counselling? Sometimes they may only need counselling ten years later.
Ms Faure said that she has only been in this field since 1997 and is still unsure about women's long term needs but felt that all women have coping skills which can sustain them.

Odi Hospital - North West Province
Ms Thembi Zulu said that the hospital has been in existence since 1995. The hospital's vision was that it should be recognised as the model for the provision of health care in the province.

She wanted to decrease backstreet abortions. A number of Value Clarification Workshops had been held for staff because few of them were interested in performing terminations. Odi Hospital is one of the few district hospitals performing terminations. They deliver the service to everyone, regardless from which district they come. Between 15 February and December the number of terminations requested was 4301. Terminations actually performed numbered 759. The other women were more than 12 weeks pregnant or during pre-counselling they had changed their minds and had made an informed decision to keep the baby.

Ms Zulu introduced a client, who wished to remain anonymous, to tell her story about her experience in seeking a termination. The client said that she had fallen pregnant and had gone to Hospital A for help but was refused because staff there said that they were Christians. She went to Hospital B who referred her back to Hospital A for a letter. When she returned to Hospital A they refused to help because they felt she might influence their other patients. She subsequently went to Hospital C who helped her because in general they help girls who need terminations.

Discussion
Ms Kalyan (DP) commented on the client's experiences, saying that where there was such a clear violation of a patient's rights, the Patients Rights' Charter should be used to follow up the case.

Ms Kalyan asked how many designated facilities are non- functional.
Ms Zulu said that of the 22 designated facilities, only 10 were functional - but she could not explain the reasons for these disparities.

Ms Dudley (UCDP) said it was reassuring that they provide pre-counselling for women. Are women given scans and access to hearing the heart beat of the foetus? Are women given financial assistance?

Dr Mbulawa (ANC) asked Ms Zulu if the work had had an emotional impact on her.
Ms Zulu said that personally she wanted to provide this service because of problems she had experienced as a teenager when she had not been ready economically or psychologically to have a baby .

Ms Njobe (ANC) asked whether they experience problems from women who are beyond 12 weeks pregnant but demand an abortion.
Ms Zulu said that in such a case they tell the client what the alternatives are to termination such as adoption. Or the client is referred to a private institution if the client is determined to have a termination.

Ms Hangana (ANC) asked whether there has been a decrease in the number of backstreet abortions.
Ms Zulu said that because the immediate community is aware of their service, backstreet abortions have decreased.

Pro-Life
Dr Newbury first explained that the ethical standpoint his organisation was taking is "Do no Harm", a specific prohibition against abortion and euthanasia. Laws which facilitate these acts are therefore immoral.

[At this point the Chair interjected, saying that as point of order the Committee would not entertain a re-hash of pre-1996 dialogues. Dr Newbury responded that Pro-Life only wanted to clarify the principles and ethical problems associated with terminations for nurses and doctors. He was then permitted to continue.]

Was the Minister of Health forcing doctors to put duty before their beliefs? The Minister's statement must therefore cast a shadow over the Department, reminiscent of the Nazi concentration camps. In terms of the Act Section 12 does not say that no one has an obligation to give effect to a woman's request. The rights were therefore conflicting. The decision of a woman to terminate depends on whether she finds a doctor willing to perform the termination. Section 15 upholds freedom of conscience, which is dependent on the individual and is the cornerstone of liberty. Such a right can only be limited within the constitutional framework, that is, by a law of general application if reasonable and justifiable. Where this right is suppressed there is tyranny. The opposition to abortion is democratic.
[At this point the Chair interjected, saying that these hearings have been called as an evaluation of the implementation of the Act. The judgmental statement made is therefore incorrect. ]

Dr Newbury continued. He said that there was no obligation in the Act to refer patients when the staff is unwilling to perform TOPs. Although the Reproductive Rights Alliance and the Minister would hope to persuade people that there is such an obligation.

[Ms Baloyi (ANC) pointed out that Dr Newbury was going through his old debate again which he had presented before. The Chair asked Dr Newbury to confine himself to the debate on conscientious objection, which was the topic he had indicated.]

Dr Newbury insisted that these are all ethical issues for health workers. Doctors feel that, notwithstanding the legal fiction, foetuses have life. If referrals were mandatory, doctors would have to forfeit their freedom of conscience. In conclusion, he exhorted members to take into consideration the following recommendations:
- Every woman seeking a TOP should be shown her foetus's stage of development.
- After this, she must be given a period of 72 hours to reconsider her decision.
- Doctors should not be forced to perform terminations.
- Refusal by doctors in public hospitals should not be viewed as a breach of contract.
- There should be no terminations for minors without consent.
- Doctors doing internships should not be forced to do terminations. They must not be barred from specialising in obstetrics, anaesthesia and so forth.
- No more facilities should be built for late terminations.
- No one should be compelled to attend Values Clarifications Workshops which are designed to overcome opposition to terminations.
- Pre-and post counselling should be mandatory.
- Psychiatric treatment should be given at State expense.
- Equal career advancement should be possible for those who refuse to perform terminations.
- All women who have had TOPs must be regularly examined for breast cancer.

Discussion
Ms Dudley (UCDP) asked what the main reasons are for the failed implementation of the Act. What pressures are doctors under? What repercussions does such pressure have? Could Dr Newbury explain what he meant by 'sanctity of life'?

Ms Dudley added that she apologised for committee members who had attempted to intimidate others who do not share the same views as them. The Chair asked her to withdraw the remark. Ms Dudley said she withdrew it although she was given the impression that there was some intimidation by members.

Dr Jassat (ANC) said that Wits doctors have not really upheld the oath which they take, look at the doctors attending to Steve Biko and the actions of Dr Wouter Basson. Wits medical students did not take a stand against these actions. Dr Jassat commented that job descriptions should include the willingness to perform termination of pregnancy services.

Ms Baloyi (ANC) asked what steps has Pro-life taken to care for babies in institutions and on the streets?

Ms Njobe said that staff have a right to freedom of conscience, but what about a woman's right to access to termination? Who compels doctors to perform services? She was disturbed by Dr Newbury's generalisations. She said that Pro-life promised that if mothers agreed to carry their babies, they would provide adoption services. Where have they provided these services?

Dr Mbulawa (ANC) asked what he means by 'life'? She said that there were some contradictions in what he had said about limited resources. Is he using breast cancer as a threat?

Dr Newbury made the following general response to the questions.
He said that no individual or the government could care for all the abandoned, unwanted babies. Pro-life do not have the resources although they make every attempt to care for these babies.
He said that doctors are obliged to refer women who had a pathological condition. But an unborn child is not a disease. The primacy of conscience is that nobody may offend deliberately the notion that a life is sacred.

The Chair, Dr Nkomo, asked whether Dr Newbury had been a conscript in the army prior to 1994. Did he know what 'conscription' meant? Has he ever dealt with cases of septicaemia in the public service?

Dr Newbury's response was that he had not been conscripted because doctors had the freedom not to be conscripted. He said that he had seen cases of septicaemia at Baragwanath Hospital. Reacting to Dr Jassat's comments about Wits University, he said that Wits was one of the medical schools which refused to buckle under apartheid and many students were placed under house arrest. He said that he had never worked in an exclusively White hospital, he always worked in Black hospitals.

Reproductive Research Unit, Baragwanath Hospital
Ms Brown said that there are greater numbers of functional facilities in Gauteng and the Western Cape. In the Eastern Cape a larger proportion of women lived at a greater distance from TOP facilities. Over a month the largest number of terminations were done in Gauteng and the fewest in the Northern Cape. Waiting times were difficult to analyse because of the large number of existing protocols. For instance, Baragwanath Hospital has a system of merit, which is against the stipulations of the Act. In Gauteng up to 50% of women have to wait two days. The limitation of the study was that it provides little information of activities happening outside the scope of the Act.

The recommendation was that there be further investigation as to why 69% of services nation-wide are not functional. The factors which contribute to long waiting lists have to be determined. Research must be conducted into the correlation between terminations requested and the number actually performed.

The conclusions reached were that significant numbers of terminations are being performed. However, she felt strongly that the process of providing women with termination of pregnancy access is not yet complete.

Discussion
Dr Rabinowitz (IFP) asked whether it would not be better to provide terminations only in hospitals and not in the second trimester due to the moral repugnance of providing terminations in the second trimester and the problems with Misoprostal.

The response was that second trimester terminations need to be done in more sophisticated facilities. It would be a waste of resources to have first trimester terminations done only in hospital when midwives can also be trained and supported.
Because of the lack of awareness amongst women about gestation, they would not be able to simply stop second trimester abortions. Baragwanath Hospital has a long waiting list for second trimester abortions. Few facilities actually offer such late terminations. Usually staff may decide to prioritise a case if the client is very young or a rape victim.

Ms Dudley (UCDP) commented that when backstreet abortion figures are presented, they are usually distorted by the numbers of miscarriages.
The speaker said that the World Health Organisation and other organisations have devised a system to grade miscarriages according to the person's medical condition, for instance, associated with morbidity where an operation has been botched.

Dr Mbulawa (ANC) asked whether the fact that Gauteng has a high population is the reason for the high termination figures. What are the percentages of designated clinics in the province?
The speaker said that the dense conditions and the anonymity of city facilities contribute to the high rate of terminations. She said there were many designated facilities and like most of the other provinces there are plans to decentralise these facilities.

Dr Rabinowitz (IFP) asked whether there is a programme to ensure that every person who applies for an abortion is given counselling.
The speaker said there were attempts to give family planning help and a comprehensive service to every woman but of course some do slip through the gaps. They try to offer support services where they can.

Ms Madumisa (ANC) asked whether it was not proper for doctors who refused to perform terminations to refer patients.
The speaker said that particularly in the public sector there is often no place to refer women to. Clinics do often offer pro deo services to them.

Dora Nginza Hospital - Northern Province
The speaker, Mrs Tobeka, stressed three points:
- The importance of the availability of female condoms
- The role of the health care professional in the termination service
- The importance of counselling

Regarding the counselling aspect, both pre-and post termination counselling is important. Social workers are trained in impartiality and to be non-judgemental. Women are informed of other options and services, such as adoption, in counselling sessions.

Terminations have to be seen as part of a good reproductive service. Workers must not be forced to be pro-abortion but must make these facilities accessible. There is a need to train more health care workers as the need for the service increases. The right to terminations must be linked to the obligation to practice family planning.

Discussion
Ms Dudley (UCDP) asked whether women are educated that they may suffer infertility as a result of the termination, in view of the fact that women often suffer complications as a result of a termination.

Dr Mbulawa (ANC) asked how common adoption across the colour line is and whether Doctors for Life and Prolife help in this regard?
Ms Tobeka said there has only been one interracial adoption. Prolife had not come forward to help the hospital with adoptions and there are still racist attitudes among people.

Ms Dudley asked whether they have contacted Prolife directly. Ms Tobeka said they had advertised in the press but had not contacted Prolife directly.

Mrs Njobe (ANC) asked whether women in the rural area request abortions.
Ms Tobeka said that women come from as far as Graaf-Reinett and there is a long waiting list. Because of education and workshops held at churches, people come forward for information on terminations so they do feel that they have the support of the community.

Doctors for Life
Dr Siyobi began her presentation by asking the Portfolio Committee whether preferential treatment had been given to the Reproductive Rights Alliance [who had organised the public hearings].

The committee's response: Dr Mbulawa (ANC) said that this was none of their business. Ms Dudley (UCDP) said that as an MP it is her business and she required clarification on this issue. Ms Madumisa, as Whip, asked the Chair to give a ruling. The Chair said this was no place for grandstanding, would Dr Siyobi withdraw her remark. Dr Siyobi agreed to withdraw the remark.

Dr Siyobi drew attention to the following aspects of termination:
-The effect of terminations on doctors is grave, they suffer from alcoholism, depression and so forth.
- The consequences of chemically-induced terminations are serious and even doctors and nurses who object to termination have to deal with complications.
- Even health care workers who simply take specimens or wash instruments for the procedure have a right to object.
- The Reproductive Rights Alliance should raise money to build clinics to be located around the country. Termination services should be taken out of hospitals.
- Facilities should only be designated if there are sufficient trained staff willing to perform TOPs.
- All facilities which do not have willing staff should not offer the service.
- Training should be done in specialised units.
- The Canadian Medical Association said that a doctor who refers a TOP patient is as morally culpable as the one who performs the TOP therefore there should be no mandatory referrals.

Another delegate from Doctors for Life added that the infringement of the rights of health care workers is inevitable. If one refuses to perform routine duties someone else must do it. Usually junior workers fall prey to the pressure this creates. This contributes to sub-optimal working conditions. As a junior doctor himself he experienced harrassment to conform to the system.

Discussion
Dr Njobe (ANC) asked whether they had research to back up the allegation that 'numerous' health care workers are pressured into performing terminations.

Dr Siyobi said that there are numerous complaints from doctors although they do not have numbers. They usually get feedback from staff. Private doctors usually have a choice but junior doctors have to do whatever is prescribed to them.

Ms Baloyi (ANC) asked how many of these doctors who feel pressured refer people elsewhere. Do they understand the integrated health service policies of government? They seem to be compartmentalising the termination service.

Ms Kalyan (DP) commented that asked whether the rights of workers take precedence over the rights of patients. Dr Njobe (ANC) asked whether students lodge their dissatisfaction at having to perform TOPs when they are being trained.

Dr Siyobi said that TOPs form part of curriculum training and is the same procedure followed as the induction of labour proceedings. Dr Siyobi said that they take an oath that they will save lives not that they will destroy life. As a doctor her duty is to save lives. Doctors who object never leave their patients and never absolve themselves of their duties.

Dr Mbulawa (ANC) asked how a doctor can know whether an abortion has been chemically induced or whether it is spontaneous.
Dr Siyobi said that a pelvic examination reveals the tablets in the cervix. They do not condemn such a patient but treat them as they would any other patient. They approach the patient holistically so that ultimately the patient benefits.

Is burnout syndrome attached to terminations alone or is it due to the pressure of the medical profession in general?
Dr Siyobi said that doctors are burdened by doubt over the morality of their actions. They experience guilt and post traumatic syndrome, which is more than just fatigue. They might become rude and their attitudes would affect patients.

Ms Madumisa (ANC) asked what staff did before the promulgation of the Act if a woman presented herself bleeding. Was she sent back home or referred?

Ms Njobe (ANC) said that this Act is not the first law on abortion. Parliament has merely made this law accessible to more women. Is it because Black women are now demanding it, that doctors feel they are being forced to perform terminations?
Dr Siyobi said this was not the reason. It is the fact that it is not optional anymore.

Women's Legal Centre
Ms Michelle O'Sullivan outlined the constitutional and legal framework within which the Termination Act is implemented.

The starting point of the Constitutional framework is the woman's right to equality [Section 9], freedom and security of the person [Section 12], freedom of religion [Section 15], freedom of expression [Section 16], freedom of access to information [Section 32] and in terms of Section 27 the health care standard must be the same for an induced and a spontaneous pregnancy.

However, no right is absolute in terms of Section 36. Although the right of health care workers to freedom of conscience is enshrined it is already limited by the Termination Act, a law of general application. Ms O'Sullivan thought it is interesting that no constitutional challenge has yet been brought but if it is the limitation will have to be proved to be reasonable and justifiable. Competing rights would have to be considered as well as the nature and extent of the limitation and its purpose. She thinks that a Court will find the limitation reasonable and justifiable.

The health care worker has a number of legal remedies if they are prevented from performing a termination through intimidation:
-The Employment Equity Act
-The Occupational Health and Safety Act
-The Labour Relations Act (in respect of dismissals and promotions)

The patient also has rights to be protected. Conscientious objection could have a negative impact on women's rights because their right to freedom of conscience could be precluded. She said that the Canadian Medical Association does require that a physician whose beliefs oppose terminations must inform the patient but said that the situation in Canada is very different. Terminations are not legislated for but women do not have the same problems of access as South African women do.

Discussion
Ms Dudley (UCDP) asked whether the Employment Equity Act does not protect nurses and doctors from being harrassed.
Ms O'Sullivan said that all health care workers' decisions not to perform a termination are protected but these can also be limited. Ancillary acts are not protected by freedom of conscience and doctors end up having to perform various administrative acts or have to deal with complications from spontaneous abortions.

Could she give a legal opinion on the difference between abortion and a father knifing the baby while in the mother's stomach?
Ms O'Sullivan explained that there has been a failed attempt to challenge the Termination Act and it was decided in that case that the foetus does not have a constitutional right to life. This was a decision by the Pretoria High Court not by the Constitutional Court. This decision currently stands.

Ms Njobe (ANC) asked what she would advise someone whose rights have been violated.
Ms O'Sullivan said there are a number of options open to women. They could bring a wrongful birth action against the doctor although this is not often used (the analogy of an unsuccessful sterilisation is used). Alternatively they could report the doctor to the Health Professions Council because if the doctor is in the public service the refusal could constitute a form of misconduct. The client could report the refusal to the Maternal Health Directorate in the Department or to the Gender Commission or the Human Rights Commission or even the Women's Legal Centre.

National Youth Commission
Ms Moira Martin outlined some of the problems which youth experience with respect to the implementation of the Act:
- Young people do not have access to information.
- They may not want to go to public facilities because of the lack of confidentiality.
- Facilities in rural areas are far away.
- Women in rural areas are the least informed about services.
- The fact that rape and abuse is so common and the fact that incest still has a stigma attached to it makes it difficult for victims to access a termination.
- Counselling for disabled women is often directed towards terminations because of the perception that they cannot cope.
- With respect to minors, time delays are experienced because doctors refer them back to their families for consent (even though minors have a right not to consult their families).
- The nature of the legal process is such that it results in a lack of confidentiality.
- The environment in facilities should be as friendly as possible.
- There should be youth-friendly access and counselling.
- Youth should be aware that they have a right not to consult their families. A Health Centre Model has been set up in the Northern Province where all persons dealing with youth are in the same age range.
- Staff should be retrained to be sympathetic to youth.
- Where women might need legal recourse but maintain confidentiality, mechanisms must be put in place.

Discussion
Ms Dudley (UCDP) asked what age does 'youth' refer to.
Ms Martin said that in South Africa a 'youth' is between 14 and 35 years of age.

Dr Jassat asked whether anything is being done to discourage early sexual activity.
Ms Martin said that a termination is not seen as a contraceptive and abstinence should be emphasised more. She realises that they need to liaise more and lobby government on young people's needs. However it is not the role of the Youth Commission to do the sex education work of the Department of Health. They only have to ensure that the service which is provided meets the needs of youth.

Mrs Kalyan (DP) asked whether the Youth Commission have considered a tele-line where youth can obtain information on centres providing these services.
Ms Martin said they have launched a website, which deals mainly with labour issues and HIV. She agreed that perhaps they should consider a tele-line.

Mrs Njobe (ANC) asked whether the Youth Commission ever links up with other groups in the province.
Ms Martin said they have a good relationship with the Department of Health but the provision of services is made difficult by the vastness of the province. She acknowledged that they need to link up with other groups.

Disa Health Centre
Of all terminations performed 30% are performed in the private sector and mostly in Gauteng. This Health Centre performs mainly second trimester terminations. Their prices vary between R270 and R1200. Manual evacuation, electronic suction and curretage are common methods. In general, counselling is seen as an explanation of the process. There are numerous clinics opening but some are not designated by the State as facilities. However, the advantages of such clinics is that the staff are willing participants.

The time is normally suited to the client and the staff at these clinics are skilled. Further decentralisation will create a more supportive environment and easier accessibility to the service. Private clinics have given women more choice.

Discussion
Ms Dudley (UCDP) asked whether women are being pressurised by husbands and boyfriends. Would women benefit from hearing the foetus's heartbeat? Are they exposed to other options?
The speaker said that women are pressured by their peers. They try to look at each woman's individual situation to see what their options are. Counselling is not mandatory so they cannot force women to choose an alternative but she feels that they are getting through.

Ms Marshoff (ANC) asked what drives people to perform these services in the private sector. She referred to financial incentives being used to hold people in the public sector.
The speaker said that people in the private sector generally have a more supportive environment. Although their benefits are not exactly financial for some it might be. She feel that it is not realistic to give financial incentives to people in the public sector.

Dr Mbulawa (ANC) asked what the cost is of an ultra-sound in the private sector. Are the abortions offered by private facilities affordable to people in Soweto?
The speaker said that many clinics have their own ultra sound equipment, which becomes part of the cost of the termination. The cost is between R166 and R299. Women who are ambivalent are encouraged to look at the sonar but they have to be careful not to push a woman from one extreme to another.
Disa's charge of R1200 is inclusive of pre-counselling, a termination by a female gynaecologist, a post-abortion check up, post-abortion counselling and a 24 hour call line.

Democratic Nursing Organisation of South Africa
The presentation was made by Ms Dudu Nzimande (Chief Consultant and Project Manager/Co-ordinator) and Ms Thembeka Gwagwa (Executive Director) of DENOSA.

They highlighted some problems experienced in respect of implementing termination of pregnancies (TOP). These include:
- TOP is an emotional issue which also affects the nurses and midwives who perform the procedure. Staff often appear to be demoralised and they suffer from burnout. The fact that there is lack of counselling for health care workers involved in TOP service delivery is a problem.
- Counselling services for clients are inadequate. Reports have been received of instances where no pre-counselling is done or where counselling is done in a group and where counselling involves only telling the client what the procedure will entail.
- In some instances midwives have been victimised and discriminated against by their colleagues and sometimes also by the community for choosing to be involved in the performance of termination of pregnancy.
- Access to TOP services remains a problem in rural areas. Clients often have to be placed on a waiting list which results in a situation where a second trimester abortion has to be done. The client must then be transferred to another institution.
- Reports have been received of second trimester abortions being done at private institutions that do not have the legally required overnight facilities. If these patients develop complications they have to go the emergency unit of another institution which creates an additional patient load at that institution.
- There have been reports that in some instances no analgesia or pain control is provided during the TOP procedure.
- Maternal deaths resulting from backstreet abortions are still too high. One of the aims of the Choice of Termination of Pregnancy Act is to reduce and eventually eliminate maternal deaths due to unsafe abortions.

Some proposals made were the following:
- Support groups for personnel so that they can work through their emotions.
- There should be sufficient staff in an institution to prevent overworking and thus burnout.
- There should be a focus on counselling for client and health care personnel.
- Training for midwives should be accelerated. If the number of staff who can perform TOP increases then the number of TOPs which can be performed also increases.
- Midwives and nursed involved in TOP should be given specialised training and should not then be transferred to other units where they cannot use their specialised skills.
- They suggested that the Act should have a conscience clause to protect staff who do not want to perform the TOP procedure.
- There should be value clarification workshops for staff in institutions where TOP is performed. This should take place on an ongoing basis. This will help staff who do not want to be involved in TOP to understand the issues and not be judgmental of their colleagues that perform the procedure.
- Midwives should be trained in TOP counselling and should visit people in their homes to provide such counselling where access is difficult (such as rural areas).

Discussion
Ms Marshoff (ANC) commented on the proposal that a TOP team go to rural areas. She said that there existed the problem of stigmatisation and asked if this would not worsen the stigma as they might be referred to as ''the abortion team''.

The panel replied that they had made this recommendation because most clients do not come back after the abortion for the post-abortion counselling. For this reason they recommended a home service. This type of approach is used with HIV/AIDS treatment. If the approach was adopted it would enable them to reach people that they do not otherwise see. There is however a human resource problem.

Dr Mbulawa (ANC) commented on their proposal that midwives should not be transferred and asked if this would not be regarded as an unfair labour practice and if it would not disadvantage their members.

The panel replied that they would not recommend an unfair labour practice. People only want to get promoted to earn better salaries. The Department must develop a package which will allow staff to grow in this area.

- Ms Njobe (ANC) referred to their recommendation for counselling for midwives. She asked who would do the counselling and whether this would have financial implications. She also referred to their comment that midwives involved in TOP opt to do so and noted that in previous presentations, the presenters had said that midwives were forced to perform TOP. She asked for a comment on this. She asked if DENOSA had discussed with the Nursing Council or the Department of Health, their request that the Act should be amended so that nurses who are doing family planning can also do TOP.

The panel replied that whether a midwife is forced to perform a TOP would depend on the size of the institution. For example, if a clinic had limited staff and almost all the nurses there refused to perform TOP then they might be forced to do so. If there was a larger pool of nurses, there was a bigger chance that more of them would be willing and thus available to do the procedure.
- The counselling services for nurses would need budgeting but there is a need for this as nurses are suffering from burnout syndrome.
- On their request to amend the Act they said that they do liaise with the Department and they intend to raise this issue.

Ms Dudley (ACDP) commented that DENOSA had said that they supported the legalisation of abortion but noted that their document referred to a nursing profession survey (1996/97) showing that 64% of the profession did not support it. She pointed out that DENOSA had asked for the protection of midwives who opted to perform TOP but what about the protection of those who do not want to be involved in ''murdering babies''?

The panel replied that a study was done in 1996/1997 which showed that some members supported the legalisation of abortion and some did not. The leadership of the organisation took no stance either way. They do however support the implementation of the Act. The conscience clause would protect people who did not want to be involved in the procedure. That is why they had requested that a conscience clause be included in the Act.

Medical Research Council (Women's Health Research Unit)
Dr Jewkes discussed the use of Misoprostal as an aid to the TOP procedure.
They had conducted a study aimed at determining whether Misoprostal was really effective in softening the cervix when given only 2 - 4 hours before the operation and whether its use made the procedure easier, quicker and safer.
The study showed that its use enhances the ease and therefore also the safety of the procedure and reduces the cost through reducing treatment failures and and shortening operation time. Most of the problems associated with Misoprostal use relate to its use outside a controlled clinical setting.

They are still in the process of conducting a study as to why and how women are resorting to backstreet abortions. The study is being done by interviewing women who are attending hospitals in Gauteng with incomplete abortions.

The preliminary findings at this time are that these services are provided by GPs and nurses for "naked profiteering". Misoprostal is definitely being used by them. Reasons for women resorting to this is because there is a lack of knowledge in communities about the law, on how to access legal TOP services and the need to have the procedure done early in pregnancy. Another factor is the shortage of facilities for second trimester abortions and fear of abuse by hospital staff. Misoprostal is a very safe drug if used properly but like most drugs it is dangerous if abused.

Efforts are needed to enable GPs who are keen to provide abortion services to become trained and have their premises designated for this purpose. Patients must be protected from abuse by staff in health facilities and action must be taken against staff who infringe the rights of patients.

Groote Schuur Hospital - Service Provision, Emergency Contraception and Specialist TOP Services
Dr Denny said that health professionals themselves have presented a stumbling block to the implementation of the Act. This is so because they have refused to perform termination of pregnancy procedures. This problem was also experienced in Britain when they first introduced such an Act. They overcame the problem by paying properly staff to do it. Dr Denny commented that this seemed to overcome their moral objections to the procedure.

Groote Schuur Top Triage Clinic Statistics (February 1999 - April 2000)
The clinic has to operate on a quota system. In terms of this they only perform a certain number of TOP operations per week and many women were turned away. (Dr Denny noted that women seeking terminations due to psychological illness or due to being raped were not included in this quota). In summary, over a period of 15 months only 43% of women who wanted TOP got it. More than one half were not accommodated.

Most women who underwent the TOP procedure were in their twenties. About one quarter of them were in their thirties. Seventy percent of them earn under R500 per month. Three percent earn more than R2 000 per month. Eighty six percent had used contraceptives at some time in their life. Forty two percent of 1000 women were using contraceptives at the time they fell pregnant. This indicated that there was either a misuse of the contraceptives or the contraceptives were failing to work.

Recommendations
- To provide adequate TOP services, health professionals should come on board. - They should consider establishing a quota for persons prepared to perform the procedure per institution. Only after this quota has been filled should other staff be hired. This will mean that there will not be a shortage of people who are prepared to perform the procedure in an institution.
- Those providing TOP need more support from health authorities.
- Facilities for TOP exists but these must be upgraded and increased.
- If women are going to undergo these procedures then they must be encouraged to come during their first trimester.
- Easy access to these TOP institutions should be promoted.
- She noted support for the idea of clinics used exclusively for TOP procedures. She said that she understood these types of clinics were controversial because there was a fear that they would be targeted by anti-abortion groups. She noted however that abortion was an emotive subject and because doctors could refuse to perform the procedure it was very difficult to integrate it into normal medical wards.
- Adequate personnel is necessary.

Due to time constraints the last two presenters were asked to be brief and no questions were put to them. The Chairperson indicated that if members had any questions they should write them down and the presenter could forward written replies to them. On the basis of these replies the committee would decide if the presenters needed to come back for a follow-up session with the committee.

The meeting was adjourned.