Termination of Pregnancy Act Implementation: hearings

Meeting report

HEALTH PORTFOLIO COMMITTEE
8 June 2000
REVIEW OF THE IMPLEMENTATION OF THE CHOICE OF TERMINATION OF PREGNANCY ACT: HEARINGS

Submissions handed out
Community Law Centre at the University of the Western Cape
Shongwe Hospital
National Abortion Care Program
Reproductive Rights Alliance
Wrap-up by the Department of Health

SUMMARY
All agreed that there was still a great deal of work to be done in ensuring that there was a proper implementation of the Choice of Termination of Pregnancy Act. There was consensus that there should be a decentralisation of services to primary health care levels to make the service more accessible to women. Educating women on their reproductive rights was also noted as an important aspect.

Ms Combrinck of the Community Law Centre at UWC said that the State must also ensure that the legislation works. In ensuring proper implementation of the Act one of the aspects that the State must look at is how its resources are allocated. TOP services need to be shown as a separate budget item so that scrutiny can occur.

A health worker from Shongwe Hospital spoke about his experiences as the sole service provider for terminations.

The National Abortion Care Program focuses on training midwives. They reported that their training has been very successful.

The Reproductive Rights Alliance highlighted some challenges to the implementation and made recommendations to address these challenges.

The Department of Health noted that a hospital or clinic can decide that they do not want terminations performed there. It must be ensured that people carry out government policy. The government should not tolerate a refusal by public sector workers to carry out its policy.

MINUTES
Community Law Centre, (Gender Project) UWC
The nature and extent of the State's duty to ensure access to pregnancy termination was discussed by Ms Nikki Nyler. The right to reproductive health care falls within the Constitution's socio-economic rights. The question which arises is where to draw the line in terms of the State's responsibility for ensuring access and how much is expected from the State to ensure that the system works.

In short, the State has an obligation to create an enabling environment. In terms of section 7(2) of the Constitution, the State has a duty to respect, protect, promote and fulfill the rights enshrined in the Bill of Rights. Thus it is the State's duty to put mechanisms in place. In terms of the right of access the State must protect women from interference with their right. Positive fulfilment means that measures have to be taken to enable access. The State must take measures within its resources to provide for the progressive realisation of this right.

''Progressive realisation'' does not mean that the State can evade its duty. The State may not postpone its duty to an uncertain future date. ''Progressively realise'' means that it must take steps. Primarily the State must effectively use its existing resources.

To ensure equitable access to TOP services, Section 3 of the Act provides that TOP may only take place at a facility designated by the Minister. Thus, a designated facility is linked to access. The right to choose abortion is meaningless if Section 3 is not given effect to.

There is a discrepancy between the number of facilities designated for terminations and the number of facilities actually used. Hospitals still turn women away. It is especially hard for rural women to access legal termination. In such cases there must be a duty on the State to access the right.

Ms Helene Combrinck stated that it is not enough for the State to guarantee the right. The State must ensure that it works. An important aspect in this regard is to look at how resources are allocated. It is difficult to see if the State has complied with its duty its duty in terms of the Constitution and international human rights law because the allocation of resources takes place on a provincial level. Provincial budgets are hard to look at so it is difficult to see if the funding was adequate.

A lack of resources is given as a reason for terminations not being offered at certain hospitals. However hospitals are given a broad discretion in how they may manage their budget. It is feasible that a hospital never becomes designated or if it does become designated that it still cannot provide the service.

Recommendations from the Community Law Centre include:
- Establish a way to see how resources are allocated.
- Each hospital must budget to implement this legislation properly.
- If there is likely to be greater resistance to TOP in a particular area then resources at regional and provincial level must deal with this.
- There should be an official declaration of policy. Individual hospitals should report the budget allocated to TOP services.
- Relook at the criteria in the Act for designated facilities.
- The Department and the actual designated facilities must take steps to ensure that terminations can be performed there (obtain instrumentation).
- For the past two years no additional public facilities have been designated. Time frames need to be set in this regard.
- There should be strategies to extend services to primary health care facilities. This must be implemented even though it may have a resource implication.

Discussion
Ms Dudley (ACDP) referred to the comment that abortion was a woman's socio-economic right. She asked if the government should not rather focus on the needs of streetchildren rather than ensuring that women have the right to get ''abortion on demand''. She also asked for a comment on the fact that some women are pressurised to have abortions by family members.

Ms Combrinck said that there should not have to be a choice between termination of pregnancy and other socio-economic rights. The resources which are available should be used properly. The question should be asked, ''How prudently is the State making its choices?'' As a counter to the second point Ms Combrinck asked how many women were being forced to give birth because of family member's pressure when they could not afford to have children. This only led to more streetchildren. She added that everyone was entitled to their own position but they should never impose their position on somebody else.

Ms Njobe (ANC) commented that an organisation like the Community Law Centre could also be involved in awareness programmes to protect people who provide TOP services from victimisation. She asked if it was necessary for TOP services to be budgeted separately.

Ms Combrinck said the problem was that because the TOP budget is not separated but included under some other category, they cannot see how much is allocated for TOP.

Ms Baloi (ANC) asked if it was not premature to have a separate budget for this programme.

Ms Combrinck disagreed saying that it is possible to make projections on existing services as data from the last three years is available.

A committee member wondered how facilities became designated if they did not have adequate resources. If designated facilities provide no service and there is no other facility nearby then that amounts to no access at all. Therefore more designated facilities are needed to ensure that women will still have access even if they are turned away from one facility.

Shongwe Hospital - Mpumalanga
Mr Khoza a nurse at this hospital explained that they follow a specific program for TOPs. Counseling and assessment of clients takes place on Mondays. On Tuesday night the client sleeps over at the facility and on Wednesdays the MVA (Manual Vacuum Aspiration) procedure is done. They can only perform these procedures on Wednesdays because they have to share instruments with the main theatre. He cited statistics:
March - Dec 1997 150 clients were seen and 67 TOPs were performed
In 1998 272 clients were seen and 126 procedures were performed.
In 1999 338 clients were seen and 176 procedures were performed.

The service is not accessible to most women. Mr Khoza said that he was the only one at the hospital who performed terminations. If he goes on leave or if he is off sick then there is no-one there to perform the procedure.

Recommendations
- The TOP service must be decentralised.
- Specific days are to be set for consultation.
- Women must be educated about the Act. This is an ongoing process.
- Farms and schools be visited to educate people about reproductive rights.
- Family planning is to be strengthened.
- HIV education must be increased because the fact that women are falling pregnant means that they are not using condoms.

Discussion
Ms Dudley asked why practitioners preferred not to do abortions after 12 weeks. Was it because they were too aware that they were murdering?

Mr Khoza said that the legislation gives doctors the right to refuse to perform TOP.

Ms Baloi asked what the attitudes of colleagues and the community, specifically traditional leaders, are toward people performing terminations.

Mr Khoza said that he had not done any kind research in this regard so he could not say what the attitude of the community was. Sometimes after the pre-counseling, women did not come back to have the TOP performed because they were afraid that someone had seen them at the hospital and that people knew what they were going to do. However he was not in a position to comment on the attitude of communities.

On asking about the number of deaths from backstreet abortions and if the incidence of these had changed since the inception of the legislation, Mr Khoza replied that he did not know.

National Abortion Care Program
Dr Kim Kickson-Tetteh said that their goal is to contribute to the reduction of the mortality rate as a result of backstreet abortions. This can be accomplished by making services more accessible to women at primary and secondary levels.

Elements of the National Abortion Care Program are to teach the MVA technique, to train midwives to provide services at primary care level and to train physicians to provide terminations.

The focus has been on training midwives. This program has had great success. The content of the training includes:
- legal aspects of the Act
- professional practice and ethics
- client preparation
- applied pharmacology (how to use certain drugs and their side-effects)
- practical aspects of the MVA technique
- management of abortion complications
- post abortion contraception (training women to use these properly)

91 midwives have been trained in the theory of abortion care. 81 have been certified as safe to practice (they have completed theory and clinicals). 69 of them are practicing. The others are not practicing.

They recommended that the TOP service be decentralised. There are not many midwives at the primary care level and this is where they should be. Some midwives are at the tertiary level but the majority are at the secondary level.

After the midwives have been trained a team of evaluators evaluates how they perform in practice. They evaluate the quality of the care and they determine the number of TOP services run by midwives without the assistance of physicians.
Evaluation of midwife training showed that midwives provide a high quality service without physicians. The patients were satisfied with the care that they received and the counseling skills of the midwives were good.

Challenges and recommendations - South Africa is not the first country to experience problems with implementation. The UK experienced the same problems for up to 4 years after their abortion law was passed.

The National Abortion Care Program recommended:
- More midwives be trained to provide services at primary care levels.
- there should be development mechanisms to provide supervision and support to practicing midwives.
- Promoting condom use in post abortion counseling
- Raising the awareness of emergency contraception
- Training staff in values clarification
- Training staff to deal with patients in a humane manner

Discussion
Ms Dudley asked what the post-abortion counseling included and whether their approach included the interests of the child or if it focused on the interests of the mother.

Dr Kickson-Tetteh replied that the counseling did not concentrate on the foetus, only on the mother. One aspect of the course dealt with family planning, explaining the different types of contraceptives which could be used. Where the woman was in an abusive relationship, they taught her negotiation skills.

Ms Njobe asked if they have plans for continuing with the training. The program provides technical and logistical support to midwives but did she think midwives also need psychological support?

Dr Kickson-Tetteh replied that they have offered psychological counselling to midwives. Some take it because some need it.

Dr Jassat (ANC) asked how many women came for TOPs because of contraceptive failure.

Dr Kickson-Tetteh replied that the condom seemed to be quite effective. Most failures were the result of oral contraceptives.

Reproductive Rights Alliance
Ms Loveday Penn-Kekana acknowledged that the introduction of the Act has succeeded in increasing the availability of the TOP service which was previously denied to the majority of South African women. However challenges to implementation still exist and a lot of work needs to be done to address them.

A few of the problem areas noted were:
- There is a lack of decentralization of the service. Services are mainly available at hospital level and therefore inaccessible to women, particularly in rural areas. Plans to decentralise to primary health care centres are being developed but these plans need to be implemented.
- There is a lack of trained staff. The RRA suggested that MVA training be incorporated into basic training for all doctors and nurses.
- More staff should be trained so that rotation of staff is possible. The provision of service by one person alone should be avoided wherever possible.
- Provincial health department managers must provide support for health care workers providing TOP services and experiencing negative reactions and abuse from personnel in their institutions. Action must be taken against those who are discriminating against them.
- Value clarification workshops should take place in centres carrying out TOPs so that all staff, regardless of their attitude to TOP, respect and tolerate each other's views and the rights of patients.

In conclusion the RRA noted that education around TOP services should be done within the broader context of reproductive health and women's health. In this regard the National and the Provincial Department of Health should work with NGOs and CBOs in getting information across to women in rural and disadvantaged communities.

Discussion
Ms Dudley noted that she had heard a report that American statistics on the number of maternal deaths due to illegal abortion had been fabricated in order to get abortion legalised. She asked for a comment on this. The Chairperson ruled her out of order and she withdrew her comment. No other questions were put.

Department of Health
Dr Eddie Mhlanga spoke about the problems experienced with implementation:
- Some health workers are dissuading women from going through with the TOP.
- The staff that performs terminations suffer from burnout.
- There is also a lack of support from managers and colleagues for staff who have opted to perform TOP procedures.
- There is an inaccessibility of TOP services for clients.
- There are long waiting periods for women who want TOP performed.
- There is poor and inadequate counselling.
- There is a reluctance on the part of health professionals to perform second trimester abortions.

Concluding comments :
Public health is costly but curative health is even costlier. This means that there is a great deal of money spent on treating complications. For this reason they must prevent backstreet terminations and in doing so they will reduce the cost and the damage to women. One problem with implementation is that a hospital or clinic can decide that they do no want terminations performed there. This is something that the government should not tolerate. The State must ensure that people carry out government policy and, if they do not want to do this, then they must not be in the public service. It is essential that there should be support for doctors and midwives who are providing the TOP service. Ultimately a termination should be available wherever a woman can deliver a baby.

No questions were put.

Ms Njobe of the ANC said that the committee would follow up on the issues that were raised during the hearings. She also commented that this was not only a woman's issue and that men must also be informed.

The meeting was adjourned.