Oversight Hearings into the Implementation of the Choice on Termination of Pregnancy Act

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Health

06 May 2002
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Meeting report

HEALTH PORTFOLIO COMMITTEE

HEALTH PORTFOLIO COMMITTEE
7 May 2002

OVERSIGHT HEARINGS INTO THE IMPLEMENTATION OF THE CHOICE ON TERMINATION OF PREGNANCY ACT

Chairperson:
Mr Ngculu (ANC)

Documents handed out:
Brief by Women's Legal Centre
Some Submissions for 7 May

SUMMARY
The Committee convened oversight hearings into the Implementation of the Choice on Termination of Pregnancy Act, 92. Representatives of the provincial Health Departments, as well as researchers into the issues surrounding the termination of pregnancy briefed the Committee on the implementation of the Act. The African Christian Democratic Party complained that the views represented at the hearings represented only those who were pro-choice.

MINUTES
Mr MacIntosh (DP) raised a point of order, asking whether the meeting was a Portfolio Committee meeting or a seminar, saying that every point of view should have been canvassed, yet only the pro-choice views seemed to be represented. He also referred to the matter before the Constitutional Court in which the TAC was trying to force the government to provide anti-retrovirals to prevent mother-to-child transmission of HIV. He said that it was ironic that the government was reluctant in one instance to save lives, when in this context it was taking them. Ms Dudley (ACDP) also asked whether the meeting was being recorded, so that at least those not invited could access the information.

Mr Ngculu (ANC) the Chairperson, said that it was a pity that Mr MacIntosh was deliberately slanting the issues. The Cabinet had issued a statement on the issue of HIV/AIDS which sought to clarify the matter. The issue before the Constitutional Court had more to do with who was to decide matters of policy - the government or the courts. The democratically elected government was responsible for making policy, and the judiciary held sway over another sphere. Health was not a political issue, but affected everyone and there was a need to avoid using it as a political tool. The meeting was not an invitation for comment, but a discussion of the implementation of legislation. Therefore it was a Portfolio Committee meeting, and not a seminar, even though, as part of the review process, members of civil society had been invited to attend the meeting. Women had been given a choice by the legislation and were not forced into anything.

Ms Dudley raised the issue of a letter she had received, which she said reflected many of the views that had been expressed to her in the past twenty-four hours by people who were vitally concerned with the issue of unborn children. She said that there were eleven speakers, but not one of them represented the pro-life view

Mr Ngculu said that the meetings had been advertised in the press, and there had been a call for submissions. Why had such groups not followed normal procedure, and phoned him, as Chairperson, or the Committee Secretary. He cautioned that the meeting was going in circles: there was no need to be apologetic. The legislation had already been passed, and he was proud of that fact. He added that he had personally seen the harm done by backyard abortions, while he was growing up in Gugulethu. The South African government had to accommodate all views. It was five years since the legislation had been passed, and the purpose of the meeting was to look at the state of the service now, and to look at the way forward.

Women's Legal Centre: Overview of the Legal aspects of the Act
Ms O'Sullivan's presentation focussed on the legal dimensions of the Act. It included a brief look at the legal origins of the Act, the legal challenges that had been brought against the Act, and the legal issues involved in the implementation of the Act. She outlined the central provisions of the act - that pregnancy could be terminated at any stage under twelve weeks of gestation, or up to twenty weeks in special circumstances. Such a termination required only the consent of the pregnant woman, not her parents or the partner. It also provided for non-mandatory, non-directive counselling both before and after the termination, as well as access to information on the choices available to women in that situation.

There had been two court challenges. The first, brought by the Christian Lawyers Association in 1998, had argued that the Act violated the constitutional right to life. The Pretoria High Court held that the Constitution did not view a foetus as a legal person, because if this were the case, the drafters would have included an express provision in this regard. It was also felt that the Constitution did not limit the right of a woman to control of her body by the creation of a right to life for a foetus. The decision was not appealed. The provision that a minor does not need the consent of an adult when seeking a TOP was also challenged by the same group in 2000. This case did not reach the courts due to a technical legal exception, the fact that the Christian Lawyers Association had not included any facts which needed to be defended in court in its summons.

Ms O'Sullivan then traced some of the origins of the act, which are in the rights included in the Constitution. One feature which deserves mention is the right to freedom of conscience, which allows health workers not to perform TOPs if they object in principle to TOPs. But it has certain limitations, which oblige the health worker to inform someone of where they can have a TOP performed, if they are unwilling to do it themselves. Ms O'Sullivan also recommended that there a Code of Good Practice be drawn up. The situation existed where willing staff were being obstructed in performing TOPs by the attitudes of other staff members, and the management of health services, who at times refused to have TOPs performed in their hospitals. Discrimination against willing staff was also evident at such institutions. Other legal remedies to these problems were costly, and the situation could be greatly improved by the introduction of a Code of Good Practice. She also said that the conscientious objections of some staff members had a negative impact on the woman's right to information, and choice.

At this point, Ms Dudley (ACDP) asked whether the information provided did not direct women to have abortions, instead of making them aware of their alternatives. Did this not encourage teenagers to use TOPs as a form of contraception?

Mr Ngculu pointed out that this was a point for discussion, not a point of clarity, and could be dealt with later.

University of Natal, Medical School
Dr Dhai said that when women sought a termination, the message was being relayed that at some point, the system had failed her because she had an unwanted pregnancy. Yet when she was denied access to a TOP, the stronger message was that the health system, and society, were failing her and possibly harming her in the long run. Dr Dhai's presentation focussed on the ethical barriers which existed to TOPs, despite the presence of an enabling legal framework. It was this ethical perspective which was felt to be one of the most significant barriers to women's choice.

The ethical dilemmas centred around the moral legitimacy of TOP, the difficulty faced by women in making the choice to have a TOP and the medical team's struggle to negotiate between the idea that they must preserve life. There is also a need to protect women from unsafe abortions, which has long-term consequences such as sterility and poor physical and mental health. The moral arguments rested on the theological status of the foetus and the potential right to life of the foetus. These were challenged by the view that the foetus had not attained personhood yet. There was the question whether the intention was to do evil, the issue of unsafe TOPs and the mother's health and the fact that safe TOPs in the first trimester are safer than full term deliveries of a child.

The issue of limitations to access was also addressed as an ethical issue, raising questions of social justice. Features of the limitation to access were the attitudes of staff, the fact that the legislation was relatively new and thus services lagged behind demand, as well as the fact that women were ignorant of the law. Other features included the inequitable distribution of medical personnel, particularly in rural areas and the failure of training programmes to prepare medical personnel for the performance of TOPs. The effect of these limitations was that poor women in particular were deprived of their rights.

Recommendations included the need to raise the status of women, so that both the need for TOPs could be reduced and the access to TOPs and effective contraception could be improved. The focus of such attempts should be on the education of girls in general, as well as the education of women about their rights in particular. There is a need to empower women to make choices about all aspects of reproduction in order to decrease the need for TOPs. The State and others should play a central role in addressing this challenge. There is also a need to educate health providers around TOP, and the legal and ethical issues. There is a need to ensure that TOP services are equitably distributed, particularly to ensure that the services are accessible to the marginalised. Dr Dhai reinforced the fact that the long term goal was to decrease the need for TOPs, and thereby enhance women's health. She suggested that the State has a positive obligation in this regard.

Ms Dudley asked to record her strong objection to the 'propaganda' and the fact that there was no opportunity to challenge it, saying that eventually, she would have 152 questions.

Mr Ngculu restated that the presentations were meant to be in clusters, and that there was one more presentation, after which Ms Dudley and everyone else could ask their questions.

A representative from a provincial legislature said that it was not proper for Ms Dudley to be allowed to call the presentations "propaganda".

Mr Ngculu informed him that only Members of the National Legislature were allowed to raise objections in Portfolio Committee meetings. There is also a need to allow access to all views.

Chris Hani Baragwanath Hospital
Dr Dinat discussed some of her research into the experiences of people involved in reproductive health services, as well as the need for an integrated approach to reproductive health services. She drew attention to some of the barriers, such as low staff morale in the reproductive health services and a lack of understanding of the issues surrounding TOP in the community and among other health service staff not directly involved in TOP services. Some of these barriers were explained in the context of a study conducted in rural KZN.

The integration of services was felt to be a necessary priority, with TOP being integrated into programmes to deal with HIV and STIs. This would take the form of addressing contraceptive issues. She drew attention to the Zambian experience, which suggested that an integrated service led to increased demand for such a service, as well as more choice, better quality of service, increased community involvement and better (and more) counselling. Similar effects had also been observed, for example in mother-to-child transmission progammes in South Africa.

Dr Dinat concluded with several recommendations. These included the need for investment in an integrated reproductive health service, fostered by a political understanding of the importance of reproductive health; the inclusion of TOP into existing medical training and an increase in the number of staff performing TOPs, to combat staff burnout.

Discussion
The Chairperson asked for questions related to the three presentations.

Ms Kalyan (DP) asked where the legal responsibility lay when a patient was not informed of their right to a TOP - with the State or with the individual health worker. She asked Dr Dhai whether there were any statistics on the incidence of morbidity among teenagers, related to septic abortions. She also asked what figures there were on the numbers of women using TOP as a form of contraceptive. She asked Dr Dinat whether the role of traditional leaders had been considered in influencing attitudes towards TOP.

In response to the question concerning the legal responsibility, Ms O'Sullivan replied that the issue was complex, and it was unclear where the legal responsibility lay. She said that people often had little access to the law, and therefore were unlikely to make such claims. She nevertheless recommended that a Code of Conduct would increase the protection of patients' rights and set out steps for the protection of these rights.

Dr Dinat said that as a group, traditional leaders were very influential, but were not homogenous, and consequently may have differing opinions on the subject. She did however agree that they could play a role in educating the community.

In response to the request for statistics, Dr Dhai referred to 'Barometer', Vol. 7, which indicated the age breakdown of TOPs in the Western Cape (p 21) and also suggested the smaller number of teenagers as opposed to others receiving TOPs (p 8). She also said that the World Health Organisation estimated that 75 000 women died every year as a result of unsafe TOPs worldwide. She also said that TOPs had to be understood as a critical health need, and resources were being channelled into dealing with the after-effects of incomplete, septic abortions, leaving fifteen year old girls with hysterectomies etc. This was the context within which the debates were being made. She also said that, at present, there were no figures which could reveal the number of women using TOP as a form of contraception, although this was being investigated.

Ms Dumisa (ANC) said that health workers had the right to freedom of conscience, but the client had the right to choose. She asked for the opinion of the presenters with regard to what the punishment should be if a health worker refused to perform the TOP or refer the person.

In a similar vein, Dr Luthuli (ANC) said that conscientious objections raised serious problems, for example in large hospitals. She asked what could realistically be done to address this. She asked whether legislation was feasible, given that there was an ethical obligation to give care which should not be any different in the case of TOP. There was a duty to do what the patient asked of you.

Ms O' Sullivan said that, while there was a clear balancing of the rights of both parties in the Act and that there were measures which could be taken in the event of misconduct, these were not always effective, particularly in the case of managers.

Ms Dudley said that funding was supposed to go towards promoting choice. How much funding went into promoting alternatives, instead of posters saying "termination is safe and legal, exercise your rights"? Money was going to terminations instead of going to the families to decrease the chances that a baby would be unwanted. She also reiterated her view that there was so much that could be debated, yet there were no alternative views being represented. With regard to unsafe abortions, she asked where the statistics were that indicated that they had been decreased. All that she had seen was an indication that more babies were now being terminated. The criminalisation of abortion in Poland had not increased the number of back-street abortions.

Ms O' Sullivan responded that, with regard to the issue of funding, there was equal funding for the various alternatives, but the issue of who was to fund the unwanted baby's development after it was born was another equally important issue.

Dr Dinat added that, in terms of adoption, the issue was not as clear cut. More terminations did not mean that there were fewer terminations, and she referred to the Soviet Union as an example.

Ms Gxowa (ANC) said that political affiliations should be forgotten here, because those Members who stayed in the townships saw the practical results of this law, even though the statistics may not show this. Ways needed to be found to reach more people and tell them the truth. The 1975 Act was for Whites, and now that there was legislation for all women, there was a need to educate women about it.

Mr Mbodwe (ANC) said that Dr Dinat, in her presentation, had referred to missed opportunities. For example, a woman coming to the service was missing other things, such as tests for HIV and so forth. Health workers also had rights, and may come from a different ethical background. How could these issues be dealt with?

Dr Baloyi (IFP) said that the issues surrounding the pregnant woman and the foetus pre- and post-pregnancy also involved challenges which came from areas other than simply health. He asked whether other considerations were relevant, when discussing rights and information.

Ms O' Sullivan, in responding to these related issues, said that the right of conscience protected people from performing TOPs, but that it was limited in certain circumstances, such as in emergencies. It also did not allow someone to refuse to give information, or victimise other health workers who did perform TOPs, and this extended to managers who obstructed the performance of TOPs. It also did not allow public sector health personnel to counsel people in a particular direction, or to impose waiting periods, so that the TOP could not be performed.

Dr Dinat added that, as a health worker and a lecturer at Wits Medical School, she had seen the move from the situation where the doctor was 'god' to one where the ideal was to keep one's own beliefs out of the treatment situation. She used the example of alcohol, which was forbidden in her belief system, but which she could not direct anyone to avoid, although she could advise them to do so. She said that the students were encouraged to develop empathy over sympathy, to ask what they would do in that situation.

Dr Dhai also added that the health of the patient was the primary consideration, and this extended not only to physical health, but also to the mental and spiritual health of the person.

Ms Mnumzana (ANC) added that her experience had taught her that, prior to the legislation, most clients were presenting with septic abortions, and today was about celebrating the move away from this situation. She asked whether there were still large numbers of women presenting with septic abortions, and whether the claim could be made that the situation had improved. She also asked whether there were structures which aimed at disseminating the information on the Act.

Dr Dinat said that Dr Brown would present a detailed study on septic abortion. But she did return to the issue raised about the use of TOP as a form of contraception, saying that only 3% of people returned for a second TOP, suggesting that it was not being widely used as a contraceptive. She added that if contraceptive services were inadequate, TOP would be used as a contraceptive in those areas. This meant that more choice around contraception would lead to more successful prevention of unwanted pregnancies, but that even then there would still be some unwanted pregnancies. In response to the issue of deissemination, she said that there were few structures in civil society which informed patients of their rights, but there were areas where this was not the case, and there were good programmes, for example making use of local radio.

Ms Dudley said that it was unacceptable that there was advertising in Parliament, indicating a Reproductive Rights Alliance banner that had been in the corner of the room since the start of the meeting.

Mr Ngculu asked that the banner be taken down. He also said that, after discussing it with some of the Members, it was felt that no exception should be made to allow anyone aside from the Members of the National Assembly to ask questions.

Reproductive Health Research Unit (University of the Witwatersrand) & Obstetrics/Gynaecology at Chris Hani Baragwanath Hospital
The presentation dealt with a study of the magnitude of unsafe abortions. This was difficult to assess accurately, because back-street abortions are illegal, but the method adopted was internationally accepted, where the data gathered dealt with the number of women that presented with incomplete abortions. The study had both a quantitative component, and a qualitative component, where respondents were interviewed.

The findings indicate that, while the number of women being admitted with incomplete abortions had not changed since 1994, the numbers of those presenting with septic abortions had decreased in the few years since the law had been enacted, particularly in the case of those presenting with high severity. There had also been a significant reduction in the numbers of those with severe genital injury. Also of interest was the fact that possibly the largest reduction had been observed in women under twenty. The qualitative study indicated that the main reasons for women not accessing the legal TOPs a lack of knowledge that such services were available (55%), and expected staff rudeness (17%). It was suggested that the lack of information needed to be addressed as well as the quality of care. It was also suggested that the role of GPs in providing TOP services needed to be reconsidered, as they might be able to provide decentralised services. Access to services remained a critical concern.

Community Law Centre, University of the Western Cape
The study conducted by the Community Law Centre was informed by findings in the USA and Germany that suggested that the right to choice was limited by economic measures. The presentation dealt with the origins of the Act, in the Constitution. Ms Combrink then indicated the ways in which the Act revolved around resource issues. The issue of designated services highlighted this, where designated facilities had specific resource allocation needs, which at times were not being met, leading to a number of sites which had been designated but which were not providing services. She said that part of the problem stemmed from the issue of who bore responsibility, since the national department was meant to bear the responsibility, yet resource allocation was a function of the provincial government, and at another remove, specific issues of resource utilisation were determined at local level. This hindered the provision of TOP services. This situation was exacerbated by the move towards integrated services, which meant that there was no specific allocation for TOP services.

Ms Combrink also pointed out that, aside from the attempts to bring already-designated services 'on-line', there was also the understanding that TOP services would be widely rolled out to rural areas in particular, and be integrated into Primary Health Care. This raised issues of sustainability. Some of the early recommendations from the research were that clear monitoring indicators be developed, to assess the success of the TOP services and that time-frames be developed to ensure that services were being provided where they were designated.

Provincial Health Co-ordinator: Free State
The submission by Mr Bohlale outlined the achievements and the challenges of the Free State Health Department in implementing TOP services. Among the key successes were the development of training programmes. These included values clarification workshops, the increase in the number of TOP-trained midwives from six in 1997 to twenty one in 2002. The development of stress management procedures are felt to have played a significant role in limiting the number of TOP-trained mid-wives that have left the service, with only one having left in that time, and her reasons for leaving were due to health problems, rather than stress or burnout.

The challenges included districts not coming on-line despite having designated facilities, the lack of resources, in terms of personnel and facilities as well as the absence of a provincially-based TOP trainer. All these problems were felt to have been addressed to some degree. It was suggested that values clarification was critical to the success of TOP training, that the promotion of awareness of the Act be an active focus, among both staff and the community and that pro-life doctors hampered TOP delivery. It was recommended that stiff penalties be introduced for doctors who administered Misoprostol without conducting an MVA, that MVA-trained mid-wives be supported and that an allowance for TOP trained staff be investigated, as this would aid in the retention of staff. Overall, Mr Bohlale said that the government was to be commended on implementing the Act, as there was a great need for it among the communities and it was welcomed by women.

Midwife, Chris Hani Baragwanath Hospital
Ms Serobe's submission dealt with some of the concerns of the health care providers who provided TOP services. These were accessibility, the emotional dimensions of the work, the lack of support from authorities and management, and the Act itself. In terms of accessibility, she said that the fact that accessibility was a problem in some areas, and that some designated facilties, with trained staff, were not providing services due to management obstructions, led to overloading of the functioning services. This increased the numbers of people who resorted to back-street abortions. It was also felt that inadequate planning compromised the quality of the services offered.

The emotional aspects identified were burn out due to a lack of support, particularly from managers, and victimisation by other health workers. Yet Ms Serobe pointed out that the midwives continued to work because of the importance of their work. They receive positive feedback from clients and the change in attitudes which have been observed in the community which has led to increased numbers of people requesting the service, and women receiving support from their families and partners. It was recommended that support groups be formed for TOP nurses, greater access to facilities be developed in the rural areas, to decrease the overloading, and that provincial management become involved, and actively challenge the managers of hospitals that were unwilling to bring their designated facilities on-line. Ms Serobe also asked that policy-makers consider allowing midwives to perform TOPs up until 14 or 15 weeks of gestation, in order to further reduce the chances that a woman would resort to a backstreet abortion.

Discussion
Dr Luthuli asked whether doctors prescribing Sitotec and Misoprostol in their private practices were doing something illegal, and whether they could be prosecuted.

Ms O'Sullivan replied that it was illegal, but that it was difficult for them to become designated, due to the requirements of the Act. She added that the practice was, however, lucrative for doctors, where they were able to charge R600 for something costing R20 wholesale.

Dr Baloyi said that, overall, he was not sure that the problems being raised were unique to TOP, such as staff rudeness and the knowledge of what any given facility offered in terms of services. With regard to the designation of facilities, he said that he was also not sure that facilities were designated to be upgraded, as his understanding was that they were capable of performing the service, and for this reason had been designated.

Ms Combrink replied that the reasons given for services not being provided was overwhelmingly one of a lack of resources. When the issue was raised in the 2000 oversight hearings, they had been told that facilities were in fact being designated despite the fact that they lacked the required equipment and staff. With regard to the issue of the quality of care, she said that there were two main reasons why TOP services were unique. The first of these was that TOP was illegal until five years ago, and there was also no law which limited, where a tonsillectomy, for example, could be provided. This impacted on the difficulties associated with TOP services.

Ms O' Sullivan also said that the proportion of those accessing birthing services, for example, was better than those accessing TOP, and this indicated that some of the problems were unique to TOP services.

Ms Dumisa said that doctors were being enticed by money to perform abortions. She asked whether there were any woman managers performing TOP services in the Free State. She also asked the speakers from the Free State and Gauteng whether there had been experiences of discrimination against those providing TOP services.

Ms Serobe responded, saying that this was one of the experiences of her colleagues, but that the urban areas were not as bad as the rural areas. She reiterated that the main problem remained management attitudes which led to obstructions.

Ms Bohlale said that he was not aware of discrimination in the Free State, as this had not come up in the interactions with TOP providers. In the Free State, two of the five managers were women, but that all the managers supported TOP services.

Ms Kalyan asked Ms Serobe whether the managers, while supporting TOPs, did not support the staff, and if so, why she felt this was the case. She also asked whether Ms Serobe felt that midwives, if given leave to perform TOPs in the fifteenth week, would be able to handle the emergency trauma that may result.

She replied that, while there was support at Baragwanath, such support should be compulsory. She also said that, as midwives, they were well trained. She did not see that anyone with such training would be unable to deal with haemorrhaging.

Dr Baloyi said that there were institutions where the effects of incomplete abortions were regularly dealt with. He asked if it had been investigated whether such institutions were among those not providing TOPs, which would undermine the claim that the facilities lacked the resources.

Ms Combrink said that they had to rely on the institutions for information. She added that such an inquiry was ideal, but as a small research unit, there were no resources to carry out that type of extensive field research. She agreed that people may be hiding behind the defence of a 'lack of resources'.

Ms Dudley asked whether anyone was looking into health workers who felt brutalised, without counselling, by having to perform abortions.

Ms Serobe replied that no midwife was forced to perform abortions, they all volunteered, to address what was seen as a pressing need.

Ms Dudley asked, with a third of the abortions being done after twelve weeks, what the legal obligations were in instances where there were live births. She also asked where the process would stop, if midwives were given leave to perform abortions after twelve weeks. She concluded by saying that it seemed that legalised abortions had not decreased the risk to women, or the need for unsafe abortions.

Ms Combrink replied that she could not answer Ms Dudley's question, as her research had a specific, and limited focus.

Ms Kalyan asked whether Misoprostol was registered for the purpose of inducing labour.

Ms Dudley asked whether, if not, it was being used off-label, something that those who produce the drug have specifically warned against doing.

Ms Brown replied that it was being used off-label at the current moment. Its use in the treatment of haemorrhaging was similarly off label, as was the use of aspirin to prevent heart attacks. Part of the reason for this was the considerable expense involved in re-registering a drug's use. She added that the proportion of unsafe abortions, which Ms Dudley refers to, has decreased, and there was clear evidence of this.

Ms Dudley said that there was a clear and serious warning on the packaging of Misoprostol which warned against that use. She also said that she had understood the statistics.

Ms Kalyan returned to the issue of the midwives, saying that she accepted that they were trained, but the provision reflected a safety measure introduced into the act, and that this should not be revoked without good reason.

Dr Dinat returned to the Misoprostol debate, adding that for the drug to be re-registered, the company had to pay and Searle did not want to bear that cost. However, the drug was recognised in the USA for that specific purpose, and there were published letters from the FDA recognising it as safe practice to use it in that way. She added that any drug, if used incorrectly, was unsafe. In response to the issue of support, she said that health care workers all needed support, and there was no particular need for additional support for those engaged in TOPs because of the trauma of the work. Rather, it was the attitudes around TOP that made it at times traumatic for staff.

In response to Ms Kalyan's question, Ms Serobe said that the reason she had suggested the change was that many clients presented very late at the clinics, and the fact that only doctors could perform second trimester terminations meant that only limited numbers could be dealt with.

Mr Ngulu said that the issue would need to be carefully considered. He asked if there were any figures that related specifically to the number of unwanted pregnancies.

Ms Brown replied that they had focussed specifically on unsafe abortions, using an internationally accepted method.

Chief Community Liaison Office: Northern Province (Limpopo)
The presentation dealt with the experience of TOP in Limpopo province, examining the strengths and challenges experienced. Ms Sophie Makoala said that 29 of the designated hospitals were on line, with the remaining thirteen to follow shortly. One of the key experiences in the province was that, in order to make the service accessible, it was necessary to make it available at the primary care level, as they were more accessible to women in rural areas. Five districts had already identified health centres and clinics to be used for this purpose, with the hospitals acting as referral centres once the process was completed. The project was undertaken as a joint operation between the Departments of Health and Social Development, IPAS and DENOSA. The Capricon district was the pilot area, because of its weaker TOP service provision, which would simultaneously be strengthened through the project. The project is due for completion in September 2002. A number of midwives had already been trained, as had two provincial trainers.

There were various challenges to be faced, such as a lack of support for clients and staff, negative attitudes towards TOP, and a lack of information, and steps were being taken to address these issues. It was recommended that support from all levels of government was necessary, and that possibly TOP should be given special attention, as was the case with TB. It was also suggested that special attention be devoted to TOP providers, particularly in the areas of stress management and support.

Medical Officer in the National Hospital, Bloemfontein
Dr Cueller, a Cuban doctor, said that there were four facilities in the Free State capable of providing second trimester TOPs, all except the National Hospital in Bloemfontein with only one doctor. The National Hospital had five doctors. He said that even five doctors were not enough to meet the demands for second trimester abortions. He asked why there was such ongoing criticism of those who chose to have TOPs, and of those who performed TOPs. In Cuba, TOP training was simply part of the normal training of a doctor, and the procedure was viewed as merely one aspect of the doctor's job.

He said that there had been a decrease in the number of second trimester TOPs in Bloemfontein between 1998 and 2001. He also outlined some of the reasons for women seeking second trimester abortions. Among these were that she found out about the pregnancy late, she was not ready for the abortion until it was too late. Or else her partner left her at a late stage, there was inadequate information on abortion available to her, she had difficulties in accessing the clinic, she was hiding her pregnancy or she was afraid, due to religion.

Health providers played a role, because they may give inadequate information, may not support abortion, may lack the skills to adequately assess a woman's pregnancy, may only come into contact with a woman attending the ante-natal clinic at a late stage, or may have ethical objections. Dr Cueller said that the stress on providers at times led to inadequate service being delivered, particularly when there were too many people to deal with, and too few staff. People were untrained in the practice of TOPs, there was ignorance about TOP on the part of management. As an indication, he said that since he had been performing TOPs, no-one in a management position had even asked him whether the service was running effectively, and a lack of willingness on the part of management to claim responsibility for TOP services, with everyone "passing the buck".

Dr Cueller said that it was his impression that the majority of doctors performing TOPs were Cuban, because they were the ones trained in TOPs for both first and second trimester TOPs. He said that there was a need to assess the most effective way of performing TOPs. He also said that the suggestion by some that TOP services should run for twenty four hours was unwise, since women could be cared for in ordinary wards, and possibly this suggestion reflected an attempt to shift responsibility for TOPs, to make TOPs a stand-alone division. This should be discouraged. He said that one of the biggest problems was that patients received medication from a GP, and then went home with the advice that, if they start to bleed, they should report to the hospital. He added that patients continued to feel stigmatised within the general services. Dr Cueller expressed his personal justification for TOPs, saying that it was better to perform a TOP than have unwanted babies, who would suffer unloved and in poverty. He recommended the following. More information needed to be disseminated by the general population, as well as by all health workers, there should be a focus on teenagers, more people should be trained (particularly doctors and nurses), the equipment needed to be improved, management needed to become more involved and there needed to be greater support for TOP providers.

Chief Professional Nurse: Conradie Hospital
The presentation by Mr Burzelman dealt with some of the experiences of TOP in the Western Cape, with particular emphasis on the experiences of staff at Conradie Hospital. Mr Burzelman indicated that the majority of the TOP designated facilities in the province were on-line, with the bulk of those not functioning yet being in the rural areas. One feature of the Western Cape service which deserves mention is the fact that one service billed others which had not yet come on-line, which hastened the facilities coming on-line. There was also the provision of a roving team, which delivered both first and second trimester TOPs. The Western Cape had also engaged in a number of Public-Private partnerships, which facilitated delivery.

Medical Abortion was being investigated in the province, and staff had been trained in this procedure. Mr Burzelman indicated that they were awaiting approval from the various levels of government, at which time the service would be implemented. This would increase access, as well as prove more cost-effective. Mr Burzelman then went into some depth about the experiences at Conradie Hospital, the details of which are in his submission (see document). The lessons from Conradie hospital are that dedicated staff are necessary for successful TOP services as well as management support. Booking systems do not work and value clarification for all health workers was an essential part of TOP service provision. He also suggested that the education of the community and the client was essential, that this education was an ongoing process and that contraceptive education and availability were an essential dimension of the reproductive health framework, of which TOP was a part. He also recommended the broadening of the scope of nurses TOP provision, to fourteen weeks, and suggested that some of the frustration which was felt to result from TOP being viewed as ancillary to nurses other functions could be circumvented if there were monetary incentives for TOP providers. This would also increase the numbers of trained providers. It was also suggested that greater support was needed for providers, and that training in TOP be part of the training for health workers. Another suggestion was that a website be set up, which would enable nurses and other providers to seek advice, and establish a database of information about TOP.

Ms Rubushe, Social Worker - Eastern Cape
Ms Rubushe traced some of the challenges faced during the implementation of the Act, such as the number of designated facilities which were not providing services, the negative attitudes towards treating minors and the moratorium on new appointments in the province, which placed stress on the existing staff. Among the successes, she said that there had been fewer abandoned babies and septic abortions, and an increasingly positive attitude towards the service, where partners were now accompanying the women, and parents were bringing in their children. This was felt to be due to the efforts to challenge the attitudes, such as visiting churches, conducting workshops and using local radio to broaden awareness. She recommended that the designated services needed to provide the required services, as failure to do so led to overloading. This situation was facilitated by the absence of punitive measures for those facilities which were not providing the services that they were meant to be providing, suggesting the need for evaluation and monitoring by the provincial co-ordinator. There was a need for continuous training of doctors and nurses, since there was a very high demand. It was also suggested that there needed to be better training in the use of ultrasound. Ms Rubushe recommended that TOP be destigmatised by making it part of health promotion, and making people aware of this fact. She suggested that there was a need for more workshops to raise awareness. she also suggested that there was a need for more physical support for TOP providers, as well as support from management.

Discussion
Ms Dudley asked whether the need to continuously train staff was due to the high turnover of staff due to trauma. She asked whether Dr Cueller had said that during the third trimester, abortions were easier to perform because it was easier to dissect it. He also asked him whether he was suggesting that only loved children deserve to live, and consequently others deserve to die.

Dr Cueller said that he had said that during the first trimester, it was easier for people to accept the TOP. The misunderstanding stemmed from Dr Cueller's accent.

Ms Dudley asked why Conradie Hospital was closing. She also asked whrether Mr Burzelman, in referring to the management of Conradie Hospital as "TOP friendly" meant that those staff who performed TOPs were being promoted over others. In terms of values clarification workshops, she asked whose values were being promoted.

Mr Burzelman explained that the values clarification workshop was a course that had been developed, which focussed on respecting the rights of the pregnant woman to make a choice. He said that the choice a woman made was never an easy one, and it was not easy for a woman to come for a TOP. For this reason, the health workers had to learn to keep their own objections aside when dealing with the woman.

Ms Dudley asked whose values were being promoted.

Mr Burzelman said that the value being promoted was respect for the client's decision.

Ms Dudley then said that her question had also been about which NGO's were involved and who provided the training.

Mr Burzelman said that it was the Western Cape Population Council and women's health organisations which had developed the ideas, but the Human Research Council actually did the training. In terms of TOP-friendly management, he said that this simply meant that they allowed staff to attend training and hearings such as this one, and that was all. In answer to the question over the hospital's closure, he said that it had been discussed in Parliament, and the Mmembers were more likely to be informed of the reasons behind the closure than he was. He said that he understood that the hospital had simply reached its "life-expectancy".

Ms Dudley asked the representative from the Limpopo whether, in terms of the much vaunted 'moral regeneration', there were problems in the community with TOP.

Ms Mokoala said that no problems had been encountered as yet, but that these might come out in the training of the public around these issues, which was due to start the following week.

Dr Baloyi said that, in the discussions so far, he was reminded of the attitudes at the time of Chris Barnard's successful performance of the first heart transplant, which had raised moral issues then, but which was now seen as normal. He suggested that this was simply part of the normal progressive development. He added that, as humans, all of our thinking was filtered by our beliefs, which did not necessarily help us when trying to make difficult decisions. He said that the question was simply are we about to help those who need help, and that this was the question which staff faced. He summarised by saying that the messages in the discussions were that stigmatisation and a lack of management support seemed to be the main problems.

Ms Gxowa said that the stigma was caused by people who intimidate women and put stickers up like the one taken down by the chairperson, instead of using their resources to educate women, in particular the black women of this country who did not have access to the act in 1975. She asked where these people were then, when abortion was accessible to whites only. She said that people were interrogating the presenters, instead of asking what could be done to improve the situation. She added that she was a staunch member of the church, and she still felt that these things were not a sin, because they were aimed at trying to improve the lives of women. She said that once women have decent lives, moral regeneration would be possible.

Ms Rubushe said that in the workshops that they conducted, the idea was to explain the Act and the rights it contained. The emphasis was on educating people not to impose their will on the patient. She added that she had never experienced a pro-lifer who was willing to adopt an unwanted baby, especially when the adoption would be inter-racial.

Ms Dudley asked for a minute's silence for all the babies that had been terminated.

Mr Ngculu again asked that the Members refrain from cheap politicking, and respect each others' views.

Ms Matimele (ANC) said that the stigma associated with this Act was the same as the stigma associated with HIV/AIDS, where it was initially said that only bad people get HIV/AIDS. She said that people needed to support those coming for TOPs.

The Chairperson rounded off the day's proceedings by thanking the presenters, the researchers and the Members. These types of meetings armed the Parliamentarians to understand and begin to assess the impact of the laws that they had passed. As Members of Parliament, he said that they could play an advocacy role. He concluded by saying that the legislation was a celebration of women, and a celebration of women should never be mourned, so he rejected Ms Dudley's request.

The meeting was adjourned.

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