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

HEALTH PORTFOLIO COMMMITTEE
8 May 2002
OVERSIGHT HEARINGS INTO THE IMPLEMENTATION OF THE CHOICE ON TERMINATION OF PREGNANCY ACT

Chairperson: Mr Ngculu (ANC)

Documents handed out:
These documents are awaited.
Submission by Reproductive Rights Alliance
Presentation by Department of Health

SUMMARY
Members of a pro-life group disrupted the hearings on the final day. The protesters had to be cleared from the room, and the meeting was ended without rounding off the process. What emerged was a sense that the TOP (termination of pregnancy) program has been implemented with some success, most notably in the reduction in the numbers of mothers presenting with the symptoms of septic abortions, the result of back-street attempts to terminate pregnancies. This has resulted in lower levels of maternal morbidity and mortality, especially in younger mothers. It also emerged that TOP needs to remain part of an integrated approach to reproductive health, which has as its overall goal the reduction in the number of unwanted pregnancies, and thus involves issues such as contraception and sex education as well. There do, however, remain challenges. There was an indication of some resistance on the part of management in hospitals to promote and implement TOP, a lack of support for TOP staff, and continued stigmatisation of those seeking TOP procedures, and of the staff who perform those procedures. This stigmatisation was evident both on the part of health service staff and the wider community. It was suggested that these issues need to be addressed. Another critical issue was that of resources, where it was felt that more resources were needed for the programmes to reach all sectors of South African society.

MINUTES
Reproductive Health Research Unit - Chris Hani Baragwanath Hospital & Wits University
Professor Rees stated that her presentation aimed to contextualise TOP within the framework of women's health in general and reproductive rights in particular. She added that these issues had to be understood in the context of human rights. She gave an outline of the history of the movement, starting in the 60s and 70s, where the finding that there were too many people in developing countries led to the funding of family planning programs. The 1980s revealed that the programs were not succeeding because the high maternal mortality rate and the low child survival rate created the impetus to have more children. This led to maternal and child health services. In the 1990s, this shifted to sexual and reproductive health, in recognition of the fact that the previous programs gave insufficient attention to women's rights, emphasised their child-bearing capacity above all else, and did not involve men. The definition of sexual and reproductive health provided by the WHO (see document) was correspondingly quite broad, emphasising rights.

Prof Rees said that TOP had to be understood within the overall reproductive health framework, since the goal was to reduce the numbers of TOPs. The number of TOPs was related to the ability to access contraception, and make use of this effectively. The importance of being able to plan pregnancies was revealed by figures which related infant mortality to preceding birth interval (see document) - the longer the interval between births, the greater the chance of infant survival. Prof Rees went on to discuss maternal mortality, saying that this was related to unsafe abortions, among other factors, and that in the developing world, the lifetime risk of maternal death was 1 in 1800, where in Africa, the figure was 1 in 16. Prof Rees said that there had already been an impact on maternal morbidity and mortality in South Africa since the introduction of the legislation, and this positive impact would be likely to increase.

The focus of her presentation was on the way that reproductive rights were intimately linked to other issues faced by women. She discussed the issue of sexual coercion, which in turn was linked to the ability, or lack thereof, of negotiating contraceptive use. Such coercion in turn was tied to violence against women in general. And all of these issues impacted on the spread of HIV and other STIs. Furthermore, Prof Rees indicated that HIV positive women were particularly vulnerable to abuse and violence. In conclusion, she returned to the definition of sexual and reporductive health, which tied reproductive health to the ability to negotiate a "satisfying and safe" sex life, as well as the ability to make decisions regarding child birth. She said that the issues raised were not just about the right to have abortions, but the rights to sexual autonomy and health.

DENOSA
Ms Zulu started by saying that DENOSA, the union that she represented, was pro-choice. Her submission focussed on the need to develop health service staff's awareness of the reasons behind a woman's choice to undergo a TOP, the need for training and the need for a focus on attitudes, which facilitate trust formation between providers, other health service staff and clients. She said that DENOSA fully supported the right of the health worker not to perform TOPs, as long as a woman's right to choose was protected and supported. As an example, she drew attention to 3 Military Hospital in Bloemfontein, where she said negative attitudes by management prevented the implementation of the service. She also raised the issue of pre-and post- TOP counselling, which in some areas was being done in groups, which did not meet the requirements of the clients. However, she recognised that this was due in part to staff shortages, and the nurses were doing their best. She recommended that other counsellors also get involved in TOP counselling, and that a referral system be developed, for referral to counsellors in the community.

She also said that TOP was emotional, for both providers and clients, yet there was no psychological support for nurses. This demoralised staff and negatively affected service provision. She also said that this situation could be improved by training enough volunteers to ensure a sustainable service. She also suggested that at present there was fragmentation within the service, since it was unclear where TOP belonged. She also recommended that the services be grouped into a 'Reproductive Health Clinic', to prevent the use of discriminatory names. She concluded with four recommendations: that there be values clarification training for all staff, that counselling services be provided, that human resources be more effectively managed to ensure continuous coverage and that other counsellors, such as HIV counsellors, get involved in TOP.

Discussion
Ms Dudley asked whether there was counselling for the emotional damage done by abortion. She also said that there were repeated claims that abortion saves lives, yet she said that backstreet abortions had not decreased. She suggested that perhaps the only reason that infections etc had decreased was that Misoprostol was being used in these illegal abortions, rather than other methods. She also referred to Prof Rees' having been awarded the OBE, an award for service to the British national interest. She asked how killing South African babies served the British national interest. She also said that there was a need to understand the objections of doctors and nurses to TOP, but those with objections had not been invited.

In relation to the issue of backstreet abortions, Prof Rees said that it could be shown that morbidity, especially among younger girls, had decreased. Yet problems with access still meant that there were a number of people resorting to backstreet abortions. She also pointed out that the study on incomplete abortions (see Dr Brown's submission) had found little evidence that Misoprostol was being widely used in backstreet abortions. In terms of the psychological damage that was being caused by abortion, she acknowledged that it was never an easy decision. Prof Rees however pointed out that the universal trend was that women's mental health was favoured by the provions of these services, provided there was adequate counselling to aid the choice either way. She added that the backstreet abortions, without psychological counselling, were the one's most likely to lead to psychological damage. In terms of the award of the OBE, she said that the British Government, like many others, had legalised abortion and understood women's rights issues. She also pointed out that the British government provided money to train midwives in this country.

Ms Dudley said that she understood that the award was meant to be given for service in the British national interest.

Mr Macintosh (DP) said that he was there when the 1975 Act was passed. He sought to draw attention to what he felt were a number of contradictions, one of which was the shifting definition identified by Prof Rees. He also said that there seemed to be gross contradictions in this country, where there were campaigns to 'Save Our Babies', struggles to get the use of anti-retrovirals approved for the prevention of mother-to-child transmission of HIV etc. The country was in the middle of an HIV pandemic, the effects of which were greater than any war. He equated this to a viral genocide, and said that it seemed contradictory that the Committee was discussing how to have more TOPs. He asked what the source of the frustration in the papers, and answered this by saying that it was because the majority of South Africans did not want legalised abortion. He said that it was ironic that the Kaiser Foundation supported both the LoveLife campaign, and the Reproductive Rights Alliance, adding that US Dollars were funding the publication of documents with pictures of Che Guevara on them. He finished by saying that the contradictions reflected the fact that South Africa did not want legalised abortion, because the people of South Africa valued lives.

At this point, there was a disruption by a woman in the audience,

The Chairperson warned her that if she continued to disrupt the meeting, she would be removed. He also said that even Members of the Provincial Legislature were not allowed to speak in this meeting, and asked her not to interrupt. This was a parliamentary meeting, attended by people elected with the honour of representing the country. He said that the woman should respect the House, and the laws of the country. He then went on to say that the issue raised in the meeting was fundamental to women. While Mr Macintosh was in Parliament passing an abortion law for whites, he was leaving Gugulethu to go into exile. He asked that everyone present respect what they were there to do. The issue of anti-retrovirals was irrelevant to the discussion, adding that they were there to understand all views, and maybe in another forum, they could invite Dr Saloojee of the campaign mentioned by Mr Macintosh, and explore that issue. He also said that it was wrong to equate HIV to genocide, adding that there had been many genocides, particularly in Africa, and even in this country, and it was not right to abuse language in that way.

Mr Macintosh explained that he had referred to a viral genocide.

Mr Ngculu said that smallpox was not a genocide, even though it had arrived with the colonisers, and affected those in poverty. He asked that everyone present be sensitive to the views expressed. He said that tbhey had heard yesterday that women wanted the services, and Mr Macintosh had not been present. He said that he was willing to bet everything that more women wanted the legislation. He again asked members not to be insensitive. He added that LoveLife received a budget from the government. He said that he wanted to respond to this issue, because it was a political one. He went on to say that this was legislation passed by Parliament, and they were there to review its implementation, not debate its merits.

Dr Baloyi said that he had some comments to make. He repeated what he had said the previous day, that it was problematic to listen when you already had made up your questions, because that prevented you from hearing what was being said. He said that he had enjoyed the presentation by Prof Rees, broadening the issue to one of rights, adding that they should all live up to these other challenges. He said that Mr Macintosh was talking about contradictions, but that it took rain and sun to make a rainbow. In the contradictions, it was possible to deal with the problems that were being faced. He said that even though it may be traumatic for some to have an abortion, it was equally traumatic to continue with a pregnancy conceived in traumatic circumstances. It should not be anyone's right to impose their beliefs on others. He concluded by saying that it was dangerous to think that they know what is best for others.

Ms Matimele said that Ms Dudley talked of trauma resulting from TOP. She asked whether Ms Dudley knew the trauma of being raped. She waited for an answer, but the chairperson said that such a question was not fair. Ms Matimele continued, saying that there was a fourteen year-old girl in KZN who was raped and impregnated by her father. The baby was born, and four months later, the girl was again pregnant by her father. She asked if Ms Dudley would like the girl to continue in that cycle.

Dr Luthuli said that Dr Baloyi had touched on this issue, the fact of choice. This was what the act was about. It did not force any individual one way or another. She argued that it should be looked at as a human right, the right to choose. If the Act was left as it was, it gave people opportunity. If it was reversed, this would be prescribing to people what they could do, and removing choice. She made a plea for the Members and all present not to ignore the issue of choice. She said that they must not impose their views on others in an authoritarian manner.

Ms Dudley said that they were correct that there was a right for all sides to be addressed, yet it was exactly this which had been prevented by excluding the pro-life viewpoint. In terms of choice, she said that choice had been given, but that huge funds were being devoted to TOP, and none were going to the alternatives. She then said that she had to say that she did know the experience of being raped. She said that the young lady would experience a great deal of trauma and would need support. But she said it was unfair to add violence to violence, by encouraging her to murder her own child.

Porof Rees said that it was right that there were different views, and that Ms Dudley had expressed her personal view. She said that abortion was not violence, it was choice. She added that that sort of emotional view was purely subjective, and not based on science.

Ms Dudley replied that Prof Rees' view was equally subjective.
Mr Ngculu at this point introduced the representative from the RRA, to conduct the next presentation. He added that, whatever the view, he was sure that everyone agreed that the review was necessary.

Reproductive Rights Alliance
The representative from the RRA started by saying that the Alliance was not pro-abortion, but pro-choice. She said that no-one wanted women to resort to TOP. She also said that, in terms of the prevention of unwanted pregnancies, there was a great deal that South Africans could be proud of. Her presentation touched on may of the same issues that had been raised by other presenters. She said that the bulk of TOPs were performed in Gauteng, with the second most being in the Western Cape. These were the two most urbanised provinces, and this spread reflected broader health service challenges. She also said that the need for second trimester abortions stemmed in large part from the difficulty in accessing services so that first trimester terminations could be performed. The RRA had explored the shift in attitudes in the community towards a more positive view of TOP services. It was gradually being accepted that TOPs were merely another dimension of health service provision, and this shift was reflected in the growing demand for the services, as well as the increased support from the community and family for those accessing the service. However, this attitude shift was uneven, again being greater in the urban areas. She also indicated that the positive experiences of women in contact with the service had played a role in shifting attitudes, and the legislation was also felt to have a role in changing attitudes. She said that there was a growing recognition of the fact that TOP services saved lives. She also said that the issue of values clarification, which had been raised during the course of the hearings, related to the separating of the values of the health service providers from their work, in an attempt not to impose their views on those accessing the service. She also said that it needed to be recognised that the stresses experienced by TOP providers were not unique to them, but rather reflected to a large extent the stresses of all health care workers. She reiterated the view that there was a real commitment to decreasing the demand for TOP services, because if TOPs were needed, this meant that the system had failed somewhere. She concluded by saying that the energy and commitment of the TOP providers were critical to making the rights contained in the legislation a reality.

National Department of Health
Dr Eddie Mhlanga thanked the Committee for their invitation, and started by saying that he was not going to provide a motivational speech on the need for TOP - the legislation had already been passed and defended in court as well. He also hoped to clarify some of the questions that may have arisen over the course of the hearings. The designation of facilities had been done in terms of the regulations, and that this had meant that some facilities were designated which were not yet ready to handle TOPs, but that this was being dealt with. He also said that, as the previous speaker had mentioned, the goal was to reduce the need for TOPs, and consequently research needed to go into how to do this. He supported all investigations, including the traditional methods which encouraged abstention, as ideally, no-one should fall pregnant against their wishes.

In South Africa, they were witnessing a decrease overall in the number of births. He said that he hoped that this was due to the success of the reproductive health and contraceptive strategies in the country, although there were a number of other possible reasons for this. Dr Mhlanga said that, from birth, women faced a number of struggles. He mentioned violence, genital mutilation, and the weight of traditional and family expectations as example. He said that the Act was aimed at trying to ensure that there was one less challenge
that women had to face.

In terms of the issue of Misoprostol, Dr Mhlanga said that there wer a number of unscrupulous GPs who were prescribing it, then saying to their patients that they must report to hospitals if they started to bleed. This impacted on the figures of 'unsafe abortions'. He said that another factor which led to skewed statistics were the cases where natural abortions were being falsely identified as incomplete abortions. He said that this issue in particular could have serious implications, particularly when combined with harsh staff attitudes to those who sought abortions. He cited the example of a young, married woman who had a natural abortion, but who, on presenting at the hospital, was left untreated because the staff thought she had had an induced abortion. She consequently developed an infection.

He said that, at the passing of the Act, it was assumed that young people would be the biggest users of the service, but it was found that in fact this was not the case. It was also assumed that doctors performed TOPs as part of their regular service and were thus trained in the procedure. It was also found that this was not the case, which led to the need for re-evaluating the training of doctors. Dr Mhlanga said that the need for counselling services was to an extent being met by church orgnaisations, challenging the view that TOPs were not supported by the Church. He also reiterated an earlier view that the lack of access to second trimester abortion services led to backstreet abortions.

Dr Mhlanga said that there were several key areas of concern that remained to be dealt with. The first was the issue of the retention of TOP staff, who were struggling with burnout. He pointed out that similar issues were being faced by all public sector employees, but the issue remained a cause for concern. The attitudes of staff remained a concern, and there was a need for expanded values clarification workshops. This was tied to community education, to broaden understanding of the context of the CTOP Act. He said that it also needed to be recognised that, in terms of counselling, it was not the formal structures which would provide the bulk of the counselling. Rather, it was the family and those around the client 24 hours of the day who were likely to have to provide counselling and support, and efforts should be directed at facilitating and empowering the family's skills in this regard. He said that the reckless prescription of Misoprostol was a cause for concern, particularly in instances when scant attention was paid to the dosages. Dr Mhlanga also recommended that greater attention be devoted to natural and traditional methods of family planning. He also mentioned his personal concern, for the issue of oral contraceptives and their reduced efficacy when taken in conjunction with anti-biotics. He concluded by quoting the Health Minister's statement from 1996, after the passing of the Act, which stated that the ideal situation was one in which no woman required a TOP, because no woman lacked the resources, support and love to go through with a pregnancy.

Discussion
An ANC Member said that there were always doubts about efficacy, with any new program. He said that when you started a program that cuts across attitudes, beliefs and religions, there will be resistance. Normally, programs were not judged by the resistance to them, but according to their efficacy. He went on to say that a country could not be run on the basis of all the views in that country, although it was important to try and accommodate them all. The fundamental issue was whether this process was being supported by the majority of people in the country, and made use of by the people of the country. If this was the case, then individuals with dissenting views should deal with their views in private.

Ms Dudley said that the presentation by Dr Mhlanga confirmed her concerns raised the previous day about the dangers of Misoprostol. She said that the drop in the numbers of unsafe abortions could be attributed to people taking the tablets and going home from the clinics. She asked what the department's views were on the changing of the legislation to allow midwives to carry out terminations until 16 weeks. She also said that she agreed that no woman who felt supported and loved would resort to a TOP. She asked whether the alternatives to TOP were being funded.

Dr Baloyi said that, as a member of the health services, he understood that disease respected no beliefs or religions and in health service provision, there was the need to be objective. He said that the Act made it possible for service providers to do exactly that. he cautioned that if TOP continued to be stigmatised, there would continue to be septic, back-door abortions. To prevent this, he said that there was a need for strategies to challenge this. He also said that not all such strategies fell within the ambit of the health services. Other sectors needed to play a role, and as politicians, this was where the members role lay, in taking these issues to other committees and following up these issues.

Mr Ngculu said that he had hoped that the issue of Misoprostol had been cleared up finally yesterday by Dr Dinat.

Dr Mhlanaga said that Dr Baloyi's comment contextualised society's role, to care and love. He said that he often felt that the Health Department was there to come in when all else failed. In an effort to prevent many of the problems, Health pointed concerns out to other sectors. He also said that it was not merely about money, but also spoke to issues such as acceptance. He said that in a 1984 study of TOP in the country, it was found that the majority of people accessing the service were from well-to-do families. They were accessing the service because of the stigma and fear, which led them to terminate their pregnancies. He said that the idea of moral regeneration captured for him the idea that we should be caring for those less fortunate than ourselves, empathising rather than condemning.

He disputed the idea that people were being given tablets and then told to go home. Under the Act, TOP meant performing an evacuation of the uterus. He said that it was the private doctors who simply dispensed the medication. With regard to the issue of decreased deaths, and backstreet abortions, he said that he would like to think that the safer sex messages are getting through and he hoped that this could continue. He added that he supported the idea of abstention - if people did what their religions recommended, the situation would be much better. He added, however, that everyone sometimes failed, and that at such times, there was a need to minister to the needs of the people, including their spiritual needs. In terms of changing the law, he said that any change would follow the normal procedure, and in all likelihood, the committee would know sooner than he would whether the law had been changed.

Ms Dudley raised a point of clarity. She said that was the Health Department not overseeing the Act, and therefore was money not being spent on 'choice', when the only choice seemed to be TOP.

Dr Mhlanga said that the Health Department did not extricate itself totally. For example, in the case of orphans, they were working with Social Development, giving input related to abuse, malnourishment etc. But he said that it would be too much if the Health Department were to claim that it needed the money for those functions. He added that only a small proportion of those who could not afford the cost of a child in strict terms came for a termination. He concluded that Health was involved in lobbying, but their role was limited.

Ms Xaba: Strategies to Increase Access to Services (National Health Dept & IPAS)
Ms Xaba stated that those Members who were present at the last hearings might remember her, as she had been at the hearings with a delegation consisting of MPs from other African states investigating South Africa's prophylactic programs. Their feedback had been that they had learnt a great deal from South Africa's systems, and congratulated South Africa on its advances.

Ms Xaba continued, saying that the progress of the last four years had been evaluated to come up with a strategy for the future. She briefly explained the process of drawing up the strategy, saying that a workshop had been held last year, at which a draft strategy had been written. This draft had been circulated for feedback from those who were unable to attend the workshop, and their suggestions had been included. She added that this forum was part of that process. Ten key strategies had been identified (see document). She said that management issues had been identified as a central problem. TOP services remained controversial, and this also had an impact on the clients. She said that the ideal situation was one in which health service providers performed TOP as part of their job, because they were trained to do it, and it was simply one dimension of the work, among many. She also said that South Africa continued to grapple with an issue which was a source of difficulty the world over - that of how best to provide a minor-friendly contraceptive/reproductive health service.

After elaborating on the strategies at some length, Ms Xaba discussed the ways in which the Members of the Committee could play a role in improving TOP. She also asked for suggestions on how this could be done. She said that there was a need to forge visible leadership on TOP nationally. There was a concomitant need to promote reproductive rights as fundamental rights. This would also feed into what was seen as another need, the need to promote a positive view of TOP services. Ms Xaba also raised the issue of ongoing capacity building for managers, saying that this was part of the process of strengthening TOP service delivery. In terms of the promotion of reproductive rights, she said that the involvement of key political figures such as the Minister of Health was crucial. She also recommended that national events be used to profile reproductive choice. She said that there was a need to lobby, for example, the Human Rights Commission, on these issues. She also recommended that reproductive rights organisations needed to develop strategic partnerships with government gender bodies, such as the Gender Commission. She also said that there was a need to increase awareness of the links between gender-based violence, HIV/AIDS and reproductive choice/rights. Her final recommendation in this regard was that there was a need to strengthen TOP advocacy among professional groups.

Mr Ngculu opened the discussion to the floor, saying that this was a critical issue for them as leaders, and asked the members for their suggestions.

Ms Dudley asked whether this was the question time. She then said that promotion of TOP was not the same as the promotion of choice. She again stated, as she had repeatedly, that no funds were devoted to choice, but merely to TOP. She asked why girls younger than sixteen were being targeted for the service. She suggested that this showed disregard for the laws concerning statutory rape. She asked whether the presenters were saying that, without TOP, there would have been 220 000 more deaths of women over the past five years. She also again asked why doctors, who seemed to have objections, were not invited to the proceedings. She also asked whether, if second trimester abortions were to become the norm, what would happen in the case of live births, and whether in such cases, the babies were being drowned.

Mr Ngculu said that the legislation had already been passed, and as leaders, it was their job to look at the advocacy of the legislation.

Dr Jassat (ANC) said that, in terms of strategies to deflect the attention of minors, whether sports programs as well as arts and culture were being investigated. He said that a lack of facilities fostered the situation. He agreed that the strategy should focus on reducing the number of TOPs.

Ms Mnumzana thanked the presenter, saying that she agreed that it was necessary for them as leaders to take part. She said that their responsibility was to ensure that the laws that had been passed were implemented. She recommended that they use the forum of meetings that they called in the community as a means of spreading the message. She said that she believed that information was power, and recommended that they could adopt or reach schools, as parliamentarians, to educate them about protecting themselves from abuse. She said that they needed to be taught about safe sex, because they were going to have sex anyway.

Ms Xaba said that sports programmes were part of the lifestyle programs, which aimed at developing all their potential. She said that Ms Dudley's questions did not really need to be entertained now, because they were part of the debate when the legislation was passed.

The meeting was disrupted by poster- carrying people, who said that they were "Christians in the true sense of the word".

Mr Ngculu said that he was not going to allow this, and asked the Committee secretary to call the police to remove them from the room. He left the table, chasing the protesters from the room, and ripping up their posters. He returned, apologising. He said that these were the people who were supposed to respect the law. He said that such "dual morality" was itself blasphemous. He said to Ms Dudley that she was representing her constituency, and as such it was her duty not to encourage that type of uncouth behaviour. He also said that, due to time constraints and the interruption, it was necessary to now summarise the main points.

Ms Xaba simply said that no-one was forced to do the service, but that they did it voluntarily.

Mr Ngculu said that there was meant to be time for a summary and a discussion of the way forward, but that now there was no time. He said that they would have to return to this issue at a later date, and asked the members to look at the legislation. He said that South African history was full of intolerance, and everyone was aware of the harm which this caused. He said that now, efforts were directed at trying to bring together society, and encourage respect for its laws. He went on to say that oversight committees were a new idea, and that prior to 1994, there had been no such thing in South Africa. People were now abusing the openness of the new democracy. Such people had no respect for the law.

The meeting was adjourned.