Implementing National Instruction on Domestic Violence; Termination of Pregnancy Problems: briefing

Meeting report

JOINT MONITORING COMMITTEE ON THE IMPROVEMENT OF THE QUALITY OF LIFE AND STATUS OF WOMEN
19 April 2000
DEPARTMENT OF HEALTH’S ROLE IN IMPLEMENTING NATIONAL INSTRUCTION ON DOMESTIC VIOLENCE & PROBLEMS WITH ACCESS TO TERMINATION OF PREGNANCY

Documents handed out:
Briefing by the Deputy Director of Health.
Presentation by representative from Department of Health.

SUMMARY
The Beijing conference raised the issue of commitment towards Women's Health. The Department of Health has taken a holistic approach to implementing the Beijing Platform of Action and the National Instruction 7/1999 on Domestic Violence within the framework of primary health care.The Department has taken some initiatives towards promoting awareness of the issue of violence against women and children. A Victim Empowerment Programme has been initiated as part of the National Crime Prevention Strategy. Centres have been opened where survivors of domestic violence can be counselled.

It has been questionable however, as to depth and extent this has been achieved in South Africa and what the role of the Department of Health (DOH) is in achieving this objective. The panel showed much concern about how women obtaining termination of pregnancies, are treated by certain health workers.

Other concerns included the long-term side effects of Depo Porvera contraception on both women and their children as well as whether the legalisation of abortion in South Africa has led to a reduction in backstreet abortions.

A Confidential Enquiry into Maternal Deaths has been done to study why women continue to die of septic deaths and in childbirth. In response to the this enquiry, provinces have set up committees to study maternal deaths and reproductive health. In spite of the Choice on Termination of Pregnancy Act, women continue to be denied the right to choose and in some cases are denied access to facilities where they can obtain terminations. The long term aim of the Department is to provide women with contraception and reduce the number of terminations. A programme for encouraging and educating men in this regard has been started.

MINUTES
The Committee had asked the Department of Health to respond to the following questions:
- What is the role of the Department with respect to implementing the National Instruction 7/1999 on Domestic Violence?
- How successful has the Department been in implementing the Beijing commitments in the light of violence against women becoming a public health priority?
- What problems have been encountered by the Department and the public with regard to access to termination of pregnancy?

Dr Harm Pretorious, Director General: Health and Dr Eddie Mahlanga addressed the Committee on behalf of Department [see document for their detailed response].

Dr Pretorious acknowledged that health cannot achieve anything on its own and as such the DOH's role in the status of women is based on the need to deal with equity in access for both women and children. He stated that by improving access to the least of society, the role of the DOH in regard to national instruction on domestic violence is based certain responsibilities. The specific responsibilities include the identification of victims of abuse, collection of forensic evidence and provision of rehabilitation. Non-specific responsibilities include community awareness, as well as promoting an environment supportive to the rights of women and children.

He further indicated that the DOH is working in conjunction with other departments and Non Governmental Organisations (NGOs) on the issue of violence against women, opening up a number of centres for victim counselling and support. Currently, there are a total of 240 trained primary health care workers as part of the victims help program and additional nurses are to be trained this year. To counter secondary victimisation by health care workers, a task team on violence against women has been formed.

However, Dr Pretorious stated that despite notable progress in implementation, it is not enough and it requires the training of more community health workers through assistance from training institutions by putting domestic violence in the curriculum. He went on to note that violence against women can encompass reproductive rights and he decried the fact that women die despite the existence of the Termination of Pregnancy Act. There are obstacles preventing women from seeking termination of pregnancies especially in rural areas and a general lack of awareness amongst the women themselves as to where to go, should they choose to terminate a pregnancy.

Dr Mhlanga stated that a confidential enquiry had revealed that a number of women had died due to abortions and that such deaths are gender biased and preventable. He indicated that the DOH wants to see a reduction in these deaths through contraceptive usage and changes in societal attitudes towards issues such as adoption and fostering so as to give alternative choices to pregnancy termination. He quoted statistics revealing that in the three year-period from 1997 to 1999, a total of about 100 000 pregnancies had been terminated. He however noted disappointment at the fact that of all the institutions that were initially identified to provide pregnancy terminations, less than fifty percent of them actually do so.

According to Dr Mhlanga, the DOH endeavours to provide contraceptives as well as make use of public awareness tactics. The DOH acknowledges that termination of pregnancy is an emotional issue and as such points to the need for continuous counselling (post abortion counselling) for the recipients as well as the workers.

Discussion
Ms Semple (DP) commented that she had been part of a delegation on a recent visit to the Rob Ferreira Hospital in Nelspruit. She observed that rape victims waited up to seven hours to be examined. She asked what the role was of the district surgeon and how this process can be speeded up.

Dr Mahlanga said that the attitude of the district surgeon often left a lot to be desired. Very often the medical profession was just a means to make money and not a calling.

Ms Semple asked whether the figures for terminations of pregnancy (TOPs) show a decrease in backstreet and botched abortions.

Dr Mahlanga’s response was that the Confidential Enquiry showed a decrease in deaths from septic abortions but a study was under way as to whether there was a decrease in septic abortions per se.

Ms Semple asked whether research has been done on the effect of increased hormones on women.

Dr Mahlanga said the high dosage of oestrogen in certain contraceptives was taken into account in the National Guidelines on Contraceptives. These were no longer recommended because of the high-risk of thrombosis and other complications. Our more sedentary lifestyle and smoking increase the risk of complications.

An ANC committee member said that reports coming through from the media and from victims show that in some parts of the country, treatment and TOPs are being denied to women. What is the National Department doing to address this?

Dr Mahlanga said that in respect of TOPs there were national and provincial responsibilities. Facilities were a provincial responsibility and the problems around TOPs were being highlighted to provinces. Health care workers barring access to these facilities must be identified and disciplined. So far, no action has been taken against anyone. In some cases however, the barring was subtle and amongst staff there was also a subtle opposition to others willing to perform the procedure. However, he felt there was a change in responsibility at the moment, for instance some religious groups are choosing to support persons after a termination or counselling them on the other options facing them. Dr Mahlanga said the contradiction between the rights a person can claim under the Constitution and what he is required to do as an employee of the State, is still unclear.

In answer to a question on the average age and racial grouping of the women opting for TOPs, Dr Mahlanga said that the majority of women are African. Sixteen to seventeen percent of the women are under eighteen years of age. Coloureds were the second largest group, followed by Whites. Few Indians made use of TOPs.

Ms Semple (DP) asked whether this breakdown was based on the demographics of the country, that is, Blacks being in the majority.

Dr Mahlanga said these figures are skewed along the lines of those who can afford to use private facilities and those who use public facilities because they have insufficient funds. As they did not reflect in the statistics, he could not say.

Acommittee member noted that Dr Harm Pretorious had mentioned that 100 midwives were being trained to perform TOPs. Would this number be sufficient to cover the entire country?

Dr Mahlanga acknowledged that this number was inadequate which is why training is ongoing. All institutions except the University of Transkei are on board and this was only due to resource problems. Provinces are facing financial constraints in meeting the cost of training. Dr Mahlanga thinks there is insufficient political agitation in the media to infuse the service with importance. Political mobilisation is required.

The member asked what the effects of the drug, Depo-Provera, which had been used on Black women and which had affected their fertility. Is the Department attempting to redress its effects?

Dr Mahlanga said there were political connotations to the use of Depo-Provera. Even in the United States people were sometimes given the drug without their consent or knowledge. The World Health Organisation (WHO) approves its use but not within the first three months of pregnancy and with appropriate counselling. It is used in Britain and the States as a contraceptive. In 1994 the FDA decided to reverse the 1972 position that had limited the use of the drug in the States to situations where no other option was available. Dr Mahlanga cautioned that in some cases there was a delay in fertility and counselling would then be appropriate. The majority of users were still Black people.

Ms Ntuli(ANC) asked whether research had been done on the use of the drug Depo-Provera. Dr Mahlanga said that the WHO would have included it in its medical eligibility criteria for contraceptives only after extensive research. He emphasised that current research showed the drug to be safe, given that all drugs have some side effects. He was prepared to state categorically that Depo-Provera was safe. Initial questions raised in New Zealand as to whether or not it causes cancer were never conclusive.

Ms Benjamin(ANC) commented that ten years ago women were given the Depo-Provera injection minutes after giving birth. Was there any evidence on the effect it had on children and in such a case should they not have some recourse?

Dr Mahlanga’s response was that evidence available was more rooted in the theory of brain development. There have been no studies to show that it is safe so soon therefore it is not recommended within the first three months of pregnancy. He said the education of the public had not really happened which is why the Department has developed guidelines on contraceptives. He reiterated that anything the WHO releases is based on research because it is the current world standard. The guidelines must still be submitted to the Minister to be signed. Dr Mahlanga did not respond to the question as to whether victims could have any recourse.


In answer to what was being done for women traumatised by miscarriages, Dr Mahlanga commented that reorientation and training has not reached the ground in some cases and people still have an unsympathetic attitude to miscarriages. A non-judgmental attitude has to be instilled into medical and nursing students from the beginning of their education.

Ms Themba (ANC), acting Chairperson, asked what informs decisions as to where health care centres should be established.

Dr Mahlanga said that where there is a basic infrastructure that can start the process, trauma centres are opened. People should come to those areas and learn in order to establish centres in their own area.

Ms Benjamin (ANC) asked what is meant by ‘secondary victimisation’ and what recourse a patient has if she is victimised.

Dr Mahlanga’s explanation was that such victimisation occurs when a person has been raped or beaten up and then faces discrimination and comments from health care workers. The only recourse these persons have at the moment is to the courts. It is the case that nurses are not protected as much as doctors. However, once the much talked about ombudsman is put in place there should be a more effective means of redress. Dr Mahlanga acknowledged that the current system is not very responsive to complaints.

Ms Benjamin commented that training was a big challenge. What broad training needs to be done by the Department of Education?

Dr Mahlanga said that in this regard issues of victimisation are important. An interdepartmental Committee on Youth has been formed recently and at these sessions issues could be raised. The Life Skills Programme was also very useful. These issues need to be addressed as social development issues not as health issues per se.

Ms Moatshe(ANC) said that some district surgeons in the North West could be closed because of racist practices. Dr Harm Pretorious said that racial differences were an inherited problem. Provinces have renegotiated contracts to ensure that practices are in line with the Department’s new approach. Other provinces have integrated existing services provided by doctors and nurses with the new services.

A committee member enquired as to why there was a flow of trained health workers between the provinces resulting in a lack of human resources to carry out termination of pregnancies in certain areas.

Dr Mhlanga responded that this could be attributed to a lack of adequate infrastructure in these areas so as to attract trained health workers to work there. He emphasised that the starting point should be an establishment of infrastructure, after which placement of human resources should only follow. Once the infrastructure is in place, it will be easier to attract trained human resources to these areas.

The meeting was adjourned.